Nine lessons about women’s heart disease that future doctors will learn in med school

by Carolyn Thomas   ♥  @HeartSisters

A cardiologist who teaches medical students at a prominent medical school was asked if his students were learning about the known disparities in cardiac research, diagnostics, treatment and outcomes in female heart patients compared to our male counterparts. His answer basically was: “If we start taking up time to talk about women, we’d have to stop teaching one of the equally important subjects in our curriculum.”  See also: Women’s Heart Health: Why it’s NOT a Zero Sum Game

That reluctant conversation-stopper may help to explain what cardiac researchers keep reminding us:  physicians now in practice likely received little if any specific med school training in women’s health aside from reproductive health issues. And as Emergency physician Dr. Alyson McGregor at Brown University reminds her colleagues:

“Women are NOT just men with boobs and tubes.”   

In her compelling book, Sex Matters:  How Male-Centric Medicine Endangers Women’s Health and What We Can Do About It , Dr. McGregor adds:

  “We have our own anatomy and physiology that deserves to be studied.  One of the biggest and most flawed assumptions in medicine is:  if it makes sense in a male body, it must make sense in a female one, too. But in every aspect, our current medical model is based on, tailored to, and evaluated according to male models and standards.”

Australian researcher Dr. Lea Merone is on the same page, explaining that the current male medical model is “androcentric” –  from the Latin ‘andro’ (man, male) and ‘centric’ (centred on). What this means, she adds, is “a tendency to place the male or masculine viewpoint and experience at the centre of a society or culture.”(1)  As she wrote last year in the medical journal Women’s Health Reports:

“The androcentric history of medicine and medical research has led to an ongoing sex and gender gap in both health research and education. Evidence suggests that globally, this sex and gender gap is ongoing. These gaps translate into real-life health inequities for women.”

For example, most medical research has been performed on (white, middle-aged) males for decades – and then generalized after the fact to apply to female bodies, as if researchers believe that women are just small men.  Even the laboratory animals used in medical research have traditionally been male animals. 

This unbalanced research gap, as Dr. Merone suggests, also translates into a medical education gap in which, “outside of reproductive and sexual health, both medical/nursing schools and clinical textbooks sometimes omit women entirely.”

Here’s a frightening example: the results of a survey called Sex- and Gender-Based Medicine Faculty Survey, as described by Mayo Clinic’s Dr. Virginia Miller, and administered to 159 medical schools in Canada and the US, revealed that 70% of respondents reported receiving no formal sex- and/or gender-based curriculum content during their training.(2) 

Dr. Miller also reminds us, by the way, that the words “sex” and “gender” are two different things:  sex is narrowly defined as a person’s reproductive organs at birth, and gender is more widely defined as a person’s identity, expressions, and role in society.

Meanwhile, medical school training has focused on what’s called the ‘bikini approach’ to women’s health –  in which women’s health focuses heavily on breasts and reproductive systems, i.e. the parts of a female body typically covered by a bikini. And we know that sex- and gender-specific educational content about cardiovascular disease diagnosis and management is sorely lacking in most med schools.

This summer, I’ve been invited to speak about women’s heart disease to students – first to nursing school students in Vancouver, and most recently to med students in New York. After the American Heart Association’s last national survey results revealed a shocking public awareness campaign failure that the AHA itself dubbed “a decade of lost ground” , I now believe that reaching out to educate young medical and nursing trainees could be a better option to improving our future as female heart patients.

There may be a light at the end of this androcentric tunnel – and it has already begun – with medical/nursing school training. In the U.K., for example, starting in 2024, specific teaching and assessments on women’s health will become mandatory for all graduating medical students (and for all incoming doctors) as part of its first Women’s Health Strategy for England.(3)

Meanwhile, the Training and Education Working Group of the Canadian Women’s Heart Health Alliance (CWHHA, affiliated with the University of Ottawa Heart Institute) has designed nine educational modules on women’s cardiovascular disease. These modules target medical/nursing trainees, as well as current healthcare professionals in Cardiology, General Internal Medicine, and Emergency Medicine. Each free pre-recorded webinar ranges from 24-37 minutes in length, and includes a downloadable Power Point slide deck with speaking notes, a full reference list linking to the articles, and a heart patient sharing her lived experience via YouTube video.

