by Carolyn Thomas ♥ @HeartSisters
Last week, I was re-reading a 2018 study that examined female survival rates following a heart attack diagnosis (a topic of great interest to me and other women whose cardiac symptoms have ever been misdiagnosed). Study authors explained what we already knew (“a large body of evidence suggests that women are less likely than men to survive traumatic health episodes like acute myocardial infarction).” There are lots of studies out there suggesting the same conclusion, but this research tracked both the outcomes of cardiac treatments and also whether the treating physician was male or female. Their conclusions raised an astonished eyebrow or two at the time (notably, in male physicians!) because researchers found that female heart patients who had been treated by female physicians had better survival outcomes than women treated by male docs. (There were some specific exceptions reported – if, for example, a male physician has had considerable experience working alongside female colleagues).
I’m guessing that many male physicians don’t like to entertain those kinds of study findings. .
Yet since that 2018 study first hit the headlines, similar studies have reported remarkably similar conclusions on what’s known as gender discordance in medicine (e.g. female doctor/male patient or male patient/female doctor). A study published in the journal JAMA Surgery in 2021, for example, found that female patients developed fewer complications if their surgeon was also female. And another study published in JAMA Surgery last year reported that all patients (male or female) had fewer complications and shorter hospital stays if they were operated on by female surgeons (adding that one reason might be that women worked more slowly than their male counterparts in the O.R).
And just last week, yet another comparable study was published in the journal, Annals of Internal Medicine. The authors reminded us that medicine is hardly alone in being seriously affected when the persons acting on behalf of women are men:
“A significant number of life’s outcomes are not determined through self-advocacy. Instead, they result, at least in part, from people who advocate for or act on a person’s behalf. And people do not always have their choice of advocate, who may differ from those they advocate for in terms of values, beliefs, background, race – and even gender.
“Distressingly, in instances where men are advocating for women, women have been found to face more significant disadvantages than their male counterparts.”
The disadvantages are not, unfortunately, unique to female heart patients alone. We know that gender discordance throughout society affects women. Some examples from real life:
-workplace pay equity: more females in management narrows the gender wage gap (1)
-women promoted to leadership positions: distribution of men and women leaders strongly affects hiring, promoting and economic rewards of women (2)
-educational outcomes: female college professors have a powerful effect on female students’ performance in math/science classes (3)
-sex discrimination lawsuits: female plaintiffs filing workplace discrimination claims are more likely to settle/win compensation when a female judge is assigned (4)
-physicians’ perception of female patients: female patient/female physician pairs were associated with physicians’ reporting higher rapport and lower diagnostic uncertainty; female patient/male physician pairs were associated with physicians’ reporting higher diagnostic uncertainty and lower rating of patient condition as “high severity” (5)
-cancer screening: female patient/male physician pairs were associated with lower rates of breast, cervical and colorectal cancer screening (6)
Meanwhile, several theories have emerged in medicine to try to explain differences in outcomes based on whether your doctor is male or female. For example, some commonly discussed theories suggest that, compared to their male counterparts, women physicians are generally more likely:
- to practice evidence-based medicine
- to follow established clinical practice guidelines
- to communicate more effectively with patients
Dr. Theresa Rohr-Kirchgraber, a professor of medicine at Augusta University, suggests that men and women can also bring different strengths to the role of physician:
“Women are more often caregivers in their own homes, and they bring that outlook to their jobs. We’re thinking about what’s going to happen when [patients] go home, who’s going to be with them. It’s not only about the care while you’re in the hospital, but it’s the forward thinking about what’s going to happen when you get out.”
