physician gender and patient centered communication

7/23/2019 Physician Gender and Patient Centered Communication

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Annu. Rev. Public Health 2004. 25:497519doi: 10.1146/annurev.publhealth.25.101802.123134

Copyright c 2004 by Annual Reviews. All rights reserved

PHYSICIANGENDER ANDPATIENT-CENTEREDCOMMUNICATION:A Critical Review ofEmpirical Research

Debra L. Roter1 and Judith A. Hall21Department of Health Policy and Management, Johns Hopkins Bloomberg School

of Public Health, Baltimore, Maryland 21205; email: [email protected] of Psychology, Northeastern University, Boston, Massachusetts 02115;

email: [email protected]

Key Words literature review, physician-patient communication, meta-analysis,physician-patient relationship, medical dialogue

Abstract Physician gender has stimulated a good deal of interest as a possiblesource of variation in the interpersonal aspects of medical practice, with speculationthat female physicians are more patient-centered in their communication with patients.

Our objective is to synthesize the results of two meta-analytic reviews the effects ofphysician gender on communication in medical visits within a communication frame-work that reflects patient-centeredness and the functions of the medical visit. We per-formed online database searches of English-language abstracts for the years 1967 to2001 (MEDLINE, AIDSLINE, PsycINFO, and BIOETHICS), and a hand search wasconducted of reprint files and the reference sections of review articles and other pub-lications. Studies using a communication data source such as audiotape, videotape, ordirect observation were identified through bibliographic and computerized searches.Medical visits with female physicians were, on average, two minutes (10%) longerthan those of male physicians. During this time, female physicians engaged in signifi-cantly more communication that can be considered patient-centered. They engaged inmore active partnership behaviors, positive talk, psychosocial counseling, psychoso-cial question asking, and emotionally focused talk. Moreover, the patients of femalephysicians spoke more overall, disclosed more biomedical and psychosocial informa-tion, and made more positive statements to their physicians than did the patients ofmale physicians. Obstetrics and gynecology may present a pattern different from thatof primary care: Male physicians demonstrated higher levels of emotionally focusedtalk than their female colleagues. Female primary care physicians and their patients en-gaged in more communication that can be considered patient-centered and had longer

visits than did their male colleagues. Limited studies exist outside of primary care, andgender-related practice patterns might differ in some subspecialties from those evidentin primary care.

0163-7525/04/0421-0497$14.00 497


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INTRODUCTION

Recent national reports, including two issued by the Institute of Medicine (25,

26) and the American College of Physicians Charter on Medical Professionalism(2) have focused attention on the centrality of patient-centered communication

to the safe delivery of quality medical care and the practice of ethical medicine.

Within this context, patient-centeredness has become the shorthand reference to the

inclusion of patients perspectives and preferences in care, as well as provision of

the information patients need if they want to participate in medical decision making

(16, 30). Supported by a growing body of literature linking these communication

skills to a host of valued outcomes, patient-centered communication is increasingly

regarded as a critical area of medical practice (26, 33). Indeed, the recent Institute

of Medicine reports have listed patient-centeredness among six key indicatorsshaping the nations future quality of health care agenda. Professional medical

education has similarly embraced the goal of enhanced patient-centeredness. Key

medical accrediting and licensing bodies in the United States have established that

during the next 10 years, proficiency in patient-centered communication skills will

be demanded and assessed.

Unlike traditional areas of instruction in the medical sciences and clinical prac-

tice for which medical schools have adopted curricular conformity and agreed

on criteria for mastery, communications curricula have varied widely in content,

teaching strategies, duration, and objectives (1). Some schools devote as littleas one hour to a lecture on the topic of interpersonal communication, whereas

other schools have developed sophisticated programs of experiential instruction

throughout undergraduate and graduate medical training (1). In some measure,

these curricular differences reflect the ambivalence with which communication is

regarded within the modern practice of medicine. Although many medical edu-

cators believe communication is a skill on par with other medical sciences and

should be a part of the required curriculum, others fear that communication sen-

sibilities lie within the intangible domain of medicines art, and, consequently,

cannot be operationally defined, directly taught, or explicitly evaluated. Withinthis context, there is great interest in personal attributes and characteristics that

may be associated with variation in communication ability and receptivity to skill

instruction.

