A Heartfelt Error

By Deborah Gardiner

"I have heard it be said that there are some 'cultural issues' that may prevent physicians from issuing the right diagnosis to non-whites. But what culture is that, the culture of racism?"

In May 1995, Zahman Ahmed*, a Silicon Valley tech worker was admitted into a Kaiser Clinic in Santa Clara, Calif. Although Ahmed was complaining of chest pains, the E.R. physicians told him that he looked too slim and healthy to be having a heart attack, denied him any sort of cardiac testing and sent him home.

But over the next six months, Ahmed, a 38-year-old Indian engineer, suffered from relentless chest pains when climbing stairs to his apartment, then again after intercourse with his wife. The Kaiser physicians repeatedly assured Ahmed that nothing was wrong and denied him treatment.

Finally in November 1995, Ahmed suffered a fatal heart attack, and an autopsy revealed that he had a single occlusion in one cardiac vessel. According to Robert Bokelman, a San Francisco lawyer who defended Ahmed's wife in arbitration against Kaiser, Ahmed's misdiagnosis and his death were avoidable.

"From that initial visit, Ahmed's complaint was something that could have been improved by angioplasty," said Bokelman. "He was an ideal candidate for heart surgery."

Unfortunately, Ahmed is not the only patient whose heart condition has been misdiagnosed.

A study published in the April 20^th New England Journal of Medicine, showed that of 1.7 million patients admitted to U.S. hospitals with heart attacks or unstable angina, emergency wards incorrectly send home 26,000 patients.

For Ahmed and other non-whites, the numbers are unfairly stacked against them. The study showed that 4.3 percent of blacks and 7 percent of women surveyed were incorrectly diagnosed compared with 1.7 percent of whites.

"You were more likely to be sent home or not hospitalized if you were non-white or a young woman," said Hector Pope M.D., a co-author of the study. "The study also showed that the risk of dying in 30 days doubled if they were sent home."

Though Pope and his colleagues are not the first to show that race and gender determine how physicians address patient's chest pain in U.S. emergency rooms, physicians appear generally alarmed by the results.

Ralph Watson, M.D., associate professor at the College of Human Medicine at Michigan State University explains that no one knows what's going on in a physician's mind. "We are talking about a doctor standing at the edge of a bed looking at a patient file and evaluating whether or not to give them a treatment".

Dr. Frank Stein, spokesman for the American Heart Association sounded equally as perplexed. "From a physicians standpoint, I don't think we fully understand all the dynamics of it."

One idea holds that women and African Americans are more likely than white men to be uninsured thus reducing their level of health care.

"This both lessens the likelihood that women and minorities have been screened for heart disease risk factors and that health care providers have a comprehensive medical history and background when the patient presents," said Brenda Romney, Director of the Black Women's Health Project, a community organization in New York.

Another interpretation is that the symptoms of a heart attack may present differently depending on gender and ethnicity.

Joe Betancourt, M.D., M.P.H., head of the Center for Multicultural and Minority Health in New York has found that the classic symptoms outlined in medical text-books refer to a white male population only. "Women's presentation of a heart attack may be more subtle and very specific to their gender," Betancourt said.

For example, women suffering from a heart attack often feel gastrointestinal burning or other less specific symptoms.

"With women, sometimes they only present fatigue, which is a very vague symptom," says Stein. "99% of the time, they won't have a heart attack but could have gastrointestinal problems, an ulcer or a viral infection."

However, from the point of view of Patricia Davidson, M.D., F.A.C.P., a cardiologist at the Washington Hospital Center and member of the American Association of Black Cardiologists, none of this addresses the issues of racial and sexual discrimination.

"I have heard it be said that there are some 'cultural issues' that may prevent physicians from issuing the right diagnosis to non-whites," said Davidson. "But what culture is that, the culture of racism? … You have to call a spade a spade."

Romney agreed saying that a patient's race, gender and socioeconomic status influence where and when they enter the health care system and, ultimately, how they are treated.

"Unfortunately, disparities in health and health care for minorities and African Americans are all too commonplace," said Romney. "We see them in many health concerns, not just heart attacks."

So what can be done to correct the dilemma?

Stein suggests that physicians increase their level of suspicion so that even with women's less obvious symptoms they can rule out the risk of a heart attack. Pope felt that there is room for improvement, saying that physicians must stop generalizing patients. "Even when it looks as though the risk is low, it's important to address that it is not zero."

But skeptics question whether an increased awareness of differing presentations are truly the core problem.

Davidson asserted that the health care system should address this alarming referral bias and acknowledge it as a form of racism. Romney agreed saying that disparities in health care for women and African Americans should be addressed as a nation-wide issue with community-based projects such as the Clinton Administration's REACH2010 project.

"We believe that this is exactly the kind of work we need to be doing so that 30 years from now, our grandchildren aren't still addressing the alarming disparity in cardiovascular disease and the misdiagnosis of heart attacks."

* Zahman Ahmed's name has been changed to ensure his wife's anonymity.

Deborah Gardiner is a freelance journalist from New Zealand based in San Francisco. If you have questions or comments, she can be reached at kiwichick@earthlink.net.

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