The Awareness-Practice Gap: Why Gender-Sensitive Cardiology Care Stalls at the Hospital Door

When a woman arrives at a hospital with a heart attack, her symptoms may not look like the textbook version. Chest pain remains the most common presentation in both sexes, but women are more likely to report pain between the shoulder blades, nausea or vomiting, and shortness of breath. Fatigue, pain in the arm, back, neck, or jaw, dizziness, and indigestion round out a symptom profile that has historically been judged against male-oriented diagnostic norms. The consequences of that mismatch are not abstract: symptoms that deviate from the male default increase the risk of delayed recognition and treatment in acute coronary syndromes. A new German study now suggests that the biggest obstacle to fixing this problem is not ignorance or indifference among clinicians, but something far more mundane and far harder to change: the structure of the hospital itself.

The research, published in Frontiers in Global Women’s Health, synthesizes findings from the HeartGap project, a health services research initiative funded by the German Innovation Fund of the Federal Joint Committee. It is an exploratory mixed-methods study that combined a scoping review of 117 articles with qualitative focus groups involving 41 physicians and 46 nurses, and nationwide surveys of 155 physicians, 111 nurses, and 390 cardiology inpatients. Gender sensitivity among healthcare professionals was measured using the validated Nijmegen Gender Awareness in Medicine Scale, or N-GAMS, while perceived implementation of gender-sensitive personalized care, abbreviated GSC+, was assessed alongside guideline-derived knowledge items. Patient perspectives were analyzed descriptively and with multivariate linear regression models, weighted by hospital care level and region to reflect the German hospital landscape.

The numbers reveal a paradox that the authors describe as a disconnect between attitudes and practice. Physicians scored highest on gender sensitivity, with a mean of 3.95 on the N-GAMS scale, compared with 3.46 among nurses. Yet when asked how extensively gender-sensitive care was actually implemented on their wards, physicians gave the most critical assessment, rating it at just 2.45 on a four-point scale. Nurses rated implementation at 2.91, and patients, remarkably, gave the most positive evaluation of all at 3.04. The group difference was statistically significant, and post-hoc analyses using Tukey’s HSD test confirmed that physicians differed significantly from both nurses and patients, while nurses and patients agreed closely with each other. In other words, the professionals with the greatest awareness of sex and gender differences in cardiovascular medicine were the least convinced that this awareness was translating into everyday care.

Higher gender sensitivity did not correspond with higher perceived implementation, a finding that held across the study components. Physicians demonstrated moderate to high guideline-based knowledge, correctly answering on average 63 percent of knowledge items on sex- and gender-specific aspects of cardiovascular guidelines. But item-level analysis exposed gaps precisely where clinical decisions hinge: sex-specific diagnostic thresholds and pharmacological differences. Multivariate analyses showed that working in a university hospital was associated with higher knowledge, yet no significant association emerged between gender sensitivity, knowledge, and perceived implementation. Awareness, it seems, is a necessary but insufficient condition for change.

The qualitative focus groups fleshed out why this gap persists. Physicians framed gender-sensitive care primarily in biomedical terms, associating it with sex-specific differences in disease prevalence, symptom presentation, and drug response. Atypical symptom presentation in women with acute coronary syndrome was the most frequently cited example. Social and communicative dimensions, such as interaction patterns, unconscious bias, or gendered expectations in clinical encounters, were mentioned less consistently and were not systematically integrated into clinical reasoning. Nurses, by contrast, described a practice-oriented and relational understanding of gender-sensitive care, encompassing communication, protection of privacy, same-sex care during intimate procedures, and sensitivity to emotional and psychosocial needs, along with intersecting factors like age, cultural background, religion, and language. Both groups reported that gender-sensitive differentiation was rarely formalized in institutional standards, documentation systems, or standard operating procedures, and was instead enacted intuitively, based on individual experience and situational discretion.

Structural barriers dominated the barrier analysis across all methods. Time pressure, staff shortages, high workload, and economic constraints were named repeatedly by physicians and nurses alike as the principal obstacles to consistent gender-sensitive care. The scoping review, which screened 23,508 articles and included 117 in content analysis, organized implementation measures into four interdependent dimensions: politics, research and science, education, and institutions of care. It found that political commitment, mandatory gender criteria in research funding, curricular integration, and organizational measures such as quality circles and diversity officers all facilitate implementation, while missing binding regulations, underrepresentation of women and gender-diverse populations in clinical studies, limited curricular space, and insufficient institutional accountability continue to hinder it. Sustainable implementation, the review concluded, depends on an overarching strategy linking all four dimensions rather than relying on individual commitment alone.

