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Gender differences in health care provider–patient communication: are they due to style, stereotypes, or accommodation?
Patient Education and Counseling 48 (2002) 201–206
Gender differences in health care provider–patient communication: are they due to style, stereotypes, or accommodation? Richard L. Street Jr.* Department of Speech Communication, Texas A&M University, College Station, TX 77843-4234, USA
Abstract This article examines gender differences in health care provider–patient communication within the framework of an ecological model of communication in the medical encounter. The ecological perspective posits that, although health care provider–patient interactions are situated within a number of contexts (e.g. organizational, political, cultural), the interpersonal domain is the primary context within which these interactions unfold. Hence, gender may influence provider–patient interaction to the extent that it can be linked to the interactants’ goals, skills, perceptions, emotions, and the way the participants adapt to their partner’s communication. The evidence reviewed in this essay indicates that gender differences in medical encounters may come from several sources including differences in men’s and women’s communicative styles, perceptions of their partners, and in the way they accommodate their partner’s behavior during the interaction. However, because gender is but one of many personal and partner variables (e.g. age, ethnicity, personal experiences) that can influence these processes, gender differences are often quite modest (if apparent at all) when examined across a population of health care providers and patients. Implications for future research and communicative skill training are discussed. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Physician–patient communication; Gender differences; Communication skill training
1. Introduction Gender has been identified as one source of systematic variation in medical encounters. As will be discussed later, a number of studies have found that, as health care providers, women and men differ in the way they communicate with their patients. While differences between male and female patients are less clear-cut, some research does show that patients, regardless of sex, often vary their responses depending on the clinician’s gender. Because provider–patient communication can have a significant impact on outcomes following the consultation (e.g. satisfaction, adherence, health improvement) [1–3], the possibility that the participants’ gender may influence the structure and content of the consultation becomes a question of considerable importance. How do we make sense of gender differences in medical encounters? One problem with previous research is that gender typically is studied as an individual difference variable and not as a construct grounded in a conceptual framework to explain why these differences exist [4]. In this essay, I analyze these findings from the perspective of an ecological model of communication in medical consultations. At * Tel.: þ1-979-845-0209; fax: þ1-979-845-6594. E-mail address: [email protected] (R.L. Street Jr.).
the heart of the model is the idea that individual differences cannot be examined in isolation of other variables or processes that also account for communicative action. I conclude with a discussion of the implications of this analysis for future research and communication skills training.
2. An ecological model of communication in medical encounters 2.1. Overview Fig. 1 presents an ecological model of communication in medical encounters [5]. Two features of the model are important for the purposes of this chapter. First, medical encounters occur in context. Thus, the way in which health care providers and patients communicate with one another may in part depend on the type of health care organization (e.g. managed care, fee-for-service), political and legal issues (experience with malpractice, patients’ bill of rights), use of and exposure to media (the Internet, direct-to-consumer-marketing of medical products), economic factors (e.g. insurance, income), and culture (ethnicity, religion). However, while any of these contexts may have some impact on medical encounters, the one within which these
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Fig. 1. An ecological model of communication in medical encounters.
interactions are most fundamentally embedded is the interpersonal context. In other words, what unfolds during the encounter ultimately depends on the interactants’ goals, skills, perceptions, and emotions as well as on the constraints and opportunities created by the actions of their partners [5,6]. As depicted in the model, most people have developed a particular style of communicating (e.g. assertive, friendly, reserved, expressive) that they use across a wide variety of situations [7]. Differences in communication style have been attributed to a number of factors including personality, identity, socialization, and linguistic skill (for a review, see [8]). However, one’s communicative style also serves a pragmatic function in that it represents a set of responses that are readily available and appropriate for communicating across various situations [5]. For example, because health care providers have many consultations involving similar health issues, it is not surprising that many clinicians have developed their own styles of communicating with patients. Roter et al. [9] recently observed that, although doctors generally exhibited more than one pattern of communication (e.g. narrowly biomedical, psychosocial, biopsychosocial), many relied on a particular style for most of their visits. In the ecological model, communication style reflects one’s predisposition to communicate in a certain way (see Fig. 1). Second, regardless of one’s typical style of communicating, interactants also adapt their responses given situation-
specific considerations. The ecological model identifies two sources of adaptive behavior. Cognitive-affective factors account for adaptation based on strategic (e.g. goals, purpose), attributional (e.g. stereotypes, impressions), and relational (e.g. trust, familiarity) considerations. For example, a health care provider typically may have a friendly, expressive style when interacting with patients, yet he or she may become more animated when talking to a child during a check-up or considerably more sedate and serious when informing a patient of a life-threatening disease. Communicative adaptations also occur in response to a partner’s communicative actions. To have a coherent and successful interaction, communicators must cooperate and coordinate their responses. Thus, any one interactant has the potential to exert considerable influence over the other. For example, a patient who expresses concern about treatment alerts the doctor to his or her needs and preferences, information that the doctor can use to modify the therapeutic plan. Moreover, given normative expectations for utterances to be topically connected [10,11], a clinician may feel obligated to answer a patient’s question or spend time talking about a topic raised by the patient [3,12]. This explains why physicians generally will provide more information, support, and reassurance [6,12,13] when they interact with patients who ask questions, offer opinions, and express concerns. Likewise, a health care provider who uses
