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.”