Welcome to Straight Talk on Health. I’m your host Dr. Chet Zelasko. Straight Talk on Health is recorded in conjunction with WGVU in Grand Rapids MI. I examine the world of health. Nutrition. Exercise. Diet. Supplementation. If there’s something new, I look at the science behind them, and let you know whether it’s real or not. You can check out other things that I do on my website Drchet.com and sign up for my free emails.
As you might imagine, I get asked a lot of questions. Most are related to diet and exercise questions but every once in a while, someone will ask a question that I think everyone could benefit from hearing. Such is the case when someone asked my opinion about a five-year-old article they happen to run across on women and heart attacks. This was a press release by the Harvard School of Business about a study one of their professors and her colleagues had written.
The title would attract anyone's attention. If you’re a woman, insist on having a female cardiologist. I read the press release. It made a compelling argument about why women may do better if treated by a female physician in the emergency room. I think that that's an important consideration in this question. The emergency room, or as it was called in this press release, the emergency department. That’s usually where people go when they believe they are having a heart attack.
Why is that a big deal? A person may not understand completely what they are feeling. Is it indigestion? Hiatal hernia? Gall bladder attack? The typical an “elephant is sitting on my chest symptom” may not be present during a myocardial infarction.in everyone, especially women. Instead of MI, I’m going to use heart attack as it’s more recognizable. We’ve known for decades that women may present with different symptoms when having a heart attack. I’ve known several women who were treated for anxiety instead of a heart attack. So far, I agreed with the premise. I’d heard the arguments about women delaying going to the ED and the presentation of symptoms that differ from those of men as I’ve already described. The statement that caught my attention was that male physicians learned by experience about women and HA. It wasn’t stated but the study implied that female physicians would be able to treat all patients better—and by better I mean that the mortality rate would be lower in all patients that presented to female physicians in ED with HA, male or female. I took the time to read the entire paper published in the journal. In that this was researched and written by three business experts, they used numbers. A lot.
Let’s take a look to see if they made their case. Here are my observations:
This was strictly a form of a cross-sectional study. There was no intervention of any type. It was simply a matter of examining medical records and determining the diagnosis upon admittance to the emergency departments of Florida hospitals for a period of 20 years from 1991 through 2010. The source of their data was the hospital Emergency Department data on HA reported to Florida’s Agency for Healthcare Administration. The records also contained the name of the attending physician. They used the name of the physician to determine gender. That sounds fuzzy but if the gender could not be identified, they did not use the data.
This was a statisticians dream and a scientist’s nightmare who doesn’t have enough training in advanced statistical analyses. I’ve had my share and it challenged me. It’s like determining what type of test to use to test body composition. Skinfold measurements appear easy but only when highly trained people use them. The impedance measurement is easy—just stand on a specific type of scale-- but the error of the method is high. I can interpret their findings but not whether they used the proper statistical techniques so for the sake of argument, let’s say they were appropriate.
What did they find? Pretty much what they expected to find. They used female physicians treating male patients as their criteria measure. Male physicians treating male patients matched the criteria measure. The predicted mortality improves when female physicians treated female patients. As expected, the predicted mortality decreases when male patients treated female patients. You may think “Why do the study?” I think the benefit comes from confirming observation with over 350,000 observations, the number of subjects in the study. That many data points are hard to argue with.
Yet, I will. My first issue is that there were no medical personnel that took part in the study. They were all economists or business related people. By all accounts, brilliant in their field. But they have never seen a patient, never been in an exam room, and maybe never observed what transpires in an actual ED. I typically criticize physicians that don’t include nutritionists in diet or supplement studies. This is similar.
I also have to comment on this observation they made.” Although mortality rates
for female patients treated by male physicians decrease as the male physician treats more female patients, this decrease may come at the expense of earlier female patients. Given the cost of male physicians’ learning on the job, it may be more effective to increase the presence of female physicians within the ED.”
Does that mean that female patients don’t learn on the job as well? They are “hatched” upon graduating from their cardiology residency and passing their boards as being complete? How many patients of both genders were not treated properly by female physicians as they learned on the job?” Just because they are as well-trained as their male counterparts doesn’t mean they won’t make mistakes as they learn on the job. That was about the poorest comment I’ve heard in a scientific journal. To be blunt, it speaks more to the authors inexperience at making observation that they didn’t test.
And about analyzing the data. Why didn’t they plot the data over years to see if the rate of better diagnosis and mortality improved? They had that data. They had the dates the physicians were licensed. They could have used experience as the variable to see how it impacted treatment. With over 300,000 patients over 20 years, they may have found some trends for better or worse in male physician treating female patients in the ED of Florida hospitals.
There are still physicians in both genders who have the God Complex and just won’t be questioned. And just because the cardiologist is a women doesn’t mean she automatically has empathy for female patients, has a great bed-side manner or is a great diagnostician.
There’s another factor they didn’t consider. Florida has for profit and not for profit hospitals. That’s something that really would be meaningful if they found a difference in the way patients in ED are treated in each type of hospital.
Having said all that I’ve said, I would generally agree with the premise when it comes to heart attacks, the symptoms can be different in women and that female physicians might be more amenable to responding to symptoms, even unusual ones. I think what we really want is someone with the patience to hear people out, someone who doesn’t make assumptions, and makes decisions on the patient before them. Be they female or male, and realizing that no matter how experienced, sometimes trial and error is the only way forward, that gives us the best chance of getting back to good health.
We have a responsibility in all this as well. To decide to request another physician if we feel we’re not being heard or understood. While having a heart attack is not the best time to make that choice, it’s something that has to be a part of this equation as well. Thanks for listening but we’re out of time. This is Dr. Chet Zelasko saying health is a choice. Choose wisely today and every day.
References:
1. https://www.hbs.edu/news/releases/Pages/laura-huang-heart-attack-female-physician.aspx