If you’re a woman experiencing cardiac symptoms who calls 911 for emergency help (which is what you SHOULD do, by the way), you may encounter relatively few female physicians when you get to the hospital. And you’ll likely need to get past the two de facto gatekeepers there: first, the Emergency Department physician, and then the cardiologist who is on-call that day (if the Emerg doc decides to consult Cardiology at all. Mine didn’t. Too busy insisting that my symptoms of central chest pain, nausea, sweating and pain down my left arm were caused by acid reflux.) Emergency physicians are typically the docs who will determine whether you’ll be admitted to the hospital for care – or not. Although women make up over half of all medical school students, only about 38% of the Emergency physicians and just 12% of the cardiologists you’ll meet are women. See also: Walking the Tightrope: Women Cardiologists in an Old Boys’ Club
I’m not a physician or a cardiac researcher, of course, but it seems to make sense that increased diversity among medical professionals – now considered an important factor in current health care disparities – just might help to lower implicit bias and to improve cardiac outcomes for women.
Despite all those studies mentioned above, some people (notably, men) have disputed the research conclusions that whether your doctor is a man or a woman plays a role in these patient outcome differences. In the Canadian Medical Association Journal, for example, Greg Basky at the University of Saskatchewan pointed out that the gender difference in outcomes between male and female physicians could be partially because more female doctors are younger, adding:
“In Canada, most physicians under 40 are women, but most older doctors are men. Newer, younger doctors may be more up-to-date on clinical practice guidelines, which some studies have shown leads to better patient outcomes.”
Now, remember that gender bias can be a touchy subject to many people (notably, men). See also: “There Is No Gender Bias In Medicine. Because I Said So.”
But in fact, it would be surprising – given the list here of just some of the pervasive gender bias examples women experience throughout society in general – if the field of medicine were somehow immune to bias.
It clearly is not.
PLEASE NOTE: Having said all that, I’d like to reassure women who are cared for by male physicians that research is NOT claiming that all female physicians are good or that all male physicians are bad. But when male physicians have both many female colleagues and experience treating many female patients, their female patients do have demonstrably improved outcomes. So go figure. . .
Personally, I feel very lucky to have the two male physicians who are part of my own healthcare team.
Both my pain specialist (at our Regional Pain Clinic) and my cardiologist are men. Both men are smart, funny, great communicators and skilled diagnosticians (especially important for somebody like me who lives with debilitating ongoing symptoms of coronary microvascular disease (MVD). My cardiologist accurately nailed this tricky-to-diagnose disorder a few months after my 2008 heart attack, and then – even better! – my pain specialist turned out to have a full year of fellowship training in Sweden specializing in MVD.
Together, they’re my dream team – along with my wonderful (female) family doctor, of course!
Heart Sisters 
Unfortunately, I have found that the one most effective word in getting even remotely treated while having a heart attack (and I used to work in CCU) is “Lawyer.” That and demanding to speak to Administration. I was told for 45 minutes while going into cardiogenic shock that “it’s all in your head. You are having a panic attack!”
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Yoiks! 45 minutes and cardiogenic shock! What a nightmare, Mary! It’s tragic that any patient would ever have to threaten legal action just to be taken seriously and appropriately treated. As I’m sure you knew from your CCU experience, cardiogenic shock is life-threatening, but treatable if diagnosed and treated quickly. I hope you are doing better now. . . ❤️
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Thank you, Carolyn.
After approximately 45 minutes, during which time they tried to remove my phone by force as I was trying to call 911, I was finally transferred to ICU after explaining that this was not a panic attack and they didn’t know what they were doing. HCA hospital.*
I’m convinced the larger the corporation, the worse the care. You are so brave Carolyn for writing your book and bringing this problem to the forefront. They had ordered troponins which were elevated but no one checked until 4 days later.
Your book is a TREMENDOUS help to all of us.
Since then, I have learned to doubt our system and make a stink. That little word lawyer never fails to get action, wish I knew that then. Next time I had trouble, I bluntly said I needed to see someone in administration NOW and the next call was going to be to a lawyer.
That produced a cardiologist in my room within 5 minutes.
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Hi again Mary – thanks so much for your kind words.
Let me get this straight: you were IN THE HOSPITAL and desperately trying to call 911 for help?! And nobody checked your troponins for FOUR DAYS?! I don’t know what feels scarier for me: the idea that an informed patient (who used to work in CCU!) has to communicate with healthcare professionals using threats in order to get appropriate help, or the idea that those professionals are not providing appropriate help in the first place (which then becomes the reason for the threats!)
