MEDLINE Abstracts: The Practicing Ob/Gyn: Gender Issues

June 27, 2003

MEDLINE Abstracts: The Practicing Ob/Gyn: Gender Issues

This collection of recent MEDLINE abstracts is one of a series that considers the Ob/Gyn as a study subject. In this easy-to-navigate collection, we feature studies that highlight gender issues for the practicing Ob/Gyn.

Adams KE
J Am Med Womens Assoc. 2003;58:117-119

As the proportion of women physicians in the United States increases, patients have increased access to physicians of either sex, and some patients express a clear preference for female providers. This is especially true in obstetrics/gynecology, where patients may have a variety of reasons for requesting female physicians. This column presents a case in which the patient not only expressed a preference for a female physician, but also, in fact, refused care from any male obstetrician/gynecologist. Possible responses to such a request are examined, with consideration of the competing priorities involved.

Franks P, Bertakis KD
J Womens Health (Larchmt). 2003;12:73-80

Background: Studies of the effects of physician gender on patient care have been limited by selected samples, examining a narrow spectrum of care, or not controlling for important confounders. We sought to examine the role of physician and patient gender across the spectrum of primary care in a nationally representative sample, large enough to examine the role of gender concordance and adjust for confounding variables.
Methods: We examined the relationships between physician and patient gender using nationally representative samples (the U. S. National Ambulatory Medical Care Surveys from 1985 to 1992) of encounters of 41,292 adult patients with 1470 primary care physicians (internists, family physicians, and obstetrician/gynecologists). Factors examined included physician (age, gender, region, rural location), patient (age, gender, race, insurance), and visit characteristics (diagnoses, gender-specific and nonspecific prevention, duration, continuity, and disposition).
Results: After multivariate adjustment, female physicians were more likely to see female patients, had longer visit durations, and were more likely to perform female prevention procedures and make some follow-up arrangements and referrals. Female physicians were slightly more likely to check patients blood pressure, but there were no significant differences in other nongender-specific prevention procedures or use of psychiatric diagnoses. Among encounters without breast or pelvic examinations, visit length was not related to physician gender, but length was longer in gender concordant visits than gender-discordant visits.
Conclusions: Female physicians were more likely to deliver female prevention procedures, but few other physician gender differences in primary care were observed. Physician-patient gender concordance was a key determinant of encounters.

Bertakis KD, Franks P, Azari R
J Am Med Womens Assoc. 2003;58:69-75

Objectives: To measure the impact of physician gender on patient satisfaction, controlling for confounding patient variables, and to examine the extent to which differences in satisfaction with male and female physicians can be explained by physician practice styles.
Method: New adult patients (n=509) were randomized to see male and female primary care physicians at a university medical center outpatient facility. Patient sociodemographics and self-reported health status (using the Medical Outcomes Study Short Form-36) were measured before the initial visit, and satisfaction with the physician was measured immediately following the visit. The entire medical encounter was videotaped and physician practice style was later analyzed using the Davis Observation Code.
Results: Female physicians spent a significantly greater proportion of the visit on preventive services and counseling than male physicians did, and male physicians devoted more time to technical practice behaviors and discussions of substance abuse. Visit length was not significantly different for male and female physicians. Patients of female physicians were more satisfied than were those of male physicians, even after adjusting for patient characteristics, visit length, and physician practice style behaviors.
Conclusion: Patient satisfaction with primary care physicians appears to be influenced not only by patient characteristics and physician behaviors, but also by the gender of the provider. Possible explanations for this may be that psychosocial aspects of the physician-patient interaction are different for male and female physicians. Patients may also bring expectations about female physicians to the encounter, presuming them to be more empathetic, nurturing, and responsive.

