Brad N Greenwood (Carlson School of Management, University of Minnesota-Twin Cities, Minneapolis, USA) and others report in Proceedings of the National Academy Sciences of the United States of America that female patients with acute myocardial infarction who are treated by a male physician have worse outcomes than female patients who are treated by female physicians. They add that this finding may be one explanation for why women historically have worse outcomes than men after a myocardial infarction.
The authors comment that, in the medical setting, “gender discordance”—when a physician treats a patient of a different gender to themselves—has been shown to result in lower rapport and patient satisfaction, reduced adherence to preventative care protocols, and weaker patient-physician communications. They add that, given that women are less likely to survive an acute myocardial infarction and that female physicians tend to outperform their male counterparts, “we posit that gender discordance between physician and patients helps to explain why female patients are less likely to survive acute myocardial infarctions”.
To explore this hypothesis, they reviewed outcome data for 581,79 patients admitted emergency departments (with an acute myocardial infarction) in Florida between 1990 and 2010. Greenwood et al comment: “Our decision to focus on emergency department admittances was deliberate, because it creates a discrete interaction between a patient and the attending physicians, allowing for a clear and immediate measure of success. In addition, when patients visit the emergency room, they have little agency over their choice of attending physician, allowing for a quasirandom assignment of physician and patient.”
Overall, the baseline mortality rate was 11.9% but this differed depending on the gender of the patient or physician. The authors report: “Female patients treated by male physicians were 1.52% less likely to survive than male patients treated by male physicians. This represents an about 12% decrease off the baseline mortality rate.” Furthermore, according to an unmatched sample, patients of any gender were more likely to survive when treated by a female physician. However, Greenwood et al state they also found that “male physicians are more effective at treating female acute myocardial infarction patients when they work with more female colleagues and when they have treated more female patients in the past”.
The authors claim that their results “suggest a reason why gender inequality in heart attack mortality persists”, noting “most physicians are male and male physicians appear to have trouble treating female patients”. As a potential solution to this issue, they recommend increasing the presence of female physicians within the emergency departments given the potential cost of the alternative—“male physicians learning on the job”—to female patients. Greenwood et al explain that mortality may decrease as male physicians treat more female patients but this “comes at the expense of earlier female patients”. They add their study “underscores the need to update the training that physicians receive to ensure that heart disease is not simply cast as a ‘male’ condition.”
Further research, the authors say, could focus on the “role played by residents, nurses, and other physicians who may be present or provide information to the supervising physicians”.
Greenwood told Cardiovascular News: “I think this study calls attention to the issue that the medical community has been grappling with, and making strides on, for a while: differences in patient presentation and making sure all patients get the care they need. I think what is critical to emphasise is the importance of understanding the diversity of the patient community and ensuring that the physician pool is diverse as well. The mechanism is particularly tricky in this setting, and we need to be careful here. Since it is a secondary data study, pinning down the exact mechanism is hard. There are several possible explanations. For example, gender concordance often facilitates communication between the patient and the physician, meaning that men might not be getting the signals they need from female patients. Alternatively, women may feel more comfortable advocating for themselves with a female physician. Further, since heart disease is often cast as ‘male’ condition, male physicians might not pick up on the atypical presentation symptoms women more often show (or at least not to the degree that female physicians do). But, like I mentioned, these are speculative and we need deeper work to dive in and figure out what is going on.”