I wrote about being perceived as a difficult patient here, in which I reminded other patients that there are indeed serious risks in being viewed by doctors/nurses as difficult (researchers tell us that “being branded as difficult or demanding by health care professionals, can have a detrimental effect on the treatment a patient receives” – but patients also walk a razor-sharp tightrope. We may risk being labelled as “difficult” if we persist, yet we risk being dead if we don’t!
P.S.
* Here’s what readers may not know about Mary’s hospital HCA Healthcare, Inc: it’s an American for-profit operator of health care facilities founded in 1968, based in Nashville, Tennessee. As of May 2020, HCA owned and operated 186 hospitals and approximately 2,000 sites of care, including surgery centers, freestanding emergency rooms, urgent care centers and physician clinics in 21 states and the United Kingdom. As of 2023, HCA Healthcare is ranked #66 on the Fortune 500 rankings of the largest United States corporations by total revenue. The company engaged in illegal accounting and other crimes in the 1990s that resulted in the payment of more than $2 billion in federal fines and other penalties, and the dismissal of their CEO Rick Scott by the board of directors.
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And crime does pay for them. Now Rick Scott is our Senator, and was governor before that.
Carolyn you are indeed a brave woman. I can see you truly changing healthcare for the better by giving us a voice.
You are one of my heroes, thank you!!
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Hi Mary – would that be the same Rick Scott who “oversaw the largest Medicare fraud in U.S. history?”
Q: Why isn’t he in prison?
❤️
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Wow. . . interesting. . . will need to add “lawyer” to my collection of strategies. what a great tip.
I have realized that every time I see a medical professional, I spend time prior to the appointment strategizing how best to effectively communicate what is going on.
At least now, all my physicians are women, with the exceptions being my physical therapist (shoulder injury) and my rheumatologist who has been outstanding and the one who realized I had FMD and got me referred to Dr. Kim. More on that story soon.
It was partly due to the erroneous assumption that I was having a gallbladder attack instead of a heart attack that uncovered the FMD. It helped that my rheumatologist is caring and diligent but it is also that I am now a p.i.t.a. and a terrier when it comes to medical care.
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Hi Helen – wouldn’t it be nice if – before every appointment with a medical professional – it was the PROFESSIONAL sitting there strategizing how best to effectively communicate with the patient about to walk through the door?
I had to think a moment to guess what p.i.t.a. means, Helen. I think I figured it out!!
Take care . . . keep up the terrier stance! ❤️
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Hi Carolyn . . . I may have missed this in your article but I have a question: Are male outcomes better when they have a female MD? Are women just all round better physicians or is it the female to female relationship that is improving outcomes? Just Curious.
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Hi Jill – I wondered the same thing while I was reading those studies. Some researchers (e.g.in last year’s study published in JAMA Surgery) reported that ALL patients (male or female) had both fewer complications and shorter hospital stays if they were operated on by female surgeons.
Another study out of the University of Tokyo suggested “multiple reasons could be behind the stark difference in outcomes for female patients when treated by female physicians, such as:
– male physicians potentially underestimating the severity of illnesses in their female patients
– female physicians having better communication skills and a more patient-centered approach when it comes to female patients.”
It’s interesting that you mention that ‘female-to-female relationship’ advantage – the Japanese researchers mentioned that too, adding “Being treated by a female physician could also help alleviate the embarrassment, discomfort and social/cultural taboos that can arise for female patients during sensitive examinations.”
Again, this is not to say that ALL male physicians can’t be kind and empathetic communicators. My cardiologist is a great example of this: when we first met (in the Emergency Department after he was called in to consult on my case), he introduced himself, sat down right next to my bed, held my hand in both of his hands (I remember this especially as a lovely and caring gesture at the time!) while he carefully and calmly explained what was happening to me, his treatment recommendations for my heart attack, and what could happen next. But the (male) Emerg doc who had misdiagnosed me with GERD and sent me home during my first visit to the same Emerg Department did not, by comparison, make eye contact with me even once while he stood in the doorway, head down, scribbling notes on a clipboard while misdiagnosing me.