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partnership-building (e.g. asks for the patient’s opinion, solicits the patient’s concerns) and other types of patientcentered responses (e.g. encouragement, reassurance) generally elicits greater patient involvement in the encounter [6,12,14,15] whereas a clinician who frequently interrupts, asks close-ended questions, and issues directives stifles patient participation. 2.2. The interplay of style, perception, and partner’s communication Thus far, these processes have been discussed as though they operate independently of one another. They do not, of course. Street [6] has tried to systematically sort out the unique contributions of several personal and partner influences on patterns of physician–patient communication. In a study of 7 physicians who interacted with 115 patients, he found that doctors gave more information and offered more support and encouragement to patients who asked questions and expressed concerns. However, independent of the patient’s behavior, additional variation in the degree to which physicians engaged in partnership-building was related to the patient’s education (see also [16]). Finally, even when controlling for the patients’ socio-demographic characteristics and behavior, the communication styles of individual doctors still differed with respect to informationgiving, partnership-building, issuing directives, and affective communication. Regarding the patients’ communication, Street [6] reported that patients did not talk differently to individual doctors per se, but they did ask more questions and offer more opinions when their physician engaged in partnershipbuilding. In addition, patients’ communication was uniquely related to their level of education and worry. More educated patients asked more questions and offered more opinions, and more worried parents expressed more concerns. In short, the results of this study highlight the fact that health care provider–patient communication unfolds according to a complex interplay of style, perception, and adaptation. Hence, gender will have a significant impact on medical interactions to the extent that it can be linked to the fundamental processes of interpersonal communication.
3. Gender differences in medical encounters 3.1. Overview Research to date indicates that women health care providers generally tend to conduct longer consultations, give more information, engage in more partnership-building, are less directive, express more interest in psychosocial aspects of health (e.g. emotions, lifestyle, family), and are more explicitly reassuring and encouraging than are male clinicians [17–24]. However, to infer that women are more patient-focused and better health care providers than men
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would be an extremely simplistic generalization. For one thing, even researchers who have extensively investigated the communicative performance of men and women acknowledge that gender differences, while apparent, are small in magnitude and that male and female clinicians are generally more similar than different in their communication [23,25]. Second, some research has reported surprisingly contradictory findings. For example, during prenatal visits, Roter et al. [26] observed that female physicians actually spent less time with patients, engaged in less facilitative communication, and made fewer expressions of concern than did the male doctors. Contrary to expectations, Huston et al. [27] found that male doctors more often discussed hormone replacement therapy with their women patients than did female physicians. Such contradictory findings are further complicated by inconsistencies in research on communication, satisfaction, and gender. While some suggest gender congruence (i.e. physician and patient are of the same gender) may lead to more productive provider–patient interactions [28], current research finds no clear pattern. Some patients are more satisfied with women doctors [17,18], with male doctors [29], with female doctors but by male patients only [30], with male doctors but by female patients only [30], and some studies report no significant differences at all [23]. Some insight into these findings may be gained by analyzing them within the framework of the ecological model. Specifically, the model can help explain why gender differences are often observed medical encounters and why sometimes they are not. 3.2. Gender as a predisposing influence One possible explanation for gender differences in health care provider–patient communication is that men and women tend to have different styles of communicating. In many ways, gender-linked communication differences in medical care parallel gender differences in other contexts. For example, Tannen [31] has proposed that women typically talk to build community and rapport whereas men use talk as a means of establishing status and independence. Similarly, even when gender markers are removed from a conversational transcript (e.g. names, gender-specific topics), the language of women tends to be perceived as having greater aesthetic quality (e.g. pleasing) but less dynamism (e.g. strong, active) than does the discourse of men [32]. In the nonverbal domain, women tend to be more expressive and more accurate at perceiving the emotions of others than are men [33]. As shown in Fig. 1, gender differences in health care providers’ styles of communicating are in part related to beliefs and values associated with one’s identity and socialization experiences [8]. Hence, the fact that women doctors often exhibit more patient-centered behaviors and are more concerned about psychosocial health issues than are men is consistent with other evidence indicating that female clinicians generally are more interpersonally oriented [28], more
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concerned about emotional and social aspects of health [34], and more interested in the patient’s input and partnership [19,35,36]. Men, on the other hand, may take a more individualistic and instrumental approach to health management. Thus, whether as clinicians or patients, men may spend proportionately more time focusing on biomedical issues, offering advice, expressing opinions, and independently making recommendations for the other to accept or reject [19]. However, it is important to recognize that gender is but of many factors (e.g. age, education, ethnicity) that can influence communicative style [6,12,37]. Moreover, gender differences are more pronounced among health care providers than among patients [23] suggesting that situation-specific considerations, such as one’s perceived role or power in the encounter, can override gender-linked behaviors as interactants adapt their communication to different situations. 3.3. Gender-based perceptions, attitudes, and expectations Gender may also be related to communication in medical encounters through its influence on the interactants’ expectations, motivations, goals, emotions, and perceptions of their partners. Although very little research has addressed this question, gender-based perceptions and beliefs may influence health care provider–patient communication in several ways. First, one’s stereotypes and attitudes toward men and women may generate a priori assumptions about the capabilities and needs of conversational partners. For example, Beck [38] describes an experience where a male obstetrician patronized her, interrupted her, and ignored her comments, presumably because he assumed she was a poor, uneducated country girl. This account is similar to that offered by critics of the way male doctors interact with female patients [39,40]. Conversely, gender-based perceptions may also affect the way patients talk to health care professionals. For example, people generally believe that female physicians are less likely use aggressive communication strategies (commands, directives, negative opinions, controlling behaviors) than are male physicians [41]. This expectation, coupled with the assumption that women clinicians are more interested in emotional and relational aspects of health [24], may explain why both male and female patients tend to talk more, reveal more psychosocial information, ask more questions, and are more involved in the decision-making process when interacting with female health care providers [21,22]. Yet another way gender-based beliefs and expectations may manifest themselves in the consultation is in the way the participants interpret their partners’ behavior. For example, men tend to be treated more aggressively for coronary heart disease (angiography, catherization, bypass surgery) than are women [42]. Elderkin-Thompson and Waitzkin [19] posit that this gender bias may in part be because doctors misperceive the seriousness and nature of women’s symptoms.
