Roadblocks to rehabilitation? A question of gender.

This issue includes two articles that address the issue of access to rehabilitation services by women. The study by MeSweeney and Crane and the one by Missik investigated the participation of women in cardiac rehabilitation. Once again the relationship between access, cost, and quality is demonstrated. The results should cause all of us to pause. In the McSweeney and Crane study 65%, and in the Missik study 75%, of the women were either not offered cardiac rehabilitation or declined it. Many factors probably contributed to these rates of nonparticipation in cardiac rehabilitation. One of the most disturbing examples is that many of the women don't remember ever having cardiac rehabilitation discussed with them or, in one case, a woman reported that her physician would not order it even after she requested it. Recent literature has demonstrated the differences in acute treatment of myocardial infarctions in women and men, with men being treated far more aggressively. These studies suggest that those gender-based differences in treatment continue into the rehabilitation phase. Perhaps in the acute phase some of the differences in how men and women are treated can be explained by the fact that we have only recently realized that men and women may present with different symptoms. But how do we explain the differences after the diagnosis has been made? Another factor to consider is that with ever-shorter hospital stays for acute events, it is not uncommon for patients and families to forget much of what is discussed during the acute hospitalization. Access to rehabilitation services may be limited when patients and families are expected to follow up on information received while hospitalized, and there is no reminder or prompt by healthcare professionals after discharge. Although this is a very real effect of the decrease in lengths of stay, it is a factor that is not related to gender. Patients and families of both genders find themselves overwhelmed by events and the amount of information provided, and at risk for not getting the postdischarge healthcare services that are recommended. The world of insurance coverage has also become an obstacle to being referred to and receiving appropriate postacute healthcare services. It is impossible for any healthcare provider to be knowledgeable about all 'the intricacies of each patient's insurance coverage without contact with the insurance provider. The time and effort that may be needed to ascertain benefits and, when necessary, provide additional rationale for why certain services are needed must be a responsibility that we never shirk-even though we are too busy or the systems are too cumbersome to deal with as easily or efficiently as we would like. But this too is an issue that transcends gender. Nursing, as a profession that is still overwhelmingly female, needs to take a leadership role in protecting against gender discrimination in the care that is provided to women. Recent awareness of gender issues has brought increased research funding to the study of women's health issues and requirements for both genders to be included in research unless specificreasons not to are articulated. The results of those efforts will improve the health care provided to women in the future. For now we need to take an active role in making everyday decisions. We need to make time to advocate for the women who entrust us with their care. We need to recognize when we may be a part of the problem because we are providing the same care we always have in a healthcare system that is just beginning to recognize the injustices of the past by not recognizing the gender differences in the presentation and treatment of diseases. We need to be vigilant and recognize the discrimination that occurs so often that we don't even see it for what it is. The women we care for deserve no less.