Bertakis_The-influence-of-gender-on-the-doctor-patient-interaction_2009
The in?uence of gender on the doctor–patient interaction§
Klea D.Bertakis*
Department of Family and Community Medicine,University of California at Davis,CA,USA
1.Introduction
The interaction between doctor and patient plays a crucial role
in healthcare delivery.As illustrated in Fig.1,the medical visit has a
central position in the process of care and has several inputs and
outcomes[1].We see that both the doctor and patient bring their
own sociodemographic characteristics,attitudes and beliefs,
expectations,and communication styles to the medical encounter.
The outcomes of a medical consultation include:the physician’s
knowledge of the patient’s problems and professional satisfaction;
utilization of healthcare resources;and the patient’s immediate
(change in concern,satisfaction with the visit,and recall of
information given),intermediate(adherence to recommenda-
tions),and long-term(change in health status)outcomes[2–23].
Gender is one of the many factors that impact the doctor–
patient interaction.This paper will discuss our research on the
in?uence of both physician and patient gender on the process of
care.In addition,the importance of physician–patient gender
dyads,both gender concordant and discordant,will be analyzed.
2.Methods
The majority of papers discussed here are based on a research
study in which509new adult patients were prospectively and
randomly assigned to family practice or internal medicine clinics at
a university medical center and followed for one year of care.The
medical visits were videotaped and physician practice styles were
characterized by the Davis Observation Code.Other patient
measures included sociodemographic information,self-reported
health status(Medical Outcomes Study,Short Form-36),patient
satisfaction,and utilization of healthcare services(and associated
charges).
3.Results
3.1.Physician gender
Interest in the impact of physician gender on the delivery of
healthcare has grown in parallel with the increasing number of
women in medicine.The percentage of women graduating from
Patient Education and Counseling76(2009)356–360
A R T I C L E I N F O
Article history:
Received9December2008
Received in revised form16July2009
Accepted17July2009
Keywords:
Physician gender
Patient gender
Doctor–patient communication
Patient satisfaction
A B S T R A C T
Objective:This paper discusses the research focused on gender issues in healthcare communication.
Methods:The majority of papers discussed here are based on a research study in which509new adult
patients were prospectively and randomly assigned to family practice or internal medicine clinics at a
university medical center and followed for one year of care.
Results:There are signi?cant differences in the practice style behaviors of female and male doctors.
Female doctors provide more preventive services and psychosocial counseling;male doctors spend more
time on technical practice behaviors,such as medical history taking and physical examination.The
patients of female doctors are more satis?ed,even after adjusting for patient characteristics and
physician practice style.
Female patients make more medical visits and have higher total annual medical charges;their visits
include more preventive services,less physical examination,and fewer discussions about tobacco,
alcohol and other substance abuse(controlling for health status and sociodemographic variables).
The examination of gender concordant and discordant doctor–patient dyads provides a unique
strategy for assessing the effect of gender on what takes place during the medical visit.
Conclusion:Doctor and patient gender can impact the physician–patient interaction and its outcomes.
Practice implications:The development of appropriate strategies for the implementation of knowledge
about physician and patient gender differences will be crucial for the delivery of high quality gender-
sensitive healthcare.
?2009Elsevier Ireland Ltd.All rights reserved.
§Our research was supported by a grant(R18HSO6167)from the Agency for
Healthcare Policy and Research,now known as the Agency for Healthcare Research
and Quality.
*Corresponding author at:Department of Family and Community Medicine,
School of Medicine,Center for Healthcare Policy and Research,University of
California at Davis,4860‘‘Y’’Street,Suite2300,Sacramento,CA95817,USA.
Tel.:+19167343167;fax:+19167345641.
E-mail address:kdbertakis@https://www.sodocs.net/doc/973582187.html,.
Contents lists available at ScienceDirect
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j o u r n a l h o m e p a g e:w w w.e l s e v i e r.c o m/l o c a t e/p a t e d u c o u
0738-3991/$–see front matter?2009Elsevier Ireland Ltd.All rights reserved.
doi:10.1016/j.pec.2009.07.022
medical schools in the United States increased from 5.5%to 49.3%between 1962and 2008[24].This growing population of female doctors magni?es the importance of evaluating whether physician gender in?uences patient care.It has been speculated that greater numbers of women providers may lead to a ‘‘feminization’’of the medical ?eld,resulting in a greater emphasis on humanistic care.
