How Does Gender Impact Medical Encounters?
June 2019 Issue
There is a riddle that goes something like this: A young man and his father were involved in a motor vehicle accident and both sustained serious injuries. They were rushed to separate hospitals so that the medical teams at each location could devote their full attention to each victim's care. The trauma surgeon walked into the emergency department to evaluate the younger patient and said, "I can't treat this boy—he's my son!" How is this possible?
I remember being completely confused when I first heard this riddle decades ago. Perhaps the father's injuries were not as serious as first believed, and through some elaborate miscommunication he ended up being the trauma surgeon on call for his son's emergency. A possibility made more likely in the decades since I first heard the riddle is that the boy has two fathers. The most likely explanation is that the trauma surgeon is the boy's mother.
In 2014, when researchers at Boston University (BU) told a similar riddle to hundreds of psychology students and children ages seven to 17 "only a small minority of subjects—15 percent of the children and 14 percent of the BU students—came up with the mom's-the-surgeon answer."1 That many other creative explanations were offered while the most obvious answer was overlooked is an example of a gender schema that assumes that physicians are male. Gender schemas are "generalizations that help us explain our complex world."1 These generalizations are powerful enough to overcome even our own experiences. It is common to encounter female physicians in clinical practice, and yet it's likely that the first time many O&P practitioners read this riddle, they will struggle to come up with the correct answer. This article reviews research that investigates how gender can affect medical encounters and patient satisfaction.
Physicians Talking to Patients
A meta-analysis by Roter et al., published in the Journal of the American Medical Association in 2002 investigated "Physician Gender Effects in Medical Communication."2 The researchers reported on 26 studies that investigated "an association between physician gender and at least one interpretable physician communication variable."2 The communication variables were grouped in categories as shown in Figure 1. For all variables other than the length of the visit, the use of eighteen different scales of measurement made combining and comparing data and results difficult.2 The authors used the means, standard deviations, frequencies or percentages, correlation coefficients, and other statistical data in each study to calculate the effect of the difference between male and female physicians.2
While many of the studies included in this meta-analysis had conflicting results, the general trends showed that where differences existed, the communication by female physicians was superior to that of male physicians. The authors report that "the pattern of results was almost entirely consistent with what one might expect from the nonmedical literature regarding gender differences in communication. Female physicians engage in communication that more broadly relates to the larger life context of patients' conditions by addressing psychosocial issues through related questioning and counseling, greater use of emotional talk, more positive talk, and more active enlistment of patient input. When taken together, these elements comprise a pattern that can broadly be considered ‘patient-centered' interviewing."2 These improvements in communication did not come at the expense of medical care, but instead seemed to improve it. "Physician gender was not related to provision of biomedical information, the manner in which the information was given, or the quality of the information that was given."2
One notable difference between female and male physicians was that female physicians spent two minutes longer per visit than the male physicians. This represents a 10 percent increase in visit time. While this may not seem like a large difference when considering O&P encounters, in the medical disciplines studied (internal medicine, family practice, general practice, pediatrics, and obstetrics/gynecology) this "increase represents a substantial burden, easily putting a female physician an hour behind her male colleagues at the end of a busy day."2 Time requirements for O&P clinical encounters vary greatly from case to case, and productivity is related to revenue generated per item delivered in addition to the number of patients seen each day. Even if a 10 percent increase in appointment times held true for female orthotists and prosthetists, it is unlikely that this would significantly impact productivity. It is also likely that the benefits of female clinicians' improved communications outweigh minor productivity losses incurred by spending more time with patients.
Patients Talking to Physicians
A meta-analysis published later that year by some of the same authors ("Do patients talk differently to male and female physicians? A meta-analytic review.") reported on seven observational studies investigating how patients talk to female and male physicians.3 The authors reasoned that since "there is evidence from non-clinical studies that people treat men and women differently in conversation" then "to the extent that male and female physicians communicate differently, one would expect reciprocal behavior patterns in patients."3 The categories of communication evaluated in this analysis were similar to those in the previous review. The authors found that "female physicians received more positive statements in all kinds of visits, but they received more talk overall, more biomedical and psychosocial information, and more partnership behaviors to a greater extent (or only) in routine medical visits as opposed to visits to obstetricians-gynecologists."3
Interestingly, two studies related to obstetrics-gynecology produced very different results: "Male obstetricians conducted longer visits and engaged in more dialogue than female obstetricians. They were more likely to check that they had understood the patient through paraphrase and interpretations, to use orientations to direct the patient through the visit, and to express concern and partnership than female physicians."3 That these studies involved only female patients may have impacted the results. However, one of the general medical practice studies reviewed in this same analysis also involved only female patients, and the results matched the studies of other general medical practices and not the studies of obstetric practices.3 One possibility for this result is that "patient preferences for female physicians has put male obstetricians at a competitive disadvantage, leading male physicians to ‘try harder' with their patients to establish a more patient-centered atmosphere than would otherwise be expected."3
Communication and Satisfaction
We may assume that improved communication by physicians is directly related to improved patient satisfaction. However, research identifies inconsistencies in how physicians are evaluated even when they communicate more effectively than other physicians. The one obstetrics study that assessed patient satisfaction in the meta-analyses mentioned earlier "found male obstetricians to be rated as less satisfying by their patients than their female counterparts, even after the explanatory power of particular communication variables for satisfaction were taken into account. These lowered satisfaction ratings…may suggest that prejudice and skepticism toward male obstetricians diminishes the positive impact of their actual performance."3 Inconsistency between improved communication and satisfaction ratings for male obstetricians matches that observed when investigating the interaction between female physicians and their patients in other medical disciplines.