Gender is a characteristic that is associated with variation in communication

style. In routine conversation, differences in the interpersonal style of women as

compared with that of men are well documented (13, 17). Women disclose more

information about themselves in conversation (12), they have a warmer and more

engaged style of nonverbal communication (17), and they encourage and facilitate

others to talk to them more freely and in a warmer and more intimate way (17). Incontrast to mens tendency to assert status differences, there is evidence that women

take greater pains to downplay their own status in an attempt to equalize status with

a conversational partner (13). Women are also more accurate in judging others feel-

ings expressed through nonverbal cues and in judging others personality traits (17).


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PHYSICIAN GENDER AND MEDICAL DIALOGUE 499

On the basis of these gender-linked conversational differences, researchers have

long speculated that female physicians may find it easier than do male physicians

to engage in communication that can be considered patient-centered (70). The pur-

pose of this chapter is to examine the contributions of physician gender to variationin patient-centered aspects of medical care communication and the implications

of these differences for communication training and quality-of-care initiatives. We

approach this goal from several directions. First, a framework for characterizing

communication elements as patient-centered is presented and applied to the results

of two meta-analytic reviews of studies. The first of these relates physician gender

to the physicians communication during medical encounters (48, 54). One might

argue that the focus on physician communication fails to appreciate the influence

of patients in shaping the doctor-patient relationship. In fact, discussions of gender

effects in medical communication have virtually ignored the question of how pa-tients behave toward male versus female physicians. This is an important question,

however, because it shifts a largely physician-centric view of communication to

one that better appreciates the reciprocal and dynamic elements of both patient

and physician in the medical interchange. Therefore, the results of a second meta-

analytic review of physician gender in relation to patients communication are also

presented (19).

Furthermore, the few studies that have investigated the communicationeffects of

a same-gender compared with a different-gender patient-physician dyad are high-

lighted. Inasmuch as communication training enhances skill both at the medicalundergraduate and postgraduate levels, studies linking gender to student perfor-

mance in communication training programs and curricula are also reviewed in

detail. Finally, policy implications and future directions in research, training, and

certification initiatives are discussed in relation to gender differences in perfor-

mance and learning.

Operationalization of a Patient-Centered Framework

Patient-centeredness has been varyingly used to describe a philosophy of medicine(15), a clinical method (33, 37), a type of therapeutic relationship (16), a quality-of-

care indicator (26), a professional and moral imperative (2), and a communication

style (6, 48). In their review of the empirical literature in this area, Mead & Bower

(38) concluded that although there is agreement on several dimensions of the con-

cept of patient-centeredness, areas of conceptual contention are evident, and there

is little consensus on operationalization of indicators or measurement approaches.

There are two important areas of conceptual ambiguity evident in the litera-

ture on patient-centered communication. The first relates to the interpretation of

physicians communication that is not explicitly identified as patient-centered, andthe second is the role and meaning attributed to patient dialogue in measures of

patient-centeredness. Although physicians communication behaviors that encour-

age patients to talk (usually operationalized as open-ended questions) are empathic

and relate to the nonmedical dimensions of care common to most patient-centered


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assessment approaches (38), there has been little discussion regarding the role of

communication that falls outside of the patient-centered domain. For example,

closed-ended questions and compliance directives are almost always used during

the course of a medical interview, and few clinicians (or patients) would arguethat the data-gathering and patient-education functions of the medical interview

could be accomplished without them (32). However, these communications are not

generally considered to be patient-centered in that they tend to restrict, control, or

direct patients in some manner. The inclusion of patient education and counseling

in the biomedical realm is likewise complex; some investigators have identified

it as an important patient-centered indicator because many studies have shown

that patients value this information, whereas other investigators have maintained

that the provision of biomedical information is a controlling communication de-

rived from a paradigm reflective of a physicians rather than a patients perspective(45).

A somewhat similar ambivalence is evident in regard to the inclusion of patient

dialogue as an element of patient-centeredness. Medical educators have largely

limited their investigations to analysis of physician behavior, although sometimes

this analysis includes physicians responsiveness to patients cues of emotional dis-

tress, concerns, or expectations (62). Others have defined patient-centeredness as a

dialogue in which an assessment of both the patients and physicians contributions

is relevant (48). As noted above, the issues evident in the classification of physi-

cian communication are also present in the classification of patient communication.For instance, investigators who include patient dialogue in their assessment would

agree that the patients provision of psychosocial information to the physician is

consistent with conceptions of patient-centeredness and the communication of the

patient narrative; however, classification of the patients biomedical disclosure is

less straightforward. Some have argued that biomedical disclosure, particularly in

response to a series of physician-directed, closed-ended questions, reflects physi-

cian dominance in the exchange. Closed-ended questions further the physicians

hypothesis-testing agenda for the visitoften without patients understanding the

significance of their responses. Yet, again, few clinicians or patients would main-tain that the data-gathering tasks of the medical interview could be accomplished

without elicitation of this information or that the information is unimportant in the

patients construction of their illness narrative.