That is, physicians (primarily male) misattribute women’s health problems to emotional issues or stress, perhaps because women tend to be more expressive in discussing their symptoms and feelings [43]. To support this claim, Elderkin-Thompson and Waitzkin cite the Commonwealth survey that found that 17% of female respondents (compared to 7% of men) reported that a physician recently had told them their problems were ‘‘in their heads’’. On the other hand, other studies find little, if any, evidence of gender bias in medical encounters. For example, although 17% of the women in the Commonwealth survey were told their symptoms were in the heads, 83% reported no such experiences. Although some doctors may have less favorable attitudes toward women’s health concerns [44,45], other research has found the opposite [46] or no difference [47]. It is also important to recognize that gender is but one of many personal attributes (e.g. age, ethnicity, body size) about which interactants may have strong beliefs and even prejudices. Moreover, clinicians have their strongest attitudes, favorable and unfavorable, with respect to the patient’s behavior (e.g. dirty, demanding, uncooperative) than to his or her socio-demographic characteristics per se [45,46,48]. 3.4. Gender and the influence of a partner’s communicative actions Finally, differences in the way male and female patients communicate with male and female clinicians may be less a function of one’s attitudes and beliefs and more the result of the communicative actions of one’s partner. For example, patients may be more expressive and assertive when interacting with women health care providers not because women are presumed to have less power and status relative to men, but because female clinicians more frequently use partnership-building and other forms of facilitative communication [3,12,24]. Conversely, health care providers may provide more information and support to female patients not because of presumptions about the health needs of women, but because these patients more openly express their feelings, concerns, and questions [17,21,22]. Hence, regardless of gender, health care providers will likely be more responsive to those patients who actively participate in the encounter and, regardless of gender, patients will likely become more involved when their doctors are more patient-centered in their communication [6,12–14]. 3.5. Conclusions and implications Several conclusions can be drawn from this analysis that have direct implications for future research, theory development, and communication skill training. First, a health care provider’s communication style matters given that both clinicians and patients generally assume that the health care professional should take an active and even a controlling role in the interaction. However, while there is evidence of gender
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differences in the way providers interact with patients, these differences typically are small in magnitude [23,24]. Rather modest gender effects are understandable give that gender is but one of many factors (e.g. age, ethnicity, education) that may shape our communicative predispositions and that clinicians typically adapt their communication given the nuances of different patient encounters [5,8,37]. Second, although gender-based perceptions and stereotypes can play a prominent role in the medical encounter, we still know very little about the scope of these beliefs and their impact. Beck [38] and Todd [39] describe experiences with obviously sexist doctors. Clinicians also encounter gender bias in that some patients have strong preferences for either a man or a woman doctor. Even if gender bias is not a widespread problem in health care, the fact that some male and female patients with similar disease indicators have received different diagnoses and treatment recommendations suggests that health care providers in some settings are making medical decisions based on some gender-related consideration. Whether this is due to beliefs and stereotypes about men and women or to differences in how men’s and women’s communication is perceived [19] should be the subject of future research. Third, rather than trying to link communication patterns to gender per se, researchers could try to identify those attitudes and beliefs about health care that help explain why socio-demographic characteristics sometimes correlate with communication behavior. For example, Krupat et al. [36] reported that women physicians scored higher on the ‘‘sharing’’ component of the provider–patient orientation scale, a measure of patient-centeredness. This may explain why women health care providers tend to engage in more partnership-building than do men. Yet, it also means that male clinicians who have these attitudes would exhibit similar behavior. Fourth, by actively participating in their consultations, patients can attenuate and even erase communicative behaviors stemming from a clinician’s style or preconceived attitudes and stereotypes. Health care providers usually accommodate a patient who asks questions, offers opinions, and expresses concerns either because they now have a better understanding of how to address the patient’s needs or because they feel some obligation to adhere to norms governing conversational conduct. Of course, people in powerful positions sometimes adhere to their own agenda and disregard conversational norms or the interests of their partners. Nevertheless, the evidence to date indicates that patients will indeed gain more information, support, and involvement in decision-making the more they actively participate in the consultation [3]. Finally, health care providers’ and patients’ communicative styles, attitudes, and perceptions are amenable to change through well-designed communication skill training programs. Because their communicative habits and beliefs may be more entrenched, interventions for clinicians will need to be intensive, involve multiple methods (instruction,
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role-playing, feedback, group discussion, practice), and provide follow-up support and reinforcement [49–51]. With respect to patients, the main barrier to active participation is uncertainty about the patient’s role in the encounter and how to discuss his or her needs and concerns. If timely (e.g. delivered immediately prior to the consultations), patient activation programs can be effective as one-time interventions [51]. Moreover, content designed to motivate the patient as well as provide strategies for communicating with the clinician (e.g. practicing, writing down questions and concerns, watching a role model) can be effective using a variety of methods such as pamphlets, workbooks, face-to-face counseling, videotapes, and multimedia programs [52–54]. In conclusion, gender differences in medical encounters are real and can have a significant impact on communication process and outcomes. Yet, gender is but one of many factors that may correlate with behavior, beliefs, and perceptions. Therefore, researchers should not focus on gender in isolation of other personal (e.g. age, ethnicity, nationality, SES) and situational attributes that also influence health care provider–patient interaction. In addition, although this essay has centered on the interpersonal context of medical encounters, more research attention is needed on how the broader contexts of health care shape the interaction [55]. For example, a women’s health center, reduced funding for health care, online support groups, and gender roles in different countries are but a few examples of resources and constraints within the organizational, political, media, and cultural contexts of health care that can influence the way patients and health care providers talk to one another.