Pearse WH, Haffner WH, Primack A
Obstet Gynecol. 2001;97:794-797

As increasing numbers of female physicians enter the specialty of obstetrics and gynecology, their productivity (defined as producing goods and services) as compared with male physicians becomes important. Data from the American Medical Association socioeconomic survey and from a survey of ACOG Fellows indicate that, as a group, female physicians in the specialty are approximately 85% as productive as male physicians in the specialty. ACOG data for physician net income validate the productivity calculations (P <.03). The increasing numbers of female physicians in the specialty will lead to a decreasing aggregate productivity. At the same time, the increasing numbers of women of all ages in the United States will lead to a decline in the available obstetrician-gynecologist work force beginning in the year 2010.

Uskul AK, Ahmad F
SocSciMed. 2003;57:205-215

Evidence for gender differences in physicians' communication with their patients comes primarily from Western countries. Little is known about whether these gender differences would also be observed in Turkey, where there are explicit rules about male-female conduct. The purpose of this study was to observe male and female gynecologists' communication with their patients in a gynecology clinic at a state hospital in Istanbul, Turkey. Four male and three female gynecologists were observed in their interaction with 70 patients over 10 days. The observations were conducted during both the history taking and the actual examination sessions by a woman researcher. The results reported in this paper are based on the extensive field notes taken during the observations. Important differences were revealed in interactions between male vs female gynecologists and their patients. Namely, interactions differed in terms of conversation initiation, communication style, use of technical and colloquial language, frequency of eye contact, patience, and provision of information. Communication characteristics specific to interactions between male gynecologists and their patients included a ´blaming the victim' approach, differential treatment of patients, and underestimation of patients' abilities. Environmental factors that affected physicians' interaction with their patients are reported in conjunction with physicians' use of these external factors to explain the problems they experienced in physician-patient interaction. The discussion focuses on alternative explanations for and future research implications of the observed differences between male and female gynecologists in this setting.

Dominick KL, Skinner CS, Bastian LA, Bosworth HB, Strigo TS, Rimer BK
J Womens Health (Larchmt). 2003;12:61-71

Objectives: Healthcare provider recommendation for mammography is one of the strongest predictors of women's mammography use, but few studies have examined the association of provider characteristics with mammography recommendations. We examined the relationship of provider gender, age, medical specialty, and duration of relationship with the patient to report mammography recommendation.
Methods: Participants were women ages 40-45 and 50-55 who were part of a larger intervention study of decision making about mammography. We examined the relationship of provider characteristics to patient-reported mammography recommendations at baseline and at 24-month follow-up.
Results: At baseline, 74% of women in their 40s and 79% of women in their 50s reported provider mammography recommendations within the prior 2 years. Proportions were similar at the 24-month follow-up. In multivariate logistic regression models including both patient and provider characteristics, women in their 40s who had female providers were more likely to report mammography recommendations than those with male providers at baseline (OR = 1.83, p= 0.01) and follow-up (OR = 1.74, p = 0.03). Among women in their 50s, participants whose regular providers were primary care physicians were more likely to report recommendations at baseline than those whose regular providers were obstetrician/gynecologists (OR = 1.68, p= 0.03).
Conclusions: About one fourth of women in this study reported not having been advised by a healthcare provider to have a mammogram. All women in the study had health insurance. Among women in their 40s, for whom mammography guidelines were controversial at the time of data collection, provider gender was an important predictor of patient-reported mammography recommendation.

Plunkett BA, Kohli P, Milad MP
Am J Obstet Gynecol. 2002;186:926-928

Objective: The purpose of this study was to determine the importance of gender in the selection of an obstetrician or a gynecologist.
Study Design: At a university-based hospital, 46 patients after delivery and 79 patients after gynecologic surgery who had selected their physician within the previous year were interviewed to determine the importance of physician gender in the selection of an obstetrician or gynecologist. Chi-square test, Fisher exact test, and the Student t test were used for statistical analysis.
Results: Of the 125 women who were surveyed, 52.8% of the women preferred a female physician, 9.6% of the women preferred a male physician, and 37.6% of the women stated no gender preference, with no significant difference between the obstetric and gynecologic groups. The groups were similar with respect to ranking the importance of gender; 24.8% of the women who were interviewed considered gender to be one of the 3 most important factors in the selection of a physician. When participants were asked to choose gender over physician experience, bedside manner, or competency, gender was selected by 12%, 10.4%, and 0.8%, respectively, with no significant differences between the groups.
Conclusion: For most women, physician gender is not of primary importance in the selection of an obstetrician or gynecologist.

