The Patient Was…

What is it with women?

In case you are wondering where I am going with this deliberately broad, purposely vague, and perhaps a bit provocative question, remember that this is a blog about medicine and health care.

So, the question becomes what is happening with women and health care?

To some, there is a crisis. To others, there is no problem. To me, and hopefully more observers and participants, there are mostly opportunities for improvements. But the solutions, in my opinion, do not reside in the proposals being proffered for separate women’s health centers.

It is true that in some areas of medicine, women are underrepresented, underdiagnosed, undertreated, and under regarded. This is regrettable and unsustainable. But it is not unique to medicine, is it? And being “under-served” is certainly not unique to women, either.

Let’s call it bias. And let’s recognize that bias has been with us for a very long time, and has a horrible role in history, both ancient and modern.

Focusing on bias against women, it’s almost unbelievable now to acknowledge that not too long ago women could not own property, could not vote, could not serve on a jury, could not, in plain words, be a first-class citizen or member of society. Things in that regard are now infinitely better.

Perfect, no. Better, yes. (Chairman Mao, Mao Zedong, founder of The People’s Republic of China, said that women hold up half of the sky, meaning they have an equal role in society. One of the few things he got right.)

So, again, what’s going on with women in medicine and health care?

Are you surprised to learn that more than half of the students in U. S. medical schools are female? And are you aware that women have been in the majority of medical school enrollees for the past six years? So, not underrepresented in that instance.

Women now make up almost 40 percent of all active U. S. physicians and are in the majority in some areas of care. And women are entering the physician workforce at a much greater rate than are men. The pay gap between men and women for similar work is troubling, but it is not confined to the field of medicine. And while women hold fewer senior positions in medicine than men do, this is also apparently changing toward greater equality.

The greater, and perhaps more important, gender disparity in medicine is not in the area of health system “infrastructure”   —  including enrollment, employment, compensation, stature, responsibility  —  but in the area of health care delivery. And it is this disparity that is driving the notion of separate women’s health care centers, a bad idea in my view.

Let’s acknowledge the obvious: Men and women are different anatomically, hormonally, and as a consequence, physiologically. But in many ways, many more ways, in fact, men and women are similar in those same areas. The cardiovascular systems of men and women do have some differences, but they are minor in terms of structural and physiological commonalities. In large measure, women are subject to the same diseases as men, including coronary blood vessel blockages, valve abnormalities, heart rhythm disturbances, heart failure, congenital heart disease, and peripheral vascular disease (disease of blood vessels outside of the heart).

Cardiovascular disease is the leading cause of mortality among women, as it is in men. It causes more deaths in women than breast cancer, lung cancer and lung disease combined. For coronary heart disease, the leading killer in heart disease patients, the major risk factors of high cholesterol, high blood pressure, and smoking, are the same for both males and females.

Astute observers point out that women with the same conditions as men may present different symptoms. A woman having a heart attack may complain of fatigue or breathing difficulty rather than the classic chest pain more often seen in men with heart attacks. This is true and worrisome, because a critical diagnosis may be missed at the time. But is this a reason for separate women’s heart health centers, or is it a call for better education within a more integrated health care system?

While differences in some disease presentations and in responses to some treatments may differ among men and women, differences also exist among ethnic groups regardless of gender. It is known, for example, that Black patients may respond differently from white patients to certain cardiovascular medications. And studies show that standard recommended dosing of various cardiac medications should be changed for certain Asian populations.  Would we recommend separate heart centers for each of these groups?

It’s notable that the current edition of the prestigious European Heart Journal, the flagship publication of the esteemed European Society of Cardiology (ESC), publishes a detailed consensus statement of several specialty societies within the ESC dealing with the establishment of Women’s Heart Centres. The article does acknowledge, however briefly, the limited evidence supporting such an idea.

My view is that establishing separate centers for women’s heart health is not the proper solution to a real problem, The integration of medical care, as we learn more about the interrelationships of different body systems, is critical in my view. The development of sub-specialties within cardiology, such as Cardio-oncology and Cardio-obstetrics, is great because it occurs within the existing system of delivering cardiac care to patients. As knowledge accrues in all areas of medicine, including cardiology, and experience and expertise are closely shared, the care of all patients should be enhanced.

My mantra: Inform and educate. Integrate, don’t separate.