Women need to go to rehab, but we say "no, no, no"

The APPROACH trial studied females who completed a 12-week cardiac-rehab program with a striking mortality reduction. Despite this unrefuted benefit of being "two-thirds less likely to die," women are still MIA. Interestingly, we benefit even more from cardiac rehab than our male counterparts who have the same diagnosis; however, some of us just thumb our noses at the notion, or even worse (well, maybe worse?), fewer of us are invited to attend.

Lack of participation in an organized cardiac-rehab program is puzzling, since there are so many quality-of-life improvement opportunities, notwithstanding the mortality benefit. When we choose not to attend we are turning down supervised exercise programs, access to heart-healthy recipes, tips on stress relief, weight management, smoking-cessation tools, and a fantastic opportunity to learn clinically relevant data about how to control the drivers of vascular disease that got us into trouble in the first place. I would be willing to bet that even compliance with the postdischarge medication regimen improves.

Perhaps our lack of attendance reflects how we are socialized as females in the US. I often hear this phrase applied to an RSVP for social function:

"Well, I got an invitation, but I didn't go . . . but it sure was nice to be invited."

Truth be known, I've said the same thing a hundred times, citing the old "I'm-just­-too-busy-this-week" excuse.

The reasons why we don't go to rehab are complex. I often compare the ability of women to get places on time with the ability of men to get places on time. Although my business partner can't defend himself in this comparison (yet he's fantastic to work with and sensitive to the issues of female vs male physicians), I think it makes a great comparison. When Jim goes to work, I suppose he gets up, rides his exercise bike for 30 to 60 minutes, eats breakfast, showers, and gets dressed. I don't begrudge it, but I suppose that's the whole of it most of the time.

When I get ready for work in the morning, it goes something like this:

I awaken without an alarm clock. I stumble toward my treadmill but realize there is laundry on the bathroom floor. I see a glass on the counter and I grab it along with the cup I left last night on the sink and balance the load of laundry in my hands, using all my digits to hang things on as I go through the house, first toward the kitchen and then the laundry room. I drop off the glasses and cups, still holding the load of laundry, dropping a few socks on the way, and realize I didn't boot my laptop. I stop at the couch, boot my laptop, and run to the laundry room. I start to put in the load of laundry only to realize there is still a load of laundry from yesterday, smelling slightly "mildew," but I ignore that, hoping the dryer will take out the smell. I exchange the load, start up the dryer and the washing machine, thinking I need to turn on the Keurig and then put the dishes in the sink, only to realize the washer is full of dishes from yesterday. I go to the kitchen, wipe down the countertops, fix a cup of coffee, empty the dishwasher and refill it, then go to the couch for 30 minutes. I do my theheart.org stuff, which I enjoy enormously—moderate the forum, read and write a little, all the while slurping my coffee. I then change out the laundry, get on the treadmill, walk 20 to 30 minutes, and do upper-body weights. I then eat yogurt, nuts, and fruit, and have a glass of water with fiber. I run toward the bathroom, turn on the bathwater, wash my face, do my Aveda beauty routine, do my makeup, and then get in the bath. The phone rings, it's my daughter or maybe both of our daughters; they have a crisis maybe, or just want to say hi! (And I always want to say hi!) I get in the bathtub, my mom calls, and I talk to her in the bathtub. Dad sat up in a chair all night and couldn't breathe. "Did he bump his Lasix?" I ask. Mom yells at dad, "Did you take your Lasix yesterday?" He can't hear. She yells at him again and finally he comes to the phone. We have the same conversation, "Did you take your Lasix?" I asked. "Yes," he says and finally hears me but asks, "Do you think I need to recheck my potassium?" Yes, I say as I get out of the bath . . . but the office is beeping in. The patient has come early and her INR is 5 and she passed blood into the toilet bowel. I tell my mom and dad, I have to hang up, I put the phone on speaker, balance my iron on the sink and finish getting dressed, but the office can't hear me well on speakerphone so I have to repeat everything until I can get sufficiently dry enough to pick up the phone and put it to my ear. I kiss my husband goodbye as he goes to work. He is a fantastic life partner I dated for six years and have been married to for 28 (I think but am never sure. I don't have time to remember how long we've been married), but by an unwritten agreement, my beloved's job is to take out the garbage, be luggage bearer for trips, do the yard, change out all lightbulbs, trim the shrubs, control the channel-changer (because I'm not paying attention to the TV anyway, I'm writing at night or reading), and  cook supper 99% of the time when we eat in.

