Gender Role Patient Physician Communications

7/31/2019 Gender Role Patient Physician Communications

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Northwestern University Feinberg School of Medicine

What we do (and don't) know about the role of gender in

influencing patient- healthcare provider communication

18 May 2010

Marla L. Clayman, PhD MPH

Division of General Internal Medicine



Why do we care about communication inthe provider-patient relationship?

Over 900 million ambulatory physician office visits each year (NAMCS

2006 summary)

Health care providers are the most trusted sources of health

information (HINTS data 2005)

Interventions increasingly implemented with the provider ’s imprimatur

•Screening for cancer

•Health behaviors

•Decision aids



Why do we care about gender in thepatient-provider relationship?

• Women are the face of most health care providers



U.S. Department of Health and Human Services, Health Resources and Services Administration,

Maternal and Child Health Bureau.Women's Health USA 2007.

Rockville, Maryland: U.S.Department of Health and Human Services, 2006.





• Women are the face of patients

• The majority (about 60%) of outpatient visits are by women (NAMCS 2006

summary).



Annual rate of outpatient departmentvisits by patient age and sex: US 2005





• The majority (about 60%) of outpatient visits are

by women (NAMCS 2006 summary).

• Even when pregnancy and childbirth stays are

excluded, females account for more hospital stays

than men (HCUP data 2007).

• In 2007, women represented two-thirds of users of

mental health services, including inpatient and

outpatient care and prescription medications.



What beyond prevalence is

important?

How does this fit in with the bigger picture of

healthcare in America?• Increasingly, communication is seen as important to the health caresystem

•Medicine may be gendered (with an emphasis on men), but mostpatients and most practitioners are women.



Crossing the Quality Chasm (IOM report)

“Patient Centered Care is Fundamental to Quality HealthCare.”

“[Patient-centered care is] health care that establishes a

partnership among practitioners, patients and their families(where appropriate) to ensure that decisions respectpatients’ wants, needs and preferences, and solicit patients input on the education and support they need tomake decisions and participate in their own care.”

Report suggests communication measures as metrics of quality.



Professional training

In the past decade, formal recognition that

communication skills are an essential part of

medicine and healthcare

• Including accrediting bodies for:

-Medical Students

-Residents

-Nurses

-Physician Assistants-Genetic Counselors



Does better communication really

lead to better quality care?More informed patients have been shown to have

•Better recall of information

•Better chronic disease control

•Higher patient satisfaction

•Less anxiety

Some data suggest that patients who are more

satisfied with the provider ’s communication ratetheir care more highly in terms of quality



Should we expect differences by gender?

Studies in non-clinical settings show that women

and men tend to have different communication

styles.

Communication is reciprocal – we respond

differently to people depending on how theyrespond to us.

The same communication behaviors can be

interpreted differently based on the gender of whoengages in them.



How can we determine if there aredifferences?

• Medical encounter recordings

• Objective measure of what happens in the visit

• The interpretation might not be

• Little reactivity (response to being taped)

• Can use audio or video

• Often used in conjunction with self-report



Analysis of taped visits

Coding systems - RIAS, CANCODE

• Mutually exclusive and exhaustive categories

- Form (e.g., open-ended questions) and/or

- Content (e.g., biomedical information)

• Specific behaviors or content

- For example, education about diabetes self care

• Non-verbal communication



Patient-provider communication andphysician gender

• Female physicians engage in more:

• Partnership

• Positive talk• Psychosocial counseling• Psychosocial question asking

• No differences by physician gender for amount, quality, or

manner of biomedical information giving.

• Visits are 2 minutes longer, on average, for female

physicians

Roter et al. 2002 JAMA meta-analysis



Physician gender, part II

• Patients speak more to female physicians

•

Patients, when talking to female physicians,• Disclose more biomedical and psychosocial information

• Are more assertive to female physicians

• Are more likely to interrupt

• No differences in patient question asking

Hall and Roter 2002 PEC meta analysis



Patient gender

Female patients:

• give more information

• ask more questions

• use more back-channels

- Un-huh, yeah, I see

- (see Roter and Hall 2006 for a summary)

No clear relationship between communication,patient satisfaction, and physician-patient gender

concordance (Hall et al. 1994)



Example of research using hypotheticalsituations• A study of 167 students acting as patients

• Interacting with a virtual physician

• Physician varied only by sex

• Found that in male-male pairs, the communication style of

physician did not affect satisfaction

• But, for female-female pairs, patients were more satisfied

if the physician was more caring (Schmid Mast 2007)

• Similar to other research that people expect women (and

women physicians) to behave in certain “feminine” ways.