The question arisesas to how these other-than-patient-centered behaviors should

be viewed within a communication framework. A reasonable approach may be that

of balance; no individual element of communication can be considered positive

or negative in isolation from a broader pattern of exchange established during

the visit. Furthermore, linking communication to fulfillment of the core medical

objectives of the interview enhances the relevance of communication study to thepractice of medicine.

The two meta-analyses on the subject of physician gender and communication

produced over 150 different variables abstracted from 23 studies that were sorted

into independent categories of communication, which allowed for quantitative

summarization (19, 54). For the current review, the communication variables


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TABLE 1 Categories of communication examined in relation to physician gender

Category Other communications Patient-centered communications

Data gathering MD Biomedical questions MD Psychosocial questions

MD Closed-ended questions MD Open-ended questions

PATIENT Questions (all)

Patient education MD Biomedical counseling MD Psychosocial counseling

and counseling PATIENT Biomedical disclosure PATIENT Psychosocial disclosure

Partnership building MD Active enlistment

MD Lowered dominance

Emotionally MD Emotional talk

responsive PATIENT Emotional talk

communicationNonverbal behavior MD Positive nonverbal

Positive exchange MD Positive talk

PATIENT Positive talk

Social exchange MD Social talk

PATIENT Social talk

Shows a significant effect favoring female physicians.

were reorganized into categories consistent with the literature describing patient-centeredness and the functions of the medical visit (48).

The key communication categories organized by the functions of the medical

interview are elaborated below and displayed in Table 1. These include: (a) data

gathering and facilitation of patient disclosure, (b) patient education and counsel-

ing, (c) emotional responsiveness, and (d) partnership building. (A detailed listing

of the individual variables included in each of the categories of the framework is

presented in the appendix.)

DATA GATHERING Data gathering includes those skills that further the patientsability to tell the story of his or her illness through disclosure of information that

the patient may deem meaningful (e.g., use of open-ended questions, particularly

in the psychosocial domain). We would also include all forms of patient question

asking as facilitating communication because it is useful in directing physician

disclosure to patient-defined areas of informational need.

PATIENT EDUCATION AND COUNSELING Patient education and counselinginclude

information and counseling skills (e.g., biomedical information and psychoso-

cial counseling) that assist patients in making sense of their condition and cop-ing with the medical regimen and lifestyle demands of treatment. Therefore,

both biomedical and psychosocial counseling can be considered patient-centered

communication.

From the patient perspective, the opportunity to relate the illness narrative

and reflect on experience, perspective, and interpretation of symptoms and


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circumstances may hold therapeutic value; consequently, we consider patients

disclosure, especially in the psychosocial realm, to be an indicator of the visits

patient-centered focus (49).

PARTNERSHIP BUILDING Partnership-building communication assists patients in

assuming a more active role in the medical dialogue, either through active en-

listment of patient input [e.g., asking for the patients opinion and expectations,

using interest cues, paraphrasing and interpreting the patients statements to check

for (physician) understanding, and explicitly asking for patient understanding], or

passively by assuming a less-dominating stance within the relationship (e.g., being

less verbally dominant). All physician behavior in this category can be considered

patient-centered.

Patients participatory communication reflects components of active enlistmentincluding facilitation of physician input through requests for opinion, understand-

ing, paraphrase and interpretations, and verbal attentiveness.

EMOTIONALLY RESPONSIVE COMMUNICATION Emotionally responsive communi-

cation conveys emotional content through explicitly emotional statements (e.g.,

use of empathy, reassurance, concern) and through nonverbal communication that

includes positive nonverbal behaviors (smiles, nods, friendly voice tone, relaxed

hands), and displaying a variety of behaviors that can have ambiguous, neutral,

or negative meaning depending on the context of use (e.g., touches patient, foldshands, gestures while speaking, points at the patient, speech disturbances, voice

tone measures reflecting anxiety or boredom). To avoid the difficulties associ-

ated with ambiguous interpretation, the analysis was limited to positive nonverbal

behaviors. Negative talk, however, was analyzed and reflects disagreements and

criticisms.