(I know what you are thinking, so I'll answer it up front.) I have a housekeeper two days per week, but I like to do all these things every morning because it makes me a "real wife and mother." I think it validates my existence on this earth and it makes up for the things I don't take the time to do. So now I can relate to you women who read this blog. You are saying, "In the middle of all of this, you tell me that you want me to go to rehab?" I do get it. I really do, but more important, my job as a physician is to not just relate to your problems and hectic schedule as a woman, but to help you see how important it is to care for ourselves so we can continue to care for others.

As I listened to this presentation on women MIA for cardiac rehab, I heard the infamous words of the late Amy Winehouse and her rehab song, but a bit differently:

They tried to make me go to rehab but I said, "No, no, no!"
I ain't got the time, 'cause I really think I'm fine.
They tried to make me go to rehab but I say, "no, no, no"

But most of the time, we really aren't fine. We are the furthest thing from "fine." Until we change the attitudes of those who are mailing the invitations to include everyone of both genders with coronary artery events and procedures, we will still continue to lose more good women and men to preventable death. But before we point fingers, as women vital to our family, our friends, and our coworkers (and yes, even our patients), it's just as important to change what we do with that invitation to rehab if and when we ever get one.

Just one final thought:

Yes, you better go to rehab. You better go, go, go!"

Your comments

	Women need to go to rehab, but we say "no, no, no"
	# 1 of 19	March 12, 2013 06:50 (EDT)
	J R	Cardiac rehab was built for men. I was astounded that all the machinery available was built for men. Women could easily hurt themselves while in cardiac rehab. I know I did. Author's disclosure (Mar 12, 2013) I have no relevant disclosures to make in connection with this topic.
	# 2 of 19	March 13, 2013 10:50 (EDT)
	Melissa Walton-Shirley	JR My patients have both enjoyed and derived great benefit from rehab throughout the years. I have a treadmill, BowFlex, upper body weights and I've hurt myself on all of them at one time or the other. The challenge of cardiovascular fitness is the preservation of orthopedic intregity for all of our body parts. You just have to exercise caution, perhaps ask some questions from a qualified exercise physio and get back on that pony and ride! Author's disclosure (Mar 13, 2013) I have no relevant disclosures to make in connection with this topic.
	# 3 of 19	March 20, 2013 04:58 (EDT)
	william reichert	exercise exercise is dangerous. I ride a bike and in the past 7 years I have crashed 6 times. Face, leg, arm lacerations. My buddies break bones. Not infrequently enough someone is killed by a car,or falling off a bridge or mountain.I do have a very low LDL and high HDL, low insulin levels and low triglycerides; during prostate surgery recently my surgeon noticed I had the blood vessels of a 17 year old and NO intra abdominal fat/. It is a conundrum. I would say more but now I have to go ride my bike. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 4 of 19	March 20, 2013 10:14 (EDT)
	Melissa Walton-Shirley	Good for you! Enjoy your ride as often as you can!! Get back up and ride! Author's disclosure (Mar 13, 2013) I have no relevant disclosures to make in connection with this topic.
	# 5 of 19	March 22, 2013 11:06 (EDT)
	Susan Bonner	Awesome I have dedicated the greater part of my professional career (a heart nurse) encouraging EVERYONE to go to Cardiac Rehab. It's my favorite place in the entire hospital. Those that work in these departments are DEDICATED to the hearts of their patients. As it turns out, the patients often tell us it's the place they hate to leave because they discovered life doesn't stop with a diagnosis of heart disease. Is exercise the only emphasis...no (we are fortunate in our program to also have diabetic educator, dietitian, certified counselor and Pharm D to help patients). As one patient aptly described it...there's "magic" behind the treadmills. Please help both female and male patients embrace this service. We often hear...my doctor didn't tell me about Cardiac Rehab - my neighbor (family, co-worker, friend)did. Not everyone has such wonderful people in their lives to give that advice, but everyone with heart disease has talked to a doctor...at least once or twice. Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 6 of 19	March 22, 2013 11:39 (EDT)
