Text: Bea Ros. This article was first published in Radboud Magazine #71. Photo: Bert Beelen
Right from the start, she was an active member of the National Network of Women Professors (“Yes, such an association is still necessary because there is still a macho culture in academia”). Monthly magazine Opzij named her most influential woman in the Netherlands in 2019, she is included in Eva Jinek's book on powerful women and she was a UN women's representative in 2020-2021. It's fair to say that women's matters are not unimportant to Angela Maas. Looking back on her career, Maas stretches the line ever further. From her involvement with the second feminist wave, as a student – “I was in all kinds of feminist talk groups, femsoc and suchlike” - right through to her work as a cardiologist with heart for women. “I wove that affinity with feminism into my work. I didn't intend to, really, but looking back now, it feels right. I recognise myself in it.”
Did male colleagues also regard you as a feminist?
"Well mostly, I was ridiculed: ‘Oh oh, poor women, always something to complain about’. I remember one cardiologist saying to me: ‘The word gender just makes me want to throw up’. And I thought: ‘You'd better get used to it and use it to your advantage’. Because cardiology is a global example of sex and gender mattering a great deal. For example, the conventional cycle test used to reveal cardiovascular diseases is pretty much useless when used for women. If you don't know that, you'll be quick to dismiss their symptoms as complaining.”
Did you do that too at the beginning?
She answers slightly guiltily: “Yes. I also said to women: ‘No, the symptoms you have don't indicate heart problems.’ I just said what I had learned and what the norm was. And then after a few years in practice, it begins to gnaw at you, but it's not true.”
What was the turning point for you?
“One patient got really angry: ‘You're just talking rubbish!’, and she was right. It doesn't feel right not knowing things and just saying something anyway. And even more so when you're the doctor they're supposed to be able to trust. Women came to us with symptoms and we just carried out the standard examinations. They were developed for white men and turned out not to be right for women. But we said that those women were wrong. We now know that women, in contrast to men, will be less likely to get constrictions in the coronary vessels but will more often experience vascular cramps. So they're not blockages, but functional disorders.”
At the beginning of 2022, you were one of the experts in the NPO television series ‘Reference Man’, about how the white male serves as a standard in numerous areas. Is that still the case in healthcare?
“Luckily, a lot has changed and we're learning more about how various diseases can manifest themselves in women and men. And yet, I still hear people say: ‘I don't really believe it.’ But it's not about belief, these are advanced scientific insights. Take for example symptoms that are not understood: 80 percent of them occur in women. That's because traditionally, the white male has been set as the standard. Take problems with the thyroid: 80 percent involves women. I sometimes ask endocrinologists why that is. ‘Well, we don't know’. But that's an extremely interesting and relevant question. What do men have which prevents them suffering thyroid problems and can we take away something from that to help women? It's precisely by looking at the differences that you can improve treatments. Fortunately, there is increasing awareness of this. I see, for example, that Bas Bloem [Professor of Neurological Motor Disorders, ed.] is doing good work with gender differences in Parkinson's disease. I asked him about that a couple of years ago and he said: 'Oh, I've never thought about that'. And now he's got several PhD students working on it.”
Wings
In 2003, Maas set up cardiology consulting hours for women, the first in the Netherlands, in the hospital in Zwolle. Initially, her male colleagues encouraged it: ‘We can send all the troublesome women to Maas’. “But as soon as it started to become a bit successful, they started throwing up obstacles. I had to learn to get over that in a good manner. At first, I was more angry and frustrated than anything else. I wanted to change everybody. But there's no point in beating a dead horse, it's better to manoeuvre around it. I've learned to search for the corners where there is energy and avoid the energy guzzlers.”
Just ten years later, in 2012, she was appointed the first Professor of Women's Cardiology. “The professorship gave me wings. Before that, I'd been just a voice in the wilderness. I was quite late with my doctorate, already fifty years old. In the end, I understood that if I was to be taken seriously, I had to go into science.”
What are you proud of?