Female doctors devote more time to psychosocial counseling than male doctors,who spend more time on technical practice behaviors,such as medical history taking,physical examination and treatment planning [2].Female physicians also do signi?cantly more preventive services.In two separate studies,one using videotapes of medical visits at the Family Practice Clinic of the University of California [3],and the other analyzing a large national data set (the U.S.National Ambulatory Medical Care Survey)from 41,292adult patient visits with 1470primary care doctors [4],we found that the female doctors provide more preventive services,such as breast and pelvic examinations (p <.0001)[4].Since a larger number of young patients see female physicians,this may in part explain why female doctors are able to focus more on preventive care.The doctor’s gender may be relevant to preventive care,because it is easier to accomplish breast and cervical screening with gender concordance between a female doctor and a female patient.Female doctors may be more attentive to preventive care because of their perceptions of their own susceptibility to cancer.
We found that the patients of female doctors are signi?cantly more satis?ed than those of male physicians,even after adjusting for patient characteristics and physician practice style (p <.05)[3].These ?ndings suggest that patient satisfaction is in?uenced by physician gender,as well as physicians’behavior.There may be certain psychosocial and socio-emotional aspects of the interac-
tion that are not being measured by the analysis instrument used.Both male and female patients may have preconceived notions of female physicians,based on stereotypes,traditional role expecta-tions,or previous experience with other female providers.These may result in the patient responding to the physician based on these expectations.Moreover,the patients’expectations and subtle physician gender differences may reinforce one another during the course of the interaction.3.2.Patient gender
In the United States,about two-thirds of all clinic visits are made by female patients,who report having a signi?cantly lower health status than men.In a study examining gender differences in health service utilization over a one-year period,we found that women had a signi?cantly higher mean number of visits to their primary care clinic and diagnostic services than men.In addition,mean charges for primary care,specialty care,emergency treatment,diagnostic services,and total annual charges were all signi?cantly higher for women compared with men.Even after controlling for health status,sociodemographics,and clinic assignments,women still had higher medical charges for all categories of outpatient charges [5].
We have also explored the impact of gender in the care of depressed patients [6].We found that women having high Beck Depression Index (BDI)scores,re?ecting signi?cant depression,were more likely than men with similar scores to be diagnosed as depressed by their primary care physician (p =0.02).Female patients also had signi?cantly higher average depression scores and made more visits to their primary care clinic than men.Statistical analyses in our study revealed that gender had both
a
Fig.1.Doctor–patient interaction inputs and outcomes.
K.D.Bertakis /Patient Education and Counseling 76(2009)356–360357
direct(through high depression scores)and indirect(through increased visit rates)effect on the likelihood of being diagnosed as depressed.Patient BDI score,clinic use,educational level,and marital status were all signi?cantly related to the diagnosis of depression.However,even controlling for all of these other independent variables,women were72%more likely than men to be identi?ed as depressed.
In another study[7],we sought to further clarify issues regarding the in?uence of patient gender on what takes place during primary care visits,while controlling for important variables previously demonstrated to in?uence the doctor–patient interaction,such as the length of the therapeutic relationship (using only initial visits),physician gender,primary care clinic assignment(family practice versus general internal medicine), self-reported patient health status,global pain,depression,body mass index(BMI),age,education and income[8–16].The relationship between physician practice style and patient gender was explored using mixed effects regression models.Female patients had visits with a greater emphasis on preventive services (p=0.001),but had fewer discussions with physicians about addictive behaviors(such as abuse of alcohol and tobacco),than their male counterparts(p=0.01).It is also noteworthy that, compared with male patients,female patients had less of their visit time spent on physical examinations(p=0.01),despite controlling for physical health status and pain.The?nding that women had more preventive services during their?rst primary care visits,may partially result from the patients’gender-based health beliefs and health-seeking behavior,with women being more aware and desirous of preventive services such as pelvic and breast examinations.
