By ORLY NADELL FARBER AUGUST
6, 2018
Much like
shoes or skinny jeans, heart attacks can fit women a little differently than
men. Their symptoms don’t always look the same, and for a meshwork of reasons,
physicians all too often fail to diagnose heart attacks in women with enough
time to intervene.
The
consequence: Women are more likely to die from heart attacks than men are. But,
according to a new study, not if they’re treated by female doctors.
The research, published Monday in Proceedings of
the National Academy of Sciences, found that female patients are two to three
times more likely to survive a heart attack when the doctor overseeing their
care is also a woman. But the difference diminished when male doctors worked in
emergency rooms with a higher percentage of female physicians.
In fact,
both men and women suffering heart attacks fared better when treated by female
doctors or when treated by men working alongside more female clinicians, the
authors reported.
These
findings raise an unavoidable question: Are women better doctors? And, does
rubbing elbows with women physicians help men become better clinicians? The
answers are more convoluted than the questions.
Previous research has
found better outcomes among hospitalized Medicare patients treated by women,
but the underlying reasons remain murky at best.
“It’s
important to not get caught up in the idea that women are better doctors,” said
Dr. Klea Bertakis, a physician and researcher at the University of California,
Davis, who studies gender dynamics in health care. “It’s not a
men-against-women kind of thing, it’s what are the best practice styles and how
can we teach them.”
Bertakis
pointed to specific practice behaviors – female physicians tend to share more
information with patients and to focus more on partnership and patient
participation. Male physicians, on the other hand, tend to stick to “the
facts,” emphasizing the patient history and physical exam, she said.
Dr.
Sharonne Hayes, a cardiologist at the Mayo Women’s Heart Clinic, broke down one
common explanation for the differences in outcomes for male and female heart
attack patients — the symptoms.
During a
heart attack, women are less likely to experience chest pain, and are more
likely to present with nausea and vomiting. But Hayes pointed out that there
are more similarities than differences: 30 percent of both men and women won’t
experience chest pain, and men can have nausea, too. The symptom hypothesis
doesn’t fully explain the different rates of diagnosis and survival.
Hayes
suggested that part of the problem is that physicians and people in general are
“still stuck with some confirmation bias about who gets a heart attack.”
The new
study, conducted by three business school professors at the University of
Minnesota, Washington University in St. Louis, and Harvard, started by looking
at whether gender concordance between patients and the attending physicians in
the emergency department influenced survival.
“There’s
relatively deep streams of literature in economics, political science, and
sociology that suggest when advocates differ from the people they advocate for,
there are often penalties,” said lead author Brad Greenwood of Minnesota’s
Carlson School of Management.
“Penalties”
are business-speak that, when applied in an emergency room, refer to mortality.
And “advocacy,” in this case, translates to physician care.
Using a
census of heart attack patients admitted to Florida hospitals between 1991 and
2010, Greenwood and his colleagues found that when the gender of the patient
matched the gender of the physician, both male and female patients were more
likely to survive.
Looking
more closely at the data revealed that female patients treated by male
physicians were the least likely to survive a heart attack.
The
magnitude of the difference impressed Greenwood, but he was not surprised by
its existence.
Greenwood
and his co-authors took their research one step further, studying not only the
physicians’ gender, but their environment. They found that patients were more
likely to survive heart attacks when treated in emergency departments with
higher percentages of female physicians.
Greenwood
and co-author Seth Carnahan, of Washington University, were both hesitant to
speculate about the reasons underlying their observations. Carnahan — who
compared the patient-physician relationship to an employee-customer one —
acknowledged that, as business professors, he and his colleagues lack the
perspective of clinicians.
“We have
expertise in analyzing data like this and thinking about organizational
problems, but we don’t have the firsthand experience and knowledge that doctors
have,” he said.
Hayes
said their statistical analysis went beyond what most doctors could even “conceptualize,”
but she and Bertakis expressed some concern over the study’s methods and
conclusions. The data, now eight years old, might miss the impact of recent
efforts to educate physicians and the public about gender differences in
cardiovascular disease.
Both
physicians also noted that the attending doctor used in the data analysis was
likely the physician that discharged the patient — or signed their death
certificate — which might not be the same doctor who treated the patient
in the emergency room.
Bertakis
took issue with the the study’s recommendation that one way to improve outcomes
would be to increase the number of female physicians in the emergency
department.
“These
approaches are not likely to be feasible,” she said. Instead, she would focus
on continuing to improve the curriculum in medical schools and in residency
programs to teach physicians about gender differences — both at the patient and
physician level — in cardiovascular care.
Hayes
would like future research to focus on understanding why male physicians who
work among more female doctors have better patient survival rates. “Where’s the
education coming from? Is it in the hallways and at the watercooler?” she
asked. “Or are there policy changes and practice changes?”
The new
study is a launchpad to address these questions, she said: “Understanding
differences in how we need to care for men and women — particularly with heart
disease, but for many other conditions — is something we should all be
teaching our medical students, and learning, and incorporating in our daily
practice.”
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