	Wendy Janett	Pre-hab? Is there such a thing as cardiac "pre-hab"? I will need mitral valve and possibly aortic valve & aneurysm (Ao root) surgery soon and also have very significant orthopedic issues, including being s/p T3 - S1 spinal fusion and revision among other ortho & neuro issues. ( I have Marfan syndrome.) I assume that it would be optimal to be as conditioned as feasible going into the surgery for quicker recovery and best outcome, but I need guidance with respect to both CV and ortho limitations. I have been walking my dogs 30-40 minutes on most days, but I am uneasy about venturing out alone because I feel vulnerable to my myriad health issues, and I often can't drum up a walking buddy. I also love to swim, but have had a chronic long thoracic nerve injury since my spinal fusion revision which is aggravated by swimming strokes. Other than ordinary PT, are there supervised cardiac-based programs for people like me? If so, how do I get an invitation? Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 7 of 19	March 22, 2013 11:45 (EDT)
	Wendy Janett	Pre-hab? I apologize to the extent that my previous query crosses the line of asking for medical advice. More generally, is pre-surgical cardiac rehab available to patients? Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 8 of 19	March 22, 2013 12:40 (EDT)
	Chris Colenso-Dunne	Rehab is too late If we need to go to rehab then for most of us it's already too late. Humans need to understand that not all the damage we do to ourselves can be easily undone or repaired. Further, if we need to go to rehab then it's more likely than not because we lacked the good sense or education to take care of ourselves in the first place by eating and drinking sensibly and exercising enough. We're not going to turn over a new leaf and change the habits of a lifetime just because our doc says it's time. Leopards don't change their spots, and by and large a feckless fool is a feckless fool for life. Morbid obesity brings permanent changes to our biochemistry that can't be undone by waving a magic wand. Type 2 diabetes mellitus cannot be reversed. Prevention is one hundred times better than cure. We need to accept that we reap what we sow, that life is short, that there comes a time when the bill must be paid and all must come to an end. Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 9 of 19	March 23, 2013 12:47 (EDT)
	Melissa Walton-Shirley	Chris I disgree. Type 2 diabetes can be cured in many patients with normal weight/diet/exercise. The tendency to revert to glucose intolerance however is never gone forever. With weight gain and poor habits, it "magically" reappears. Author's disclosure (Mar 13, 2013) I have no relevant disclosures to make in connection with this topic.
	# 10 of 19	March 24, 2013 04:13 (EDT)
	D Hackam	"Type 2 diabetes mellitus cannot be reversed." I could not disagree more. SImilarly, hypertension, hypertriglyceridemia, metabolic syndrome and the syndrome of low HDL can all be cured through dietary intervention and normalization of insulin sensitivity (not through medications, which are a band-aid solution). Author's disclosure (Mar 24, 2013) I have no relevant disclosures to make in connection with this topic.
	# 11 of 19	March 25, 2013 11:27 (EDT)
	Susan Bonner	"Prehab" Actually, many Cardiac Rehab programs have self pay services that might fit your needs. Go to AACVPR website and see the program list for one in your area. It is NEVER too late for rehab - these programs can be life saving, I've seen it firsthand. Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 12 of 19	April 18, 2013 12:03 (EDT)