Since the length of time for visits was not signi?cantly different for female compared to male patients,spending more time on pelvic and breast examinations may have precluded the physician from being able to perform more physical examinations on women.The?nding that female patients were signi?cantly less likely to have visits in which their tobacco use was discussed (despite having smoking rates similar to those of male patients) and had fewer discussions about their use of alcohol,may re?ect women being less comfortable than men in discussing their tobacco and alcohol use,perhaps believing that it is less socially acceptable for a women to smoke and drink alcohol.Another explanation may be that,given the higher general prevalence of males who smoke and drink alcohol,physicians differentially discuss these health risk behaviors more often with their male patients.Nevertheless,the fact that male and female patients are treated differently,despite other factors being equal,indicates that health providers may be making medical decisions based on gender-related considerations and stereotypes.
3.3.Physician–patient gender dyads
To fully assess the effects of doctor and patient gender,gender concordance(same-sex dyads)and gender discordance(opposite-sex dyads)should be examined.We have conducted a study of the in?uence of patient and physician gender,as well as gender concordance between patient and physician,on the‘‘patient-centeredness’’of primary care visits[17].Participating primary care physicians with clinical practices in the Rochester(New York) area,had two unannounced covertly audio-recorded standardized patients’visits.Encounters were analyzed using the Measure of Patient-Centered Communication(MPCC),which measures three components of physician communication:(1)Exploring Both the Disease and Illness Experience,(2)Understanding the Whole Person,(3)Finding Common https://www.sodocs.net/doc/973582187.html,pared with male patients,females had interactions characterized by greater patient-centered communication(Total and Component2scores,p=0.03and p=0.007,respectively).While female physicians exhibited higher Component1scores,male physicians had higher Component2scores.Gender concordant visits also exhibited higher Component2scores.However,there were no signi?cant differences in total MPCC scores for encounters of female versus male physicians or for gender concordant compared with gender discordant patient-physician dyads.
These?ndings provide evidence that there may be signi?cant differences between concordant and discordant dyads.Our?nding that gender-concordant visits exhibited higher scores on under-standing the whole person compared with gender-discordant visits may stem from same-sex dyads?nding this kind of discussion to be more comfortable.While higher scores on understanding the whole person are obtained by engaging in more super?cial inquiries regarding psychosocial issues(social chat)and fewer cutoffs of these topics,the highest scores are achieved by more extensive exploration of patients’substantial concerns about the psychosocial aspects of health and well-being and by the expression of empathy or validation.
4.Discussion and conclusion
4.1.Discussion
There is a growing body of literature examining how the gender of both doctors and patients affects medical care.Previous studies in this area have often suffered from methodological?aws,which limit their ability to provide de?nitive answers as to how gender impacts the process of care[18,19].Confounding variables such as the length of the therapeutic relationship and physician specialty, as well as patient sociodemographic characteristics,health status, and health risk behaviors,have not been controlled in the majority of these studies.While the elimination of confounders is necessary to explain causalities in epidemiological research,it is less straightforward in studies examining dynamic processes such as the doctor–patient interaction.Nonetheless,we have attempted to identify and control for variables in?uencing the process of care. Incorporating these factors in statistical analyses can help to reveal interesting,previously unseen relationships.
For example,one apparent difference between male and female doctors is the amount of time spent with patients.A review of the research literature regarding the effects of physician gender on communication during medical visits,reported that the length of the medical visit averaged23min for female physicians compared to21min for male physicians[18].Female doctors have also been found to spend more time with female patients than with male patients[19].The difference between male and female doctors in length of time spent with patients,however,may be associated with the gender distribution and health status of the patients seen. Women doctors tend to see more female patients[20];female patients report being less healthy[5]and have longer visits than male patients[18].A larger percentage of younger patients make their?rst appointments to see women doctors[20],and initial visits are signi?cantly longer than established patients’return visits[8].Contrary to prior reports,my colleagues and I found that the difference between male and female doctors in total time spent with patients is statistically insigni?cant,when patient gender and health status are controlled[2].
