Survival Improved for Female Patients With MI Treated by Female Docs

Batya Swift Yasgur, MA, LSW

August 14, 2018

Women who have a myocardial infarction (MI) are more likely to survive when treated by female rather than male emergency department (ED) physicians, new research suggests.

Investigators analyzed data of close to 600,000 patients who were admitted to Florida EDs between 1991 and 2010 with an MI, comparing the patients' outcomes and survival rates when attended to by a male or female ED physician.

Gender concordance lowered the probability of death by 5.4% relative to the baseline mortality rate in the study sample. Moreover, women treated by male physicians were the least likely to survive the MI compared with patients of both sexes treated by female physicians or men treated by male physicians.

"I think this paper 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," Brad Greenwood, PhD, MBA, associate professor, information & decision sciences, University of Minnesota, Carlson School of Management, Minneapolis, told | Medscape Cardiology.

"I think what's critical to emphasize is the importance of understanding the diversity of the patient community and ensuring that the physician pool is diverse as well," he said.

The study was published online August 6 in Proceedings of the National Academy of Sciences of the United States of America.

Advocacy Concordance

Previous research suggests that gender discordance "may yield to lower rapport and patient satisfaction, reduced adherence to preventive care protocols, and weaker patient-physician communication," the authors write.

Researchers have also observed that female physicians "outperform their male counterparts" in mortality rates and hospital readmissions, even after accounting for potential confounders.

"There has been growing work in medicine suggesting both that women are more skilled physicians across a variety of ailments and that female patients are particularly challenging when it comes to heart attacks for a variety of reasons, ranging from delays in seeking treatment to atypical presentation," Greenwood observed.

"When coupling this with the deep literature in economics, sociology, and political science suggesting that advocatees experience better outcomes when they share traits with their advocates, it seemed plausible that an effect would manifest, so we dove in" to investigating this question in the medical setting, he said.

To investigate the impact of gender match between patients and physicians during an acute myocardial infarction (AMI), the researchers used data on ED admissions of patients to Florida hospitals between 1990 and 2010 (n = 581,797), drawn from the Florida Agency for Healthcare Administration database.

Florida was chosen because it is a "large and economically diverse state," with almost 20 million residents and more than 1.3 million heart attacks over the course of the sample, they note.

They focused on ED admissions because "it creates a discrete interaction between a patient and the attending physician, allowing for a clear and immediate measure of success (i.e., patient survival)," the authors explain.

The data provided information about the patient (eg, comorbidities, age, and gender), as well as the name of the physician, which was used to infer the gender of the physician. Gender-ambiguous names were excluded from the analysis.

The researchers included a "robust set of controls," including age- and race-fixed effects, to "account for the fact that heart attacks and heart attack survival occur with different frequency among some sub-populations (eg, African Americans or the elderly)."

Hard to Pin Down

The researchers found a "robust" and "significant and positive effect of shared physician-patient gender on survival (P < .01).

The baseline mortality rate was 11.9%, and the estimated coefficient of gender concordance implied that gender concordance reduced the probably of death by 5.6%, relative to this baseline.

Female patients treated by male physicians were least likely to survive an episode of care, and patients treated by female physicians were, in the unmatched sample, more likely to survive, regardless of patient gender.

Female patients treated by male physicians were 1.52% less likely to survive than male patients treated by female physicians (P < .01). 

Survival rates were two to three 3 times higher for female patients being treated by female physicians than for female patients treated by male physicians (P < .01).

This finding held true when physician fixed effects were included in the matched sample.

To further validate their findings, the researchers used length of hospital stay as an alternate dependent variable. They found that patients remained in the hospital for less time when treated by physicians who shared their gender.

Female patients were found to have better outcomes in EDs with a higher percentage of female physicians — a relationship that was particularly true for patients treated by male physicians, although female patients also experienced better outcomes from female physicians in EDs with a higher density of female physicians.

In fact, female patients treated in EDs with 5% more female physicians were 0.4% more likely to survive. Compared with the baseline mortality rate, this represents an increased survival rate of almost 3.5%.

These results remained whether the calculation included the raw number or the percentage of female colleagues.

Patient treatment history played a role in survival rates: Female patients treated by male physicians experienced a 0.02% increase in survival for each female patient treated by the physician in the prior quarter, an increase of 0.16% over the baseline mortality rate.

However, there was no change in female survival when a female physician had seen more female patients.

The researchers describe their findings as "a distinct asymmetry in AMI mortality, based on physician–patient gender concordance."

Additionally, male physicians were found to be more effective at treating female patients with AMI when they worked with more female patients and when they had treated more female patents in the past.

Greenwood cautioned that it is "hard to pin down the exact mechanism" for the relationship between survival rates and gender and that potential explanations are "speculative."

"Gender concordance often facilitates communication between patient and physician, meaning that men might not be getting the signals they need [to treat female patients]," he suggested.

"Alternatively, women may feel more comfortable advocating for themselves with a female physician," he continued.

Since "heart disease is often seen as a 'male' condition, male physicians might not pick up on the atypical presentation symptoms that women more often show — or at least not to the degree that female physicians do," he speculated.

Clinical Secrets

Commenting on the study for | Medscape Cardiology, Nieca Goldberg, MD, medical director, Joan H. Tisch Center for Women's Health, NYU Langone Medical Center, and clinical associate professor, NYU School of Medicine, New York City, called the findings "interesting and informative."

"We're talking about a disease where we know oftentimes women are missed and underdiagnosed," she said.

She noted that information regarding the exact mechanism of the findings is lacking, including "what the patients with various outcomes were thinking about healthcare, whether the female doctors were more empathetic, listened more carefully to symptoms, or were able to convince patients to go for further testing."

The study accords with her own clinical experience, she said.

"When I ask [my female patients] what brings them to me for treatment, often they say they're seeking the care of a female cardiologist because they think male doctors don't take the symptoms as seriously."

She suggested that to "improve cardiac care for all patients, it would be important for us to understand the clinical secrets that lead women to sometimes gravitate to female doctors, and these improved outcomes."

Greenwood added, "increasing the presence of women and minorities as colleagues and increasing the diversity of perspectives — for example, by treating more than just the prototypical male patient — during medical education and continuing education, and increasing the diversity of patients entering the knowledge-generating process of medical trials and the like, can contribute to helping every patient to get the care they need."

Greenwood and coauthors and Goldberg have disclosed no relevant financial relationships.

Proc Natl Acad Sci U S A. Published online August 6, 2018. Abstract

For more Medscape Neurology news, join us on Facebook and Twitter


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.