Family members/companions

Companions tend to be women (~80% of the time)

Less studied than the doctor-patient dyad

Family members often present in geriatric primary

care, prenatal, and cancer visits

Family members are often studied as caregivers

rather than interested parties

Some have expressed concern that they dominatethe visit



Research on companions

Companions can facilitate patients’ involvement in the visit

• Asking the patient questions

•Prompting the patient to talk

• Asking for the patient's opinion

In these cases, patients were more than four times as likely to be activein decision-making as patients whose companions did not assist in thismanner (Clayman et al. 2005 Soc Sci Med)

Medicare beneficiaries with companions were more satisfied with their physician's technical skills, information giving, and interpersonal skillsthan unaccompanied beneficiaries (Wolff & Roter 2008 Arch Int Med)



Let s go back for a minute....

“[Patient-centered care is] health care that establishes apartnership among practitioners, patients and their families (where appropriate) to ensure that decisionsrespect patients’ wants, needs and preferences, and

solicit patients input on the education and supportthey need to make decisions and participate in their owncare.”



OK, but I can t change the fact

that I m a woman As a patient

As a healthcare provider

What do I do about it?



Where can we intervene?

How people talk

What they talk about

How well they understand

The systems we have in place

Note – this isn’t about GENDER



How people talk



Interrupting

• How long until patients are interrupted?- Beckman and Frankel 1984

•18 seconds

- Marvel et al. 1999

•23 seconds

•Patients allowed to complete their statement of concernsused only 6 seconds more on average

•Late-arising concerns were more common when physicians

did not solicit patient concerns•Physicians with training in communication

- More likely to solicit patient concerns

- Allow patients to complete their initial statement of concerns



Teach backStructure Verbal Instructions, Confirm Understanding

• “Now, I’m going to tell you what I think is wrong, the

tests I’m going to order, the medicine I want you to

take, and when I will see you back.”

• Increases recall

• “ Any questions? OK, just to make sure I explained theplan clearly, tell me what you are going to do after you

go home?”

• If incorrect, explain again, and repeat teach-back





What they talk about

Patients can be influenced by:

Friends and family

Information on the Web

Direct to Consumer advertising

Providers shape what gets discussed

How decisions are made, how information is given



How well they understand

Use plain language in explanations and instructions

Think about how risks are presented

• Most people (including many clinicians) are not good at probabilistic

thinking

• Recognize that terms like “high risk” and “low risk” are arbitrary andmean different things in different contexts



Electronic prescribing

Although guidelines* recommend not using Latin

terms or abbreviations to avoid medication errors,

handwritten prescriptions often include Latin (Bailey

et al. 2009)

Electronic prescribing can be written clearly for both

pharmacy and patient

*Joint Commission and the National Coordinating Council for Medication Error Reporting

and Prevention



Fostering insightFrom Gigerenzer and Edwards BMJ 2003

Single event probabilities

"You have a 30% chance of a side effect from this drug"

A frequency statement:

"Three out of every 10 patients have a side effect from this drug"



Conditional probabilities

Two ways of representing the same statistical information

The probability that a woman has breast cancer is 0.8%. If she has

breast cancer, the probability that a mammogram will show a positive

result is 90%. If a woman does not have breast cancer the probability of a

positive result is 7%. Take, for example, a woman who has a positive

result. What is the probability that she actually has breast cancer?



As natural frequencies

Eight out of every 1000 women have breast cancer. Of these

eight women with breast cancer, seven will have a positive

result on mammography.

Of the 992 women who do not have breast cancer some 70

will still have a positive mammogram. Take, for example, a

sample of women who have positive mammograms.

How many of these women actually have breast cancer?

(Answer: of 77 with a positive result, 7 (~9%) have cancer)



Copyright ©2003 BMJ Publishing Group Ltd.

Gigerenzer, G. et al. BMJ 2003;327:741-744

Doctors' estimates of the probability of breast cancer in women with a positive result onmammography, according to whether the doctors were given the statistical information as

conditional probabilities or natural frequencies (each point represents one doctor)



Best practices

Use teach-back. Define learning goals.

Use plain language for instructions

Give numbers in natural frequencies – try to avoid

jargon.

1 out of 100 instead of 1 percent



Should we give up on providers?

No.

•Some communication skills can be taught and learned-Giving bad news, communicating risk

But, we need to think about when to place burden on

• physicians vs.

• patients vs.

•

both vs.• Other health care professionals or lay health educators

•Some miscommunication is inevitable. Some is not...

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Gender Role Patient Physician Communications