Although it has been possible for our research team to design studies which have measured and controlled for multiple physician and patient variables,videotaped and characterized physician practice style,calculated healthcare utilization,and assessed patient outcomes,our academic healthcare setting limits the generalizability of our research results.Both doctor and patient participants may not be representative of community clinical practices,and reproducing our study methods in other larger
K.D.Bertakis/Patient Education and Counseling76(2009)356–360 358
community-based sites might prove unrealistic.Moreover,exist-ing large clinical data sets,such as the U.S.National Ambulatory Medical Care Surveys and the Medical Expenditure Panel Survey, may not include measures of potential confounders that we have utilized.However,the results of our studies serve to identify relationships and associations that build upon the work of others and suggest areas for further research.
Good communication between doctors and patients is critical for the delivery of high quality medical care.Other researchers have reported differences in the way male and female physicians communicate with their patients.Studies examining the effect of gender on physician communication have reported that male physicians are more assertive,and give more advice and interpretation.On the other hand,female physicians have a greater likelihood of giving more subjective and objective information,more acknowledgment,and engaging in more positive talk,partnership building,and question asking.They also tend to smile and nod in agreement more often,inviting further communication[19-22],These differences may emanate from the different verbal and nonverbal communication styles that men and women display in general,with gender-linked communication differences in medical care resembling gender differences in other settings.Our?ndings support and expand these?ndings:female physicians were more likely to engage in counseling and in conversations about social and family issues,compared with male physicians who spend more time on the more technical aspects of care(medical history taking and physical examinations)[2].We also found that female physicians,compared with their male counterparts,explore both the disease and illness experience with the patient to a greater extent[17].In addition,we demonstrated that patients were more satis?ed with their interactions with female physicians[3].Future research evaluating practice style differences between male and female physicians should assess how these gender-based differences are related to other patient outcomes,such as health outcomes.While patient satisfaction is important,improved health is the ultimate measure of quality medical care.
Only a limited number of previous studies have examined differences in doctor–patient communication associated with patient gender.They have tended to?nd fewer differences than for physician gender.It has been reported that female patients have longer visits,ask more questions,get more information, receive more counseling,engage in more emotionally concerned statements,utter more positive statements,and appear more involved in the interaction than male patients[22].In our study, examining initial patient visits and controlling for physician gender and specialty,as well as patient sociodemographics,self-reported health status,pain,depression,and BMI,we did not observe that female patients had longer visits,asked more questions or received more counseling[7].In fact,female patients had fewer discussions with their physicians about their use of alcohol and tobacco.In another study,however,we did demon-strate that compared with males,female patients had interactions with their physicians that were more patient-centered[17]. Patient-centered visits may have characteristics which overlap with those previously reported[22].More research is needed to elucidate how and why health providers appear to be commu-nicating differently and making differential medical decisions based on patient gender.
Preliminary evidence has been found for the in?uence of physician–patient gender concordance on the process of medical care[4,19,23],With regard to communication differences in various physician–patient gender dyads,one group of investigators have found that male patients who see male physicians have less participatory visits compared with male patients who see female physicians,and compared with female patients seeing physicians of either gender[23].We found evidence for gender-concordant visits displaying one important component of patient-centered-ness[17].There is a need for more studies examining how gender concordance might contribute to the quality of communication between doctors and patients.
4.2.Conclusion
In conclusion,gender is one of many factors associated with what takes place during the medical visit,and it should be considered in studies examining the doctor–patient interaction.It is important to realize,however,that increased information about gender differences does not insure that medical education or clinical practice will change.Medical schools,residency training programs,and clinical delivery systems need to incorporate this information into strategies focused on improving the commu-nication between physicians and patients.
4.3.Practice implications
Gender is one of the numerous factors in?uencing the doctor–patient interaction.Healthcare organizations need to be aware that both physician and patients gender,as well as gender concordance, affect the delivery of medical services.The development of appropriate strategies for the implementation of knowledge about these gender differences will be crucial for the delivery of medical care that is both high quality and gender-sensitive.
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