Hall JA, Roter DL
Patient Educ Couns. 2002;48:217-224

A meta-analytic review was undertaken of seven observational studies which investigated the relation between physician gender and patient communication in medical visits. In five of the studies the physicians were in general practice, internal medicine, or family practice and were seeing general medical patients, and in two of the studies the physicians were in obstetrics-gynecology and were seeing women for obstetrical or gynecological care. Significant findings revealed that, overall, patients spoke more to female physicians than to male physicians, disclosed more biomedical and psychosocial information, and made more positive statements to female physicians. Patients also were rated as more assertive toward female physicians and tended to interrupt them more. Several results were weaker, or even reversed, in the two obstetrics-gynecology studies. Partnership statements were made significantly more often to female than male physicians in general medical visits but not in obstetrical-gynecological visits.

Zuckerman M, Navizedeh N, Feldman J, McCalla S, Minkoff H
J Womens Health Gend Based Med. 2002;11:175-180

Introduction: There has been a reported increase in women's desires to have female medical providers. It is unclear if this finding extends to obstetrician/gynecologists or how important gender is relative to other factors in choosing a provider. This study seeks to address these issues.
Methods and Materials: In community locations in Brooklyn, New York, 537 women completed a questionnaire regarding demographics, gender of their current provider, and whether they considered age, gender, experience, location, or cost to be the most important factor in choosing an obstetrician/gynecologist. They rated their current experience and the importance of gender using a 10-point Likert scale.
Results: Overall, 61% of participants preferred a female provider. The proportion did not vary with gender of the interviewer or participants' age. A female provider was preferred by 56% of Protestants, 58% of Catholics, and 58% of Jews and by 74% of Hindus and 89% of Muslims (p = 0.02). Regardless of whether a woman preferred a male or a female provider, 38% of participants felt strongly (7-10 on Likert scale) that gender was important. There was no difference in satisfaction with current provider between women who preferred a male or female provider. Gender was as important in choosing an obstetrician as experience or cost. Almost as many women with a female provider indicated a preference for a male (46%) as women with a male provider who preferred a female provider (54%).
Conclusions: A slight majority of these women, particularly those who are Hindu or Moslem or currently use a female, prefer female providers. Only a minority of these women feel strongly about their preference, and women with male providers are as satisfied as are women with female providers. Gender of provider was about as important as a physician's experience in choice of clinician.

Howell EA, Gardiner B, Concato J
Obstet Gynecol. 2002;99:1031-1035

Objective: To investigate gender preferences for obstetricians in a hospital setting and to examine its relationship to patient satisfaction.
Methods: Using methods of qualitative analysis, we interviewed a convenience sample of 67 obstetric patients during their postpartum hospital stay, asking open-ended questions about gender preferences of health care providers and satisfaction with health care.
Results: Overall, 58% of patients (n = 39) had no preference for physician gender, 34% (n = 23) preferred female physicians, and 7% (n = 5) preferred male physicians. Physicians' interpersonal style, communication style, and technical expertise were considered important characteristics by patients. Although most patients had no preference for physician gender, the majority of patients preferred a female nurse. Patient satisfaction scores were not associated with physician gender.
Conclusions: Our study found that a majority of women did not prefer a female obstetrician. Our results suggest that physician gender is less important to patients than other physician characteristics.

