Eart diseases are chronically misdiagnosed in women. Stories of women who come to hospitals with symptoms of a heart attack are common. It has been difficult for me to get to the root of the problem because of professional, systemic and technical biases. The effects of individual patients are complex to analyse and interpret, but now we can see them on a larger scale.
When women have a heart attack, they are more likely to get a wrong initial diagnosis. People who are initially misdiagnosed are more likely to die. Women have worse outcomes for heart operations than men. Women are less likely to be treated quickly, less likely to get the best surgical treatment, and less likely to be discharged with the optimal set of drugs. Is this understandable?
The study’s most shocking statistic was that the failures only happened if the doctor was male
Women don't develop heart disease as much as men and so seeing a woman with a heart attack is "un expected". Women may overlook the first symptoms of a heart attack because they don't expect to have one. I am not sure if the justifications I hear from clinicians are correct. It is not a rare occurrence that the heart disease rate is lower in younger women. More than 30,000 women are admitted to hospital in the UK every year for a heart attack. Between three and five young women can be seen by a doctor for every 10 young men with heart disease. General practitioners may only see one or two cases of the disease in their career. Women are more likely to die from heart disease than men are. Seeing a woman with heart disease in casualty is not unexpected for a clinician.
There are two popular excuses for women's symptoms. There is a lot of overlap between the sexes when it comes to symptoms. The classic symptom of crushing chest pain is felt by both, as well as feeling sick, sweaty, or lightheaded. Women are more likely to experience this pain in their back than men are. Since there will be a lot of women coming to the hospital with heart attacks, there should be no excuse for not knowing.
Guidelines for treatment after a heart attack are well defined. Women should be given the optimum standard of care when it comes to their heart health. This is not occurring. When treating women, clinicians are less likely to stick to the guidelines and send them home with a lot of pain killers. The gold-standard treatment, where the blood vessels are opened using catheters, is less likely to be received by women. According to a study of more than 100,000 hospital patients, men are more likely to survive in the hospital than women are. There is not a lot of haste in treating women. For every five-minute delay, there is a 5% increase in the risk of death. Women were moved to the catheter laboratory more slowly than men and this contributed to the higher death rate.
This only happened if the doctor was male. What should this be?
1.3 million Florida residents who had been admitted to the hospital for a heart attack were the subject of the largest study on physician gender and treatment. Female patients treated by female doctors had better survival rates than female patients treated by male doctors. There was a measurable increase in survival with every new female patient that a male physician saw. Women clinicians in the team made a big difference to the men they worked with. The success of the team as a whole and the competence of men in the team for treating women were improved by a higher proportion of female doctors. The study concluded that the best way to help female patients was to have a gender-balanced team, rather than waiting for individual male doctors to gain experience.
Female patients are treated differently by the male doctors. The response in the clinician is triggered by what behaviours or characteristics. The difference between genders plays a part here. Each of us, independent of our biological sex, has a range of gendered attributes that are traditionally thought of as male or female and, importantly, that could be valued differently if displayed by a man or a woman. Do you shy, gentle and compassionate or assertive? Almost all of us will fall somewhere between the two extremes on the Bem sex-role inventory, which is a test you can take to assess how male or female you are.
Factors such as being the primary wage earner, having a high income or doing most of the housework affect how we are seen. It adds up to how we look. The perceived gender was the most important factor in how treatment was influenced by gender and biological sex. Men and women were more likely to return to the hospital with the same symptoms after being discharged. There is a higher chance that your distress will be seen as overblown, inaccurate or hysterical if you act in a way that is perceived as traditionally female.
Uncontrollable emotional excess has been associated with women and has been categorized as either a disease of the body or mind. The Greeks called it hysteria and only at the time of Freud did the same thing happen to men. In her book Sex Matters, a US physician describes how difficult it is for women in pain to convince a doctor of their seriousness. They are perceived to be hysterical if they try to convince the doctor. Women from cultures with a lot of formality have a difficult time. This can work against them in casualty if they have always been encouraged to be very vocal about their feelings. The best thing you can do as a woman is to have a man with you.
One way to understand if these observations are the result of bias is to look at the same for other disadvantaged groups as well as women. Patients from minorities doing better with a physician of the same race, or in a team with a good proportion of minority doctors, is the same phenomenon for doctor- patient matching. When there is good matching, the use of healthcare resources and satisfaction increase. There are many differences in medical care in the US and the UK. Minority women are more likely to be disadvantaged in terms of healthcare.
Why isn't gender balanced teams happening in cardiology? Because of the many and varied devices that can be implanted in the heart, male clinicians tend to gravitate towards clinical cardiology. Over the course of 10 years, the UK Athena Swan gender equality scheme made many changes to reduce bias in hiring and promotion practices. The number of female science professors in cardiology was going to be equal to the number of male professors by 2020. The female clinical cardiology professor numbers in our hospitals were still 10% of the number of males. More than half of medical school students in the US are women, but only 4.5% of cardiologists are women. This difference is important in the treatment of women with cardiac symptoms.
We are waiting for the world of cardiology to achieve gender parity. A recent study used data science to combine the clinical signs, heart measurements and blood test results from thousands of patients. With the help of artificial intelligence, the researchers were able to create a method that was better at detecting heart attacks in general, and more accurate in sending patients for further tests, than conventional tests. There are shocking statistics such as the estimated 8,200 women who died of heart problems in England and Wales because of misdiagnoses, and we hope that advances such as this will make a difference. Data science with its analysis of large numbers of patients will hopefully give us new insights and will show the potential for artificial intelligence to give a solution.
There is a professor at Imperial College London. The Exquisite Machine: The New Science of the Heart will be published by MIT Press in September. You can order your copy at guardianbookshop.com. Delivery charges can be applied.
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