Acknowledgements This research was supported in part from an AHRQ Project Grant (PO1 HS10876), Racial and Ethnic Variation in Medical Interactions.
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[8] Giles H, Street Jr RL. Communicator characteristics and behavior. In: Miller GR, Knapp M, editors. Handbook of interpersonal communication, 2nd ed. Newbury Park (CA): Sage; 1994. p. 103–61. [9] Roter DL, Stewart M, Putnam SM, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians. J Am Med Assoc 1997;227:350–6. [10] Sacks H, Schegloff EA, Jefferson G. A simplest systematics for the organization of turn-taking for conversation. Language 1974;50:696– 735. [11] Tracy K. Conversational coherence: a cognitively grounded rules approach. In: Street Jr RL, Cappella J, editors. Sequence and pattern in communicative behavior. London: Edward Arnold; 1985. p. 30–49. [12] Street Jr. RL. Information-giving in medical consultations: the influence of patients’ communicative styles and personal characteristics. Soc Sci Med 1991;32:541–8. [13] Greenfield S, Kaplan S, Ware Jr. JE. Expanding patient involvement in care. Ann Intern Med 1985;102:520–8. [14] Wissow LS, Roter D, Bauman LJ, Crain E, Kercsmar C, Weiss K, et al. Patient–provider communication during emergency department care of children with asthma. Med Care 1998;36:1439–50. [15] Wissow LS, Roter D, Wilson MEH. Pediatrician interview style and mothers’ disclosure of psychosocial issues. Pediatrics 1994;93:289– 95. [16] Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decisionmaking style. Med Care 1995;33:1176–87. [17] Bernzweig J, Takayama JI, Phibbs C, Lewis C, Pantell RH. Gender differences in physician–patient communication: evidence from pediatric visits. Arch Pediatr Adolesc Med 1997;151:586–91. [18] Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA. The effect of patient health status on physician practice style. Fam Med 1995;25:530–5. [19] Elderkin-Thompson V, Waitzkin H. Differences in clinical communication by gender. J Gen Intern Med 1999;14:112–21. [20] Meeuwesen L, Schaap C, van der Staak C. Verbal analysis of doctor– patient communication. Soc Sci Med 1991;32:1143–50. [21] Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psychol 1994;13:384–92. [22] Roter D, Lipkin M, Korsgaard A. Sex differences in patients’ and physicians’ communication during primary care medical visits. Med Care 1991;29:1083–93. [23] Hall JA, Roter DL. Medical communication and gender: a summary of research. J Gender-Specific Med 1998;1:39–42. [24] Roter DL, Hall JA. Why physician gender matters in shaping the physician–patient relationship. J Women’s Health 1998;7:1093–7. [25] Roter DL, Hall JA. How physician gender shapes the communication and evaluation of medical care. Mayo Clin Proc 2001;76:673–6. [26] Roter DL, Geller G, Bernhardt BA, Larson SM, Doksum T. Effects of obstetrician gender on communication and patient satisfaction. Obstet Gynecol 1999;93:635–41. [27] Huston S, Sleath B, Rubin RH. Physician gender and hormone replacement therapy. J Women’s Health Gender-Based Med 2001;10:279–87. [28] Weisman CS, Teitelbaum MA. Physician gender and the physician– patient relationship: recent evidence and relevant questions. Soc Sci Med 1985;20:1119–27. [29] Ross CE, Mirowsky J, Duff RS. Physician status characteristics and client satisfaction in two types of medical practice. J Health Soc Behav 1982;23:317. [30] Schmittdiel J, Grumbach K, Selby JV, Quesenberry Jr. CP. Effect of physician and patient gender concordance on patient satisfaction and preventive care practices. J Gen Intern Med 2000;15:761–9. [31] Tannen D. You just don’t understand. New York: Balantine; 1990. [32] Mulac A, Lundell TB. Differences in perceptions created by syntactic–semantic productions of male and female speakers. Commun Monogr 1980;47:111–8.