A 2018 review article by Marianne Mast, PhD, a professor of organizational behavior, provides a thorough overview of "how female and male physicians' communication is perceived differently."4 The negative behaviors of female physicians appear to be scrutinized more and evaluated more negatively by patients. At the same time, "for female physicians, the patient-centered communication seems to be expected, thus normal and does, as a consequence, not deserve extra credit…. Because a more patient-centered communication style is a sign of relationship-orientation which is stereotypically associated more with women, female physicians showing this communication are simply behaving in a female fashion."4 Mast quotes Roter and Hall, authors of the meta-analyses mentioned earlier: "A patient-centered male doctor is seen as a good doctor, while a patient-centered female doctor is seen merely as a good woman."4
Mast bases her analysis on three theories that could explain differences in how female and male physicians are perceived (Figure 2). Unfortunately, while each theory offers insights, none of them fully explain the inconsistent results found when researchers evaluate physician gender and patient satisfaction. The gender schemas that inform patient perception of male and female physicians appear to be complex. "Female physicians are not evaluated more negatively than male physicians, but the behaviors used to assess female and male doctors differ, meaning that the same behavior does not mean the same thing for patients when it comes from a female or a male physician. This goes to show that perceivers use different information processing strategies when assessing female and male physicians. These are sometimes in line with existing gender stereotypes and sometimes not."4 While differences in patient perception appear to go beyond simple gender stereotypes, Mast concludes that "some research suggests that women are held to gender stereotypical standards more so than men."4
Application to O&P
The Henry J. Kaiser Family Foundation reports that in March 2019, 36 percent of physicians practicing in the United States were female.5 According to data from the American Board for Certification in Orthotics, Prosthetics & Pedorthics and the National Commission on Orthotic and Prosthetic Education published in the January 2019 issue of the O&P Almanac, approximately 15 percent of certified orthotists, 29 percent of certified prosthetists, and 26 percent of practitioners certified in both areas are female. The percentage of female practitioners doubled from 12 percent to 24 percent between 2004 and 2018. Female residents make up just under 50 percent of all current residents.6 Schools report that in recent cohorts more than half of the students have been female, so we can expect the percentage of female practitioners to grow. Educators, employers, and individual practitioners should be aware of how the changing gender profile of the profession may impact care and the day-to-day experience of providing it. Based on the research described above, the issue does not appear to be that female clinicians underperform male clinicians when it comes to communication, but that they face additional challenges in spite of generally higher performance in that regard. According to Mast, "when physicians want to increase patient satisfaction, female and male physicians will have to do very different things."4 It may be helpful for male physicians to receive training in verbal patient-centered communication, an area where female physicians appear to perform at a higher level. Since patient perception is improved when female physicians adhere to gender stereotypes for nonverbal behavior, it may be beneficial for them to adapt this behavior for different patients. Mast suggests that female physicians "train behavioral adaptability, meaning to develop their skills in correctly assessing their patients…and then to acquire a repertoire of corresponding nonverbal behaviors…."4
If we changed the riddle at the beginning of this article to involve a patient visiting an orthotist or prosthetist, many people may still picture a male clinician. Since gender schemas are often more powerful than our experience, simply working with more female clinicians may not be enough to change the perceptions of patients and coworkers. A conscious, thoughtful approach is required to become aware of and change our biases. Carefully considering how gender biases can complicate the work of female clinicians allows employers and the whole team to work together to overcome those challenges. Awareness of broad gender stereotypes can be a helpful starting point. Understanding the perspectives of individual patients and practitioners and the various challenges within each encounter will help us to adapt our approach and offer our colleagues the support they need to provide optimal care.
The authors of the analyses of gender effects in medical communication observed that "there is far more common ground than difference in the communication behaviors of male and female physicians…."2 They point out that the experience of male obstetricians suggests that "physicians are capable of modifying their communication style" and "there is ample evidence that instruction in communication skills is associated with improvement in skills, with some studies showing these improvements to be long-lasting."2 Let's work together to make our profession a supportive environment for all qualified clinicians, understand the unique challenges faced by female practitioners, and remove any unnecessary barriers to providing optimal care for our all of our patients.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
1. Boston University. BU Research: A Riddle Reveals Depth of Gender Bias, https://www.bu.edu/today/2014/bu-research-riddle-reveals-the-depth-of-gender-bias (accessed April 28, 2019).
2. Roter, D. L., J. A. Hall, and Y. Aoki. 2002. Physician gender effects in medical communication: a meta-analytic review. JAMA 288(6):756-64.
3. Hall, J. A., and D. L. Roter. 2002. Do patients talk differently to male and female physicians? A meta-analytic review. Patient Education and Counseling 48(3):217-24.
4. Mast, M. S., and K. K. Kadji. 2018. How female and male physicians' communication is perceived differently. Patient Education and Counseling 101(9):1697-701.
5. Henry J. Kaiser Family Foundation. Professionally Active Physicians by Gender, https://www.kff.org/other/state-indicator/physicians-by-gender/ (accessed May 2, 2019)