But of course, not all male docs are like that first Emerg doc, and not all female docs are warm and fuzzy!
Take care. . . ❤️
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In my lifetime, I’ve had some terrible experiences with male physicians, with one stellar exception.
I began seeking female practitioners at a time there were few where I live, but for about the last 30 years I have had mostly females. My chart specifies only females now, and that includes everyone from doctors to nurses, phlebotomists, etc.
I also find if I kindly remind the males that show up in my room of this preference, there are no hard feelings and the swap is made. Of course there are necessary exceptions, but on the whole I see almost all females.
I believe this is why my practitioners and I act as a team in preserving and promoting my health, and why at 75, I am considered healthy despite a somewhat lengthy list of health challenges.
We problem-solve together and I feel empowered and a responsible part of the team.
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Hello Pat – you’re describing a doctor-patient relationship as everybody else would wish for! I suspect that one of the big reasons that you’ve had positive experiences (even “kindly reminding” certain care providers of your preferences that they leave the room!) depend on that very kindness you display.
I think feeling like you’re not just the recipient of care and expertise, but are a true member of your healthcare team makes all the difference!
Take care. . . ❤️
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Great post. I do think one of the other gatekeepers in this scenario are the ambulance crew. Mine made me get out and walk into the ER because he didn’t think I was having a heart attack. Just lovely.
Recently, I saw Esther Kim, MD who is a cardiologist and vascular specialist who diagnosed me with FMD, which is another interesting story. I will send an email.
She advised that if you think you are having a heart attack to say that, but to also insist on a troponin test. It’s also important to ask for referral to cardiac rehab before you are discharged.
Thanks for all your dedication.
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Hi Helen – I was originally going to mention those ambulance crew gatekeepers in this post (but then changed my mind – only because the topic here was specifically about those with the letters M.D. after their names). But you’re right: I remember your dreadful story about being forced to get out of the ambulance and WALK into the ER! What kind of paramedic does that to a heart patient?!?
I’m sorry to learn that you have a new diagnosis of Fibromuscular Dysplasia (FMD). Just what you need – one more diagnosis. But I’m very glad you’re seeing Dr. Kim, who has a well-respected reputation in treating conditions that tend to affect women more than men – e.g. spontaneous coronary artery dissection (SCAD) and fibromuscular dysplasia (FMD). So you’re in good hands with her!
She’s so right: people insisting on a simple series of troponin blood tests is important – but most women in the throes of cardiac symptoms serious enough to seek emergency help may have a tough time “insisting” on much.
Cardiac researcher Dr. Karin Humphries in Vancouver has been studying differences in troponin results in men and women, and her findings are shocking:
Troponin is a cardiac enzyme that’s normally undetectable in blood – if it is present, it’s considered a sign of heart muscle damage, and likely due to a heart attack. But Dr. Humphries has found that the commonly used troponin threshold in this blood test is based on a level that’s appropriate for men, but may be set too high for women – whose blood tests (like my own tests in mid-heart attack) could be interpreted as “normal”. Dr. Humphries believes that “setting a lower female-specific troponin threshold “would improve the diagnosis, treatment and outcomes of women presenting to the Emergency Department.”
She’s also right about asking for a referral to cardiac rehab before hospital discharge. Yet this requirement makes me crazy: why should it be up to the sick people to tell physicians what’s needed? I wrote more on this here: “Failure to refer: why are doctors ignoring cardiac rehab?”
COVID really threw a wrench into our ability to attend in-person cardiac rehabilitation programs, with many programs morphing to online versions instead – in my personal opinion, nothing beats an in-person post-discharge rehab program for known improvements to both our physical and emotional health, but online is better than nothing, which is what many heart patients unfortunately have now.
For example, here’s a good example of free virtual cardiac rehab from Vancouver Coastal Health’s cardiac rehabilitation programs.
Take care Helen – and good luck to you. . . ❤️
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