	Lynn Kelly	Very interesting observations, but question the suppositions I am a retired NP and a CAD/MI/CABG survivor and in my support groups with women, I find that VERY FEW of them are offered rehab! One of our main goals and purposes for supporting newly diagnosed/recovering women is to urge/no, INSIST that they request their cardiologists refer them for rehab! Most of them say it was never offered or mentioned! What's the disconnect here? I do love your column and read most of them! Author's disclosure (Apr 18, 2013) I have no relevant disclosures to make in connection with this topic.
	# 13 of 19	April 18, 2013 12:07 (EDT)
	Shannon Winakur	Amen! Amen, Melissa! I loved your post and plan to spread the word to my patients and colleagues. It is such a shame, but such a well-known phenomenon, that we don't take time for ourselves. Thank you again for sharing your experience and your wise words. Author's disclosure (Apr 18, 2013) I have no relevant disclosures to make in connection with this topic.
	# 14 of 19	April 18, 2013 01:11 (EDT)
	Laura Lowe	Thank you! I printed off your article and will be giving a copy to every feamile I visit in the hospital following their heart event. You article was very well put! I have worked in cardiac rehab 18 years. I push for women to come to rehab for years and have seen this disparity. For the comment about "leopards not changing their spots: check out "Wellcoaching" It has taught me to take off my "expert hat" and stop tell my patients what they need to do(it does not work), and now I know motivational interviewing and postive psychological to help people change "their spots". Kudos to all who work in cardiac rehabilitation and to the doctors, family memebers and friends who spread the word about this great service. Author's disclosure (Apr 18, 2013) I have no relevant disclosures to make in connection with this topic.
	# 15 of 19	April 18, 2013 01:23 (EDT)
	Kathryn Blanchard	Finally putting myself first I was suddenly hospitalized and dx. (out of town during Christmas vacation) with most probably viral cardiomyopathy and CHF. When I returned home and saw my new cardiologist, I had to ask about cardiac rehab. It was definitely an afterthought for him, but he was enthusiastic. I just completed 36 sessions (per my insurance) and I will start maintenance with them next week. I had an ejection fraction of 10%-20% and it was slow going at first, but I am on a treadmill at 3.6mph at a grade 13, and also on a rowing and elliptical machine. My EF in March was up to 30-35%. Obviously, I take my medication faithfully and strictly limit my sodium and fluids. There are probably twice the men vs. women in attendance which is ironic since more women are dying from heart disease than men at this point in time. Frankly, I decided to commit this time and energy to finally (after 60 years) to myself and health. It is long overdue and worth every bit of time and energy. Be sure to advocate for yourself - you deserve it! Author's disclosure (Apr 18, 2013) I have no relevant disclosures to make in connection with this topic.
	# 16 of 19	April 18, 2013 10:05 (EDT)
	Melissa Walton-Shirley	Good luck Kathryn! Good for you! Keep up the great work of getting healthy! Those who love you and those you love deserve to have you around for a good long time!!! Author's disclosure (Mar 13, 2013) I have no relevant disclosures to make in connection with this topic.
	# 17 of 19	April 18, 2013 10:06 (EDT)
	Melissa Walton-Shirley	Laura Thanks so much for reading! I'm always hopeful I can help someone somewhere every time I blog! Author's disclosure (Mar 13, 2013) I have no relevant disclosures to make in connection with this topic.
	# 18 of 19	May 3, 2013 09:38 (EDT)
	Lisa Rose	Thank You I did take the time to attend Cardiac Rehab after my double STEMI, a few months ago. My own Cardio did not recommend this but I insisted. I am home recuperating. I fell off the threadmill and tore my right meniscus and injured the coccyx. )-: I plan to return but 2 days a week but also attend the sit down lecturers. I am walking slowly but determined to beat this. Author's disclosure (May 3, 2013) I have no relevant disclosures to make in connection with this topic.
	# 19 of 19	May 5, 2013 09:18 (EDT)
	Melissa Walton-Shirley	Best Wishes Lisa! Hang in there!!! Hope things turn out great! Melissa Author's disclosure (Mar 13, 2013) I have no relevant disclosures to make in connection with this topic.

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