Women With Acute MI More Likely to Survive If Treated by Female Physicians

Women suffering a myocardial infarction have the best chance of surviving if they are treated by a female physician as opposed to a male physician, according to a provocative new study. Moreover, male doctors who have treated more women, or who have more female physicians as colleagues, also appear to be “more effective” at treating female MI patients, its authors conclude.

“These results suggest a reason why gender inequality in heart attack mortality persists: most physicians are male, and male physicians appear to have trouble treating female patients,” the authors, led by Brad N. Greenwood, PhD (University of Minnesota–Twin Cities, Minneapolis), write in the Proceedings of the National Academy of Sciences this week.

“There are clearly some differences that we’re observing in how male cardiologists treat female patients, as compared with their female counterparts, and there are clearly differences in how female patients present symptoms,” senior author Laura Huang, PhD (Harvard University, Boston), told TCTMD. “Since we also find that the effect is mitigated when male physicians have more female colleagues, and the same when male physicians have treated more female patients, it does suggest that with increased exposure there is something . . . that physicians are able to pick up that helps them be more effective in treating women.”

Nisha Jhalani, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), who was not involved in the study, said that the research reflects “what I’ve seen to be true in real practice.”

She pointed out that women are “drastically undertreated” for major cardiovascular risk factors and less aggressively managed following a myocardial infarction. “I find that women cardiologists understand female patients better and are more equipped to guide them through life after a heart attack, both emotionally and medically,” Jhalani said in an email. “Many of my female patients are very reluctant to start medications—needing a clear reason before agreeing to take a daily pill or pills. It takes a lot of time and a skill set that is more natural for female physicians."

Also commenting on the study for TCTMD, Wayne Batchelor, MD (Southern Medical Group, Tallahassee, FL), said, “The study results aren't entirely surprising, but they are definitely thought-provoking.”

That said, he continued, the findings don’t necessarily support a cause-and-effect relationship. “There's a whole lot that goes on between a patient and a physician that could theoretically impact outcome, including how physicians listen to patients, how much time they spend with patients, how seriously they take obscure symptoms, and how much of a delay there is in care. All these things could be potentially influenced by the gender, race, culture, language spoken by the patient versus the physician, and how much concordance there is.”

Surviving While Female

Previous studies have shown that women are less likely to survive an acute MI than men, with delays to seeking treatment, uncommon symptoms, and more challenging diagnoses often pegged as the chief underlying causes. Huang and colleagues, however, point to a body of evidence showing that gender “discordance”—where men are in the position of advocating for women—has led to worse outcomes for women in other scenarios such as pay equity, ascension to leadership positions, legal disputes, and educational outcomes.

For their study, Greenwood et al looked at the impact of gender mismatch between patients and physicians among the more than half a million acute MI patients presenting to Florida hospitals between 1991 and 2010, then looked at survival according to the gender of the treating physician.

Baseline mortality rate for the entire cohort was 11.9%, the authors report. When patients were treated by physicians of the same gender, the probability of death was reduced by 5.4% relative to the baseline rate. Female patients being treated by male physicians, however, were 1.52% less likely to survive than men treated by female physicians, representing a roughly 12% decrease off the baseline rate of 11.9%.

The reality is that patients cannot simply demand to be seen by female physicians when they are admitted to the ER, especially for something like a heart attack. Laura Huang

In an analysis that looked at the gender mix among the physicians seeing acute MI patients at a given hospital, the survival of female patients being treated by male physicians was higher when a greater number of female physicians were also working at that same hospital. Yet another analysis calculated the number of female patients a male physician had treated in the past. Here, women suffering an acute MI were more likely to survive if their doctor had treated a higher number of female MI patients in the past.

“This is something that is particularly troubling,” Huang told TCTMD in an email. “Male physicians indeed perform better when they have treated more women—but at what cost. What is the cost to all those women who have been treated along the way, during this learning process?

A press release accompanying the publication of the PNAS paper, as well as some of its considerable lay press coverage, has offered this advice: “if you are a woman having a heart attack, insist on a female physician.”

Both Huang and Batchelor warned against this interpretation.

“I think that is one perspective that people have taken, but the reality is that patients cannot simply demand to be seen by female physicians when they are admitted to the ER, especially for something like a heart attack,” Huang said. “We show that gender concordance is an important consideration and is one factor in explaining differences in mortality rates for AMIs, but this is not something that should necessarily be used to describe widespread treatment and care options.” She continued: “I think bringing awareness to this issue is a good thing in general, though with things like this, there is always the risk that some of the findings become sensationalized.”

Indeed, the idea of holding out for a female physician holds potential for harm, Batchelor warned. “My gut feeling is that probably there is something that we're seeing with this data, but I would be very cautious, if I were a patient, to demand that the sex of the physician who I see is concordant with my sex without taking into account the quality of the hospital, the quality of the physician, and all the other factors that we know overwhelmingly determine outcome, especially delays in care.”

If there are these differences that are based on gender you can only imagine—and it has been shown—that there are also differences based on race, culture, and ethnicity. Wayne Batchelor

Batchelor urged “delving deeper” into the possible mechanisms underpinning the survival differences—which he stressed were small—as well as additional studies aimed at replicating the results. In the meantime, he said, the study could be seen as “a call to action to stakeholders involved in medical education to ensure that we are turning out adequate numbers of female physicians in all specialties.”

Jhalani took a similar position: “So many systems that are in place focus on care that has been proven through research predominantly done in men. Leaders in the field of cardiology—both men and women—need to promote the growth of women cardiologists with a passion and expertise in caring for other women.”

Indeed, cardiology generally, and interventional cardiology in particular, has an "embarrassing" track record for attracting women to the specialty, Batchelor said.

“Emergency medicine has probably done a far better job than interventional cardiology in training women,” he pointed out. “We know that only 4% of interventional cardiologists are female across the United States and only 3% of coronary interventions are done by women. It's abysmal.” Both Batchelor and Huang pointed to other research suggesting that the patients of female physicians are more likely to survive than patients seen by male doctors—another reason to try to boost the number of women in areas of medicine with the greatest gender disparities.

“The reality is, we are doing a disservice not only to women but to men, too,” said Batchelor.

That said, gender concordance is only one aspect of the equation, he added. “We're just scratching the surface here. If there are these differences that are based on gender you can only imagine—and it has been shown—that there are also differences based on race, culture, and ethnicity.”

While training a generation of physicians that perfectly mirrors the populations they treat is not a reasonable goal, understanding the value of concordance is a first step, he continued. “We have to recognize that this is real and make an effort to educate our young physicians about these potential biases. Knowledge is power and I have a feeling that if male physicians took this to heart in the way we address female patients who come in with obscure symptoms, maybe there'd be a little more time taken to distill the nature of those symptoms, make more sense of them, and not just sort of brush them off.”