[33] Burgoon JK, Nonverbal signals. In: Knapp ML, Miller GR, editors. Handbook of interpersonal communication, 2nd ed. Thousand Oaks (CA): Sage; 1994. p. 229–85. [34] Maheux B, Dufort F, Beland F, Jacques A, Levesque A. Female medical practitioners: more preventive and patient oriented? Med Care 1990;28:87–92. [35] Beisecker AE, Murden RA, Moore WP, Graham D, Nelmig L. Attitudes of medical students and primary care physicians regarding input of older and younger patients in medical decisions. Med Care 1996;34:126–37. [36] Krupat E, Rosenkranz SL, Yeager CM, Barnard K, Putnam SM, Inui TM. The practice orientations of physicians and patients: the effect of doctor–patient congruence on satisfaction. Patient Educ Couns 2000;39:49–59. [37] Waitzkin H. Information-giving in medical care. J Health Soc Behav 1985;26:81–101. [38] Beck CS. Communicating for better health: a guide through medical mazes. Boston: Allyn & Bacon; 2001. [39] Todd AD. Intimate adversaries: cultural conflict between doctors and women patients. Philadelphia: University of Pennsylvania Press; 1989. [40] West C. Routine complications. Bloomington (IN): University of Indiana Press; 1984. [41] Burgoon M, Birk TS, Hall JR. Compliance and satisfaction with physician–patient communication: an expectancy theory interpretation of gender differences. Hum Commun Res 1991;18:177–208. [42] Steingart RM, Packer M, Hamm P, Coglianese E, Gersh B, Geltman EM, et al. Sex differences in the management of coronary heart disease. N Engl J Med 1991;325:226–30. [43] Hall JA, Roter DL. Patient gender and communication with physicians: results of a community-based study. Women’s Health 1995;1:77–95. [44] Chandy J, Schwenck TL, Roi LD, Cohen M. Medical care and demographic characteristics of ‘difficult’ patients. J Fam Pract 1987;24:607–10. [45] Hall JA, Epstein AM, DeCiantis ML, McNeil BJ. Physicians’ liking for their patients: more evidence for the role of affect in medical care. Health Psychol 1993;12:140–6. [46] Harris IB, Rich EC, Crowson TW. Attitudes of internal medicine residents and staff physicians toward various patient characteristics. J Med Educ 1985;60:192–5. [47] Lin EHB, Katon W, Von Korff M, Bush T, Lipscomb P, Russo J, et al. Frustrating patients: physician and patient perspectives among distressed high users of medical services. J Gen Intern Med 1991;6:241–6. [48] Klien D, Najman J, Kohrman AF, Munro C. Patient characteristics that elicit negative responses from family physicians. J Fam Pract 1982;14:881–8. [49] Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med 1993;8:318–24. [50] Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877–84. [51] Street Jr RL. Interpersonal skills in health care contexts. In: Greene JO, Burleson BR, editors. Handbook of communication and social interaction skills. Mahwah (NJ): Erlbaum, in press. [52] Anderson LA, DeVellis BM, DeVellis RF. Effects of modeling on patient communication, satisfaction, and knowledge. Med Care 1987;25:1044–56. [53] Cegala DJ, McClure L, Marinelli TM, Post DM. The effects of communication skills training on patients’ participation during medical interviews. Patient Educ Couns 2000;41:209–22. [54] Street Jr. RL, Voigt B, Geyer C, Manning T, Swanson GP. Increasing patient involvement in choosing treatment for early breast cancer. Cancer 1995;76:2275–85. [55] Waitzkin H. The politics of medical encounters. New Haven (CT): Yale University Press; 1991.
Gender differences in health care provider–patient communication: are they due to style, stereotypes, or accommodation? Richard L. Street Jr.* Department of Speech Communication, Texas A&M University, College Station, TX 77843-4234, USA
Abstract This article examines gender differences in health care provider–patient communication within the framework of an ecological model of communication in the medical encounter. The ecological perspective posits that, although health care provider–patient interactions are situated within a number of contexts (e.g. organizational, political, cultural), the interpersonal domain is the primary context within which these interactions unfold. Hence, gender may influence provider–patient interaction to the extent that it can be linked to the interactants’ goals, skills, perceptions, emotions, and the way the participants adapt to their partner’s communication. The evidence reviewed in this essay indicates that gender differences in medical encounters may come from several sources including differences in men’s and women’s communicative styles, perceptions of their partners, and in the way they accommodate their partner’s behavior during the interaction. However, because gender is but one of many personal and partner variables (e.g. age, ethnicity, personal experiences) that can influence these processes, gender differences are often quite modest (if apparent at all) when examined across a population of health care providers and patients. Implications for future research and communicative skill training are discussed. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Physician–patient communication; Gender differences; Communication skill training
1. Introduction Gender has been identified as one source of systematic variation in medical encounters. As will be discussed later, a number of studies have found that, as health care providers, women and men differ in the way they communicate with their patients. While differences between male and female patients are less clear-cut, some research does show that patients, regardless of sex, often vary their responses depending on the clinician’s gender. Because provider–patient communication can have a significant impact on outcomes following the consultation (e.g. satisfaction, adherence, health improvement) [1–3], the possibility that the participants’ gender may influence the structure and content of the consultation becomes a question of considerable importance. How do we make sense of gender differences in medical encounters? One problem with previous research is that gender typically is studied as an individual difference variable and not as a construct grounded in a conceptual framework to explain why these differences exist [4]. In this essay, I analyze these findings from the perspective of an ecological model of communication in medical consultations. At * Tel.: þ1-979-845-0209; fax: þ1-979-845-6594. E-mail address: [email protected] (R.L. Street Jr.).
the heart of the model is the idea that individual differences cannot be examined in isolation of other variables or processes that also account for communicative action. I conclude with a discussion of the implications of this analysis for future research and communication skills training.