Thompson M, Nussbaum R
J Am Med Womens Assoc. 2001;56:11-14

Objective: To gauge women's flexibility in receiving Pap smears from someone other than their regular gynecologists, specifically, their general physicians.
Methods: A random sample of 500 English-speaking women members (age 18-80) of Kaiser Permanente completed a 20-minute telephone survey (72% response rate). Ten focus groups and 75 in-person interviews gathered qualitative information.
Results: Approximately half the surveyed women would see an unfamiliar gynecologist for a Pap smear (48%) and did not have a preference for the gender of the clinician (53%). Most women (72%) were open to seeing nurse practitioners if their regular gynecologists were not available. Although few women (26%) were initially positive about receiving Pap smears in their general medical clinics, half (45%) said they would prefer that to waiting for an appointment in gynecology. Interest was especially high (52%) among women with female rather than male internists or family practitioners (33%).
Conclusions: Redesign efforts must emphasize choice in Pap smear delivery in order to increase convenience while respecting preferences for the existing system.

Chandler PJ, Chandler C, Dabbs ML
Mil Med. 2000;165:938-940

Objective: This study evaluates patient reasons and preferences for gender selection of their obstetrician-gynecologist.
Methods: A written survey was given to patients attending a military obstetrics and gynecology clinic (N = 203). Mean age was 36 years, with 69% of patients between 20 and 40 years. Caucasian (52%) and African American (34%) were the most common races.
Results: Overall, 52% of patients preferred a female practitioner, 4% preferred males, and gender did not matter for 44%. Experience and reputation were the most important factors in 93% of all patient provider selections. Only 10% of patients felt that gender was the most important factor, and 35% ranked gender as one of the top two factors.
Conclusions: Although a majority of our study population preferred female obstetrician-gynecologist providers, experience and reputation were more frequently cited than gender as the most important factors in selecting a provider. Patients felt that female physicians understand their problems better.

Frank E, Wright EH, Serdula MK, Elon LK, Baldwin G
Am J Clin Nutr. 2002;75:326-332

Background: The extent to which female physicians personally and clinically adhere to dietary recommendations is unknown and has implications for patients.
Objectives: We aimed to identify US female physicians' personal and professional nutrition- and weight-related habits and to identify which, if any, of their personal habits predicted their clinical practices.
Design: Our sample included the 4501 respondents to the Women Physicians' Health Study, a large, cross-sectional, questionnaire-based study of the health behaviors and counseling practices of US female physicians.
Results: Forty-three percent of physicians performed nutrition counseling, and 50% performed weight counseling with patients at least yearly. Forty-six percent thought that discussing nutrition was highly relevant to their practices, 47% thought the same about discussing weight, and 21% stated that they had received extensive related training. Primary care physicians, obstetricians-gynecologists, pediatricians, vegetarians, and those with a personal history of obesity were more likely to provide nutrition and weight counseling to patients. Female physicians report regularly performing more nutrition and weight counseling than they do most other types of prevention-related counseling. Female physicians report relatively healthy diet-related habits, and these personal habits are related to their likelihood to counsel their patients about nutrition and weight.
Conclusions: Nutrition and weight-related issues are important to female physicians in both their personal and professional lives, and these 2 spheres influence each other.

Saflund K, Sjogren B, Wredling R
J Psychosom Obstet Gynaecol. 2002;23:109-115

The aim of this study was to identify physicians' approaches to pregnancy subsequent to the birth of a stillborn child. In a 48-question, cross-sectional survey performed in 1997 one specific question dealt with advice given to the women/parents about possible subsequent pregnancy. The present study analyzes the responses to that open-ended question. Fifty-eight out of 61 Swedish hospitals with departments of obstetrics and gynecology participated in the study. Of 594 physicians, 552 answered the open-ended question (93%) with 802 items of advice. The most frequent approach to subsequent pregnancy, expressed by a majority of physicians, was their own support to the couples (59%). Regarding gender differences the females were more likely to mention support strategies than their colleagues (p = 0.005). Significantly more female gynecologists than male (p = 0.005) recommended care during the new pregnancy at a special antenatal clinic. The statement that 'advice depends on diagnosis' was made by 27%, while 22% advocated that parents first work through the grief of the stillbirth (mentioned significantly more often by females, p = 0.014). A minority of physicians mention giving specific advice about the timing of next pregnancy. The study highlights physicians' concerns to support parents through a subsequent pregnancy whilst demonstrating that considerable variation exists in their advice, or lack of it, with regard to timing of another pregnancy.