Together the nine modules offer a one-stop Master Class package to any academic tasked with teaching future doctors and nurses about women’s heart health. These include:

1. Cardiovascular Risk Assessment in Women – The Role of Risk Factors and Scores:  This module explains limitations of current cardiac risk calculator scores doctors use (none of which include pregnancy complications, a risk factor unique to women which can double our risk of heart disease. That’s as serious a risk factor in women as smoking and high cholesterol, yet how many docs even ask women about their history of such complications?)
2. Acute Coronary Syndrome (ACS) in Women: This topic covers assessment and strategies for managing this sudden, reduced blood flow to the heart muscle (as in heart attack or unstable angina) and also reviews additional challenges presented by younger women with ACS.
3. Approaches to Chest Pain – A Sex & Gender Focus: (the most commonly reported cardiac symptom in both women and men – even though women might not use the word “pain” to describe chest symptoms (e.g. pressure, fullness, dull ache, etc.) which does NOT mean symptoms aren’t heart-related. This module reviews an appropriate diagnostic workup for women with symptoms.
4. Myocardial Infarction (MI) with Non-Obstructive Coronary Arteries (MINOCA):  Myocardial infarction (MI) means heart attack that’s typically caused by an obstructed coronary artery – compared with MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) – both more commonly seen in women. This module helps to identify the next step in diagnosis when the angiogram appears “normal” and describes how treatment differs between the sub-types of MINOCA/INOCA.
5. Stress-Induced Cardiomyopathy (SIC): Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood through the rest of the body. This module addresses the clinical presentation and associated triggers for SIC, and revisits the differences between treating SIC and acute coronary syndrome.
6. Spontaneous Coronary Artery Dissection (SCAD): The majority of SCAD patients are young women (average age 45-53 ) with few if any cardiac risk factors; this module explains the important differences between SCAD and other causes of chest pain, and what emerging research concludes about best practices in treating SCAD.
7. Contemporary Management of Women with Heart Failure: This module examines the difference between men’s and women’s heart failure diagnoses, and especially the medical therapies used to treat heart failure with preserved ejection fraction (HFpEF – which is most often seen in women) and also why sex-specific risk factors like early menopause or adverse pregnancy outcomes can help predict which women are more likely to have this diagnosis. 
8. Cardiovascular Risk In Women With Gestational Diabetes & Hypertensive Disorders Of Pregnancy:  This module reviews the gaps and optimal management strategies for these women, and the underlying mechanisms and link between pregnancy-related cardiac risk factors and heart disease.
9. Recovery & Cardiac Rehabilitation:  This module explains the remarkable benefits of cardiac rehab for all female heart patients, identifies barriers that deter women from participating, and influences (such as physician endorsement) that can increase women’s participation.

Stakeholders committed to improving professional health education on women and heart disease (like these nine modules) include students, faculty, deans, alumni, donors and advocates. It’s a big and optimistic tent!

♥  Learn more on how to access these nine free CWHHC educational modules.

Once you’re registered (registration is free in Canada or the U.S.) there are two potential ways to use these nine educational modules:

1. if you’re interested in learning more about women’s cardiovascular health, you can view the webinar sessions
   
2. if you’re part of a medical or nursing school faculty, you can download the tools (PowerPoint slides, speaker scripts and resources list) to present content at your own institutions (i.e. Grand Rounds) –  and you can also contact CWHHC for invited talks

I must add here that featuring real heart patients talking about their own lived experience is a stroke of genius in each of the nine teaching modules. I’d like to acknowledge the nine women who brought these modules to life by sharing their unique perspectives: Monique, Kelly, Nicole, Bobbi Jo, Bev, Sudi, Marie, Christine and Charlotte.♥

And remember that surprising comment from the cardiologist I mentioned at the beginning of this post? I suspect that even he could somehow manage to schedule nine short educational modules during a med school term without threatening  the rest of his curriculum content.

I’m already a wee bit giddy anticipating entire graduating classes of new physicians and nurses informed by these powerful modules in the nearest possible future.

 

♥

Q:  Do you believe that reaching medical and nursing students might finally lead to improved cardiac care for women?

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See also:  “Incorporating a Women’s Cardiovascular Health Curriculum Into Medical Education“, published in the Canadian Journal of Cardiology.

 

NOTE from CAROLYN:   I wrote more about the disparity in women’s cardiac research, diagnostics, treatments and outcomes compared to men in Chapter 3 of my book, A Woman’s Guide to Living with Heart Disease.  You can ask for it at your local library or bookshop, or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

♥

1. Lea Merone et al. “I Just Want to Feel Safe Going to a Doctor: Experiences of Female Patients with Chronic Conditions in Australia”, Women’s Health Reports. Dec 2022.1016-1028.

2. Miller V.M. et al. “Embedding Concepts of Sex and Gender Health Differences into Medical Curricula.” Journal of Women’s Health. 2013; : 194-202.

(3) Wise J. “Women’s Health: Specific Assessments to Become Mandatory in Medical Training” BMJ 2022; 378 :01820