2. An ecological model of communication in medical encounters 2.1. Overview Fig. 1 presents an ecological model of communication in medical encounters [5]. Two features of the model are important for the purposes of this chapter. First, medical encounters occur in context. Thus, the way in which health care providers and patients communicate with one another may in part depend on the type of health care organization (e.g. managed care, fee-for-service), political and legal issues (experience with malpractice, patients’ bill of rights), use of and exposure to media (the Internet, direct-to-consumer-marketing of medical products), economic factors (e.g. insurance, income), and culture (ethnicity, religion). However, while any of these contexts may have some impact on medical encounters, the one within which these
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Fig. 1. An ecological model of communication in medical encounters.
interactions are most fundamentally embedded is the interpersonal context. In other words, what unfolds during the encounter ultimately depends on the interactants’ goals, skills, perceptions, and emotions as well as on the constraints and opportunities created by the actions of their partners [5,6]. As depicted in the model, most people have developed a particular style of communicating (e.g. assertive, friendly, reserved, expressive) that they use across a wide variety of situations [7]. Differences in communication style have been attributed to a number of factors including personality, identity, socialization, and linguistic skill (for a review, see [8]). However, one’s communicative style also serves a pragmatic function in that it represents a set of responses that are readily available and appropriate for communicating across various situations [5]. For example, because health care providers have many consultations involving similar health issues, it is not surprising that many clinicians have developed their own styles of communicating with patients. Roter et al. [9] recently observed that, although doctors generally exhibited more than one pattern of communication (e.g. narrowly biomedical, psychosocial, biopsychosocial), many relied on a particular style for most of their visits. In the ecological model, communication style reflects one’s predisposition to communicate in a certain way (see Fig. 1). Second, regardless of one’s typical style of communicating, interactants also adapt their responses given situation-
specific considerations. The ecological model identifies two sources of adaptive behavior. Cognitive-affective factors account for adaptation based on strategic (e.g. goals, purpose), attributional (e.g. stereotypes, impressions), and relational (e.g. trust, familiarity) considerations. For example, a health care provider typically may have a friendly, expressive style when interacting with patients, yet he or she may become more animated when talking to a child during a check-up or considerably more sedate and serious when informing a patient of a life-threatening disease. Communicative adaptations also occur in response to a partner’s communicative actions. To have a coherent and successful interaction, communicators must cooperate and coordinate their responses. Thus, any one interactant has the potential to exert considerable influence over the other. For example, a patient who expresses concern about treatment alerts the doctor to his or her needs and preferences, information that the doctor can use to modify the therapeutic plan. Moreover, given normative expectations for utterances to be topically connected [10,11], a clinician may feel obligated to answer a patient’s question or spend time talking about a topic raised by the patient [3,12]. This explains why physicians generally will provide more information, support, and reassurance [6,12,13] when they interact with patients who ask questions, offer opinions, and express concerns. Likewise, a health care provider who uses
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partnership-building (e.g. asks for the patient’s opinion, solicits the patient’s concerns) and other types of patientcentered responses (e.g. encouragement, reassurance) generally elicits greater patient involvement in the encounter [6,12,14,15] whereas a clinician who frequently interrupts, asks close-ended questions, and issues directives stifles patient participation. 2.2. The interplay of style, perception, and partner’s communication Thus far, these processes have been discussed as though they operate independently of one another. They do not, of course. Street [6] has tried to systematically sort out the unique contributions of several personal and partner influences on patterns of physician–patient communication. In a study of 7 physicians who interacted with 115 patients, he found that doctors gave more information and offered more support and encouragement to patients who asked questions and expressed concerns. However, independent of the patient’s behavior, additional variation in the degree to which physicians engaged in partnership-building was related to the patient’s education (see also [16]). Finally, even when controlling for the patients’ socio-demographic characteristics and behavior, the communication styles of individual doctors still differed with respect to informationgiving, partnership-building, issuing directives, and affective communication. Regarding the patients’ communication, Street [6] reported that patients did not talk differently to individual doctors per se, but they did ask more questions and offer more opinions when their physician engaged in partnershipbuilding. In addition, patients’ communication was uniquely related to their level of education and worry. More educated patients asked more questions and offered more opinions, and more worried parents expressed more concerns. In short, the results of this study highlight the fact that health care provider–patient communication unfolds according to a complex interplay of style, perception, and adaptation. Hence, gender will have a significant impact on medical interactions to the extent that it can be linked to the fundamental processes of interpersonal communication.