The patient survey adds a layer of nuance that complicates the picture. Of the 390 inpatients surveyed across 14 hospitals in six German federal states, 44.2 percent were women and the average age was 71.1 years. Patients evaluated gender-sensitive care positively and reported comparatively low additional needs. Same-sex nursing care, for instance, was rated as relatively unimportant on average, though women desired it significantly more than men. Women were also more satisfied with the trust and confidentiality of medical consultations. Regression analyses revealed that patients born in Germany reported a significantly lower need for gender-sensitive care than patients born elsewhere, and women reported a greater need than men, though the sociodemographic variables explained only 5 percent of the variance. The authors propose an expectation paradox: patients may evaluate visible and experiential aspects of care, such as trust, communication quality, and perceived attentiveness, while the biomedical, diagnostic, and structural components of gender-sensitive differentiation remain largely invisible to them. Implicit norms of equal treatment may further reinforce this pattern, since equal treatment is often perceived as fair even when relevant differences are not actively addressed.

Self-reported awareness of sex-related cardiovascular differences was unevenly distributed. Slightly more respondents, 62 percent, were aware that heart attack symptoms can differ between women and men, compared with 51 percent who knew that normal blood pressure values differ by sex. Women reported significantly greater awareness of myocardial infarction symptom differences than men, and 47 percent of respondents had encountered information about gender-sensitive care through television, radio, or magazines. Higher awareness was also associated with higher levels of school education. The authors caution that these items measured perceived awareness rather than objective cardiovascular knowledge, and that the accompanied survey format, in which researchers read questions aloud to inpatients recovering from cardiac events, may have encouraged socially desirable responses.

The study’s limitations are acknowledged candidly. The patient questionnaire used a single German-language item for sex and gender and did not separately assess sex assigned at birth and current gender identity, so the quantitative comparisons are restricted to women and men and cannot be generalized to gender-diverse populations. The survey period was extended due to recruitment difficulties, and the low internal reliability of the six-item needs index, with a Cronbach’s alpha of 0.512, means results involving it should be interpreted with caution in this exploratory context. The study also focused exclusively on inpatient cardiology; in specialties characterized by more intimate or long-term care relationships, such as gynecology, urology, or psychiatry, other dimensions of gender-sensitive care, including same-sex care and experiences of shame, may be perceived as more relevant and evaluated differently.

The central conclusion is unambiguous: organizational, structural, and systemic barriers, rather than negative attitudes or lack of awareness, are the relevant factors associated with implementation gaps in gender-sensitive cardiology care. The authors, an interdisciplinary team from Hannover Medical School, Figus Research Institute, the Institute for Gender Health, and University Hospital Magdeburg, distilled five recommendations for action with the help of a six-member expert advisory council. They call for strengthening the evidence base on sex- and gender-specific differences, systematically integrating gender sensitivity into clinical guidelines and nursing expert standards in visible and operational form, raising awareness among both the population and healthcare professionals, utilizing organizational structures such as documentation systems and quality management to embed gender-sensitive care into routines, and integrating gender-sensitive and intersectional perspectives into education and training across all healthcare professions. In cardiology, where sex and gender affect symptom recognition, diagnostic pathways, therapeutic decisions, and outcomes, insufficient implementation may have consequences that extend beyond fairness to directly impact care quality and patient safety. Gender-sensitive personalized care, the study argues, is not an optional supplement but a core element of quality, equity, and patient safety, and closing the gap between awareness and practice will require structural anchoring across research, education, policy, and healthcare organizations rather than individual initiative alone.

Subject of Research: Health

Article Title: Gender sensitivity and its implementation in inpatient cardiology: a mixed-methods study of patient and healthcare professional perspectives

Article References: Gender sensitivity and its implementation in inpatient cardiology: a mixed-methods study of patient and healthcare professional perspectives. (n.d.). https://doi.org/10.3389/fgwh.2026.1871546

Image Credits: AI Generated

DOI: 10.3389/fgwh.2026.1871546

Keywords: gender medicine, cardiology, health equity, implementation science, patient-centered care, Gender, sensitivity, implementation, inpatient, mixed-methods, patient, healthcare