“That we've been able to speed up the theme of women's cardiology and really book some progress. For example, it has now been incorporated into international guidelines that women who had high blood pressure during pregnancy must be monitored, because that can be an indication of a higher risk of cardiovascular disease later. In addition to gynaecologists, we are increasingly collaborating with oncologists because chemotherapy and radiation therapy in patients with breast cancer, for example, can cause an increased risk of cardiovascular disease in the short and longer term. And the last few years, we've been carrying out targeted research within Radboud university medical center into ways of diagnosing vascular cramps efficiently. We have an exemplary role in that in the Netherlands. So yes, I'm proud of that because ultimately, it's about better care for women.”
Mission accomplished?
“I acted as a lever, the person perhaps trying to force slightly undiplomatic things now and then. You don't get much done by only being nice and friendly. I'm very happy to see that others are now wholeheartedly taking the baton. I've been heard. That makes this a nice moment to leave the stage. At least, not entirely, since I will still be involved with working on such things as a specific kind of heart attack that occurs in young women. That's one of my babies that I still find hard to let go of.”
What is that about exactly?
“We're increasingly seeing heart attacks in women between forty and sixty that involve a tear in the coronary vessel. If you look more closely at that group, you see that it consists almost solely of highly educated women who are busy trying to keep all the balls in the air. They want to do everything well and tend to be perfectionists. And then suddenly, one Saturday evening while they're sitting quietly, bang! That blood vessel tears. I'm a member of a European group registering these cases and I now have a list of roughly 340 patients of whom 94 percent are women.”
Do you recognise yourself in that profile?
“To a certain extent, I do. But I have one favourable characteristic: I'm not a perfectionist. And that's precisely the bottleneck. I have patients who can't sleep properly if the cups in the cupboard don't have all the handles pointing in the same direction. Now, that makes your life difficult. Women need to learn to let go of things. With the children too. If my husband was looking after the children, I used to think: ‘How do they look?!’. Strange colour combinations, stains on their clothes. But I never mentioned it. Because let's be honest, how big a deal is that actually? So stop doing that and don't make things so difficult for yourself. I don't believe that I'm a likely subject for a burnout or heart attack. My blood pressure is slightly high, it runs in the family. Fortunately, with the right medication, you can still live a long life.”
What kinds of new developments can we expect?
“Something that concerns me is the growing group of transgenders. There are medical consequences. For example, a transgender woman has to take oestrogen her whole life and therefore runs a higher risk of thrombosis. That is essentially different to a cis woman who starts taking hormone supplements in her fifties because of menopause problems. She will have an increased risk of thrombosis in the first six months in particular. The risk of cardiovascular diseases is also greater in transgenders. We need to get more insight into that. We also need there to be much more collaboration between the various professional fields. We talk about decompartmentalisation but in practice, not much is changing. Even though it's really important. Take for example a woman who has had cardiac catheterisation and later gets breast cancer. How does that affect treatment and medication? For too long, each specialist has done a part of the treatment but the patient doesn't divide themselves into parts. You have to look at the whole person.”
Have you changed as a doctor throughout the years?
“Yes. And that has to do with holistic care. I used to say: ‘You need a new heart valve’. Nowadays, I also listen to what the patient wants. If someone says: ‘I've actually had a great life and don't really feel the need for that’, I think that's quite legitimate. I experienced it personally, with my father who suffered from dementia. He made his wishes quite clear: ‘I never want to go back to hospital’. I took him out of a hospital once, in the evening, with doctors shouting that I could never come back again. In his care home, they welcomed him wonderfully: ‘Mr Maas, we've got a nice snack for you’. That's quality of life. If the ground slips away from under your feet, you want a bit of love, warmth, conviviality and something nice to eat. Something I've always found difficult to accept is doctors who say: ‘There's nothing more I can do for you’. Even if you can't cure someone, you can always do something for them even if it's just listening. Being meaningful is you maturing as a doctor. Having the courage to push aside guidelines and really look: ‘What does this person need right now?’. And yes, of course you have to justify why you deviated from the guidelines. Guidelines are very important to good care but they mustn't become a straitjacket that makes us forget the person behind the patient.”
Last word
“Immerse yourself in things that you originally had an aversion to, such as the role of gender. It will increase your knowledge and then aversion can turn into pleasure. And you're never too old for that. Let's look further at how we can open up the boundaries between medical specialisms, so that we can provide people with better care.”