3. Gender differences in medical encounters 3.1. Overview Research to date indicates that women health care providers generally tend to conduct longer consultations, give more information, engage in more partnership-building, are less directive, express more interest in psychosocial aspects of health (e.g. emotions, lifestyle, family), and are more explicitly reassuring and encouraging than are male clinicians [17–24]. However, to infer that women are more patient-focused and better health care providers than men
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would be an extremely simplistic generalization. For one thing, even researchers who have extensively investigated the communicative performance of men and women acknowledge that gender differences, while apparent, are small in magnitude and that male and female clinicians are generally more similar than different in their communication [23,25]. Second, some research has reported surprisingly contradictory findings. For example, during prenatal visits, Roter et al. [26] observed that female physicians actually spent less time with patients, engaged in less facilitative communication, and made fewer expressions of concern than did the male doctors. Contrary to expectations, Huston et al. [27] found that male doctors more often discussed hormone replacement therapy with their women patients than did female physicians. Such contradictory findings are further complicated by inconsistencies in research on communication, satisfaction, and gender. While some suggest gender congruence (i.e. physician and patient are of the same gender) may lead to more productive provider–patient interactions [28], current research finds no clear pattern. Some patients are more satisfied with women doctors [17,18], with male doctors [29], with female doctors but by male patients only [30], with male doctors but by female patients only [30], and some studies report no significant differences at all [23]. Some insight into these findings may be gained by analyzing them within the framework of the ecological model. Specifically, the model can help explain why gender differences are often observed medical encounters and why sometimes they are not. 3.2. Gender as a predisposing influence One possible explanation for gender differences in health care provider–patient communication is that men and women tend to have different styles of communicating. In many ways, gender-linked communication differences in medical care parallel gender differences in other contexts. For example, Tannen [31] has proposed that women typically talk to build community and rapport whereas men use talk as a means of establishing status and independence. Similarly, even when gender markers are removed from a conversational transcript (e.g. names, gender-specific topics), the language of women tends to be perceived as having greater aesthetic quality (e.g. pleasing) but less dynamism (e.g. strong, active) than does the discourse of men [32]. In the nonverbal domain, women tend to be more expressive and more accurate at perceiving the emotions of others than are men [33]. As shown in Fig. 1, gender differences in health care providers’ styles of communicating are in part related to beliefs and values associated with one’s identity and socialization experiences [8]. Hence, the fact that women doctors often exhibit more patient-centered behaviors and are more concerned about psychosocial health issues than are men is consistent with other evidence indicating that female clinicians generally are more interpersonally oriented [28], more
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concerned about emotional and social aspects of health [34], and more interested in the patient’s input and partnership [19,35,36]. Men, on the other hand, may take a more individualistic and instrumental approach to health management. Thus, whether as clinicians or patients, men may spend proportionately more time focusing on biomedical issues, offering advice, expressing opinions, and independently making recommendations for the other to accept or reject [19]. However, it is important to recognize that gender is but of many factors (e.g. age, education, ethnicity) that can influence communicative style [6,12,37]. Moreover, gender differences are more pronounced among health care providers than among patients [23] suggesting that situation-specific considerations, such as one’s perceived role or power in the encounter, can override gender-linked behaviors as interactants adapt their communication to different situations. 3.3. Gender-based perceptions, attitudes, and expectations Gender may also be related to communication in medical encounters through its influence on the interactants’ expectations, motivations, goals, emotions, and perceptions of their partners. Although very little research has addressed this question, gender-based perceptions and beliefs may influence health care provider–patient communication in several ways. First, one’s stereotypes and attitudes toward men and women may generate a priori assumptions about the capabilities and needs of conversational partners. For example, Beck [38] describes an experience where a male obstetrician patronized her, interrupted her, and ignored her comments, presumably because he assumed she was a poor, uneducated country girl. This account is similar to that offered by critics of the way male doctors interact with female patients [39,40]. Conversely, gender-based perceptions may also affect the way patients talk to health care professionals. For example, people generally believe that female physicians are less likely use aggressive communication strategies (commands, directives, negative opinions, controlling behaviors) than are male physicians [41]. This expectation, coupled with the assumption that women clinicians are more interested in emotional and relational aspects of health [24], may explain why both male and female patients tend to talk more, reveal more psychosocial information, ask more questions, and are more involved in the decision-making process when interacting with female health care providers [21,22]. Yet another way gender-based beliefs and expectations may manifest themselves in the consultation is in the way the participants interpret their partners’ behavior. For example, men tend to be treated more aggressively for coronary heart disease (angiography, catherization, bypass surgery) than are women [42]. Elderkin-Thompson and Waitzkin [19] posit that this gender bias may in part be because doctors misperceive the seriousness and nature of women’s symptoms.
That is, physicians (primarily male) misattribute women’s health problems to emotional issues or stress, perhaps because women tend to be more expressive in discussing their symptoms and feelings [43]. To support this claim, Elderkin-Thompson and Waitzkin cite the Commonwealth survey that found that 17% of female respondents (compared to 7% of men) reported that a physician recently had told them their problems were ‘‘in their heads’’. On the other hand, other studies find little, if any, evidence of gender bias in medical encounters. For example, although 17% of the women in the Commonwealth survey were told their symptoms were in the heads, 83% reported no such experiences. Although some doctors may have less favorable attitudes toward women’s health concerns [44,45], other research has found the opposite [46] or no difference [47]. It is also important to recognize that gender is but one of many personal attributes (e.g. age, ethnicity, body size) about which interactants may have strong beliefs and even prejudices. Moreover, clinicians have their strongest attitudes, favorable and unfavorable, with respect to the patient’s behavior (e.g. dirty, demanding, uncooperative) than to his or her socio-demographic characteristics per se [45,46,48]. 3.4. Gender and the influence of a partner’s communicative actions Finally, differences in the way male and female patients communicate with male and female clinicians may be less a function of one’s attitudes and beliefs and more the result of the communicative actions of one’s partner. For example, patients may be more expressive and assertive when interacting with women health care providers not because women are presumed to have less power and status relative to men, but because female clinicians more frequently use partnership-building and other forms of facilitative communication [3,12,24]. Conversely, health care providers may provide more information and support to female patients not because of presumptions about the health needs of women, but because these patients more openly express their feelings, concerns, and questions [17,21,22]. Hence, regardless of gender, health care providers will likely be more responsive to those patients who actively participate in the encounter and, regardless of gender, patients will likely become more involved when their doctors are more patient-centered in their communication [6,12–14]. 3.5. Conclusions and implications Several conclusions can be drawn from this analysis that have direct implications for future research, theory development, and communication skill training. First, a health care provider’s communication style matters given that both clinicians and patients generally assume that the health care professional should take an active and even a controlling role in the interaction. However, while there is evidence of gender
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differences in the way providers interact with patients, these differences typically are small in magnitude [23,24]. Rather modest gender effects are understandable give that gender is but one of many factors (e.g. age, ethnicity, education) that may shape our communicative predispositions and that clinicians typically adapt their communication given the nuances of different patient encounters [5,8,37]. Second, although gender-based perceptions and stereotypes can play a prominent role in the medical encounter, we still know very little about the scope of these beliefs and their impact. Beck [38] and Todd [39] describe experiences with obviously sexist doctors. Clinicians also encounter gender bias in that some patients have strong preferences for either a man or a woman doctor. Even if gender bias is not a widespread problem in health care, the fact that some male and female patients with similar disease indicators have received different diagnoses and treatment recommendations suggests that health care providers in some settings are making medical decisions based on some gender-related consideration. Whether this is due to beliefs and stereotypes about men and women or to differences in how men’s and women’s communication is perceived [19] should be the subject of future research. Third, rather than trying to link communication patterns to gender per se, researchers could try to identify those attitudes and beliefs about health care that help explain why socio-demographic characteristics sometimes correlate with communication behavior. For example, Krupat et al. [36] reported that women physicians scored higher on the ‘‘sharing’’ component of the provider–patient orientation scale, a measure of patient-centeredness. This may explain why women health care providers tend to engage in more partnership-building than do men. Yet, it also means that male clinicians who have these attitudes would exhibit similar behavior. Fourth, by actively participating in their consultations, patients can attenuate and even erase communicative behaviors stemming from a clinician’s style or preconceived attitudes and stereotypes. Health care providers usually accommodate a patient who asks questions, offers opinions, and expresses concerns either because they now have a better understanding of how to address the patient’s needs or because they feel some obligation to adhere to norms governing conversational conduct. Of course, people in powerful positions sometimes adhere to their own agenda and disregard conversational norms or the interests of their partners. Nevertheless, the evidence to date indicates that patients will indeed gain more information, support, and involvement in decision-making the more they actively participate in the consultation [3]. Finally, health care providers’ and patients’ communicative styles, attitudes, and perceptions are amenable to change through well-designed communication skill training programs. Because their communicative habits and beliefs may be more entrenched, interventions for clinicians will need to be intensive, involve multiple methods (instruction,
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role-playing, feedback, group discussion, practice), and provide follow-up support and reinforcement [49–51]. With respect to patients, the main barrier to active participation is uncertainty about the patient’s role in the encounter and how to discuss his or her needs and concerns. If timely (e.g. delivered immediately prior to the consultations), patient activation programs can be effective as one-time interventions [51]. Moreover, content designed to motivate the patient as well as provide strategies for communicating with the clinician (e.g. practicing, writing down questions and concerns, watching a role model) can be effective using a variety of methods such as pamphlets, workbooks, face-to-face counseling, videotapes, and multimedia programs [52–54]. In conclusion, gender differences in medical encounters are real and can have a significant impact on communication process and outcomes. Yet, gender is but one of many factors that may correlate with behavior, beliefs, and perceptions. Therefore, researchers should not focus on gender in isolation of other personal (e.g. age, ethnicity, nationality, SES) and situational attributes that also influence health care provider–patient interaction. In addition, although this essay has centered on the interpersonal context of medical encounters, more research attention is needed on how the broader contexts of health care shape the interaction [55]. For example, a women’s health center, reduced funding for health care, online support groups, and gender roles in different countries are but a few examples of resources and constraints within the organizational, political, media, and cultural contexts of health care that can influence the way patients and health care providers talk to one another.
Acknowledgements This research was supported in part from an AHRQ Project Grant (PO1 HS10876), Racial and Ethnic Variation in Medical Interactions.
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