Less explicitly emotional categories of communication are captured in positive

and social talk. Positive talk captures the general positive atmosphere created in the

visit through verbal behaviors such as agreements, approvals, and compliments.

Social conversation defined as nonmedical exchanges largely consist of socialpleasantries and greetings, usually functioning as a linguistic bridge from the social

opening or closing of the visit to the business of the visit. Social talk is not as emo-

tionally charged as positive talk but does convey friendliness and personal regard.

Emotionally responsive communication may be considered as patient-centered

when expressed by either physician or patient.

METHODS

Studies were included in the original meta-analytic reviews if they: (a) involved

physicians, physicians in training (interns or residents), or medical students; (b) in-

volved actual or standardized patients; (c) measured communication using neutral

observers (including standardized patients as observers), audiotape, or videotape,

with an exception being the inclusion of physician-reported length of the medi-

cal visit; (d) tested for an association between physician gender and at least one


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interpretable physician or patient communication variable; (e) dealt with nonpsy-

chiatric medical visits; and (f) were published in an English-language book or

journal. The studies were identified through online database searches using a com-

bination of keywords, including doctor-patient interaction; patient-interaction;physician-patient interaction; doctor-patient relationship with female; gender

effects; female physicians; female doctors; effect of sex of doctor.

For the current review, additional studies are discussed that address physician

or student gender related to the evaluation of communication training programs.

Analytic Approach

In the meta-analyses, the standard normal deviate (Z), the statistic associated with

ap-value, was derived for each result and summed within categories of communi-cation variables. The sum was then divided by the square root of the total number

of studies to obtain a combined Zand its associated probability (combined p).

The combined p is a statistical summary that captures information that is often

embedded in null results and generally lost, and it provides a commonly under-

stood probability metric to compare results from multiple studies across variables

of interest. It is the combinedp, representing the probability that physician gender

is related to particular categories of communication, that is reported in Table 1. An

effect size (ES), Cohens d, was also calculated in the meta-analysis to estimate

the magnitude of the difference between male and female physicians communi-cation. All of the significant ES estimates were small in magnitude, ranging from

0.22 to 0.36. Because of the limited variation in the magnitude of Cohens d, these

estimates are not reported here.

Twenty-six studies were included in the meta-analytic calculations summarized

below. Most studies were conducted in primary care settings, with the exception

of two obstetrics and gynecology studies, and physicians at all levels of training

were represented. The average number of physicians was 40, with male physicians

substantially outnumbering female physicians (n = 25 and 15, respectively). The

average number of visits per study was 157; this reflected an average of 97 visits tomale physicians and 65 visits to female physicians in each study. There was wide

variation in the number of patients observed for each physician; the average was

4, and the range was 1 to 32.

Seven of these studies reported quantitative results on the relation of physician

gender to patient communication (8, 18, 51, 52, 65, 66, 68, 71), and a summary of

these results is also presented.

RESULTS

As reflected in Table 1, physician gender was related to each of the four functions

of the medical interview. (The appendix identifies individual variables that have

demonstrated a significant relationship to physician gender in at least one study

for this behavior.)


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(1) DATA GATHERING

Data gathering was characterized in terms of both content (biomedical and psy-

chosocial) and format (closed-ended and open-ended).

Physicians Question Content

As reflected in Table 1, there is evidence that female physicians ask more psychoso-

cial questions of their patients than do male physicians. Three of six studies re-

ported significant results indicating higher levels for female physicians (18, 56, 57),

and no studies reported higher levels of psychosocial questioning by male physi-

cians. For biomedical questions, two of three studies reported significant results;

one reported significantly higher levels of biomedical question asking for femalephysicians (18), whereas the other study found higher levels for male physicians

(68). Because the two significant results were of near equal magnitude, the pooled

combined p was nonsignificant. It is interesting to note that the study reporting

higher levels of biomedical question asking for females was conducted in primary

care, whereas higher levels for males were reported from a gynecology study.

Physicians Question Format

Only one of four studies coding closed questions reported significantly higher

levels for female physicians (51); however, none of the remaining three reported

higher levels for males. The pooled findings reflect a marginally significant com-

binedp(


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Analysis of findings in this area revealed mixed results. There was little consis-

tent evidence that physician gender affected medically specific counseling. Two

studies reported significant results; one (65) reported significantly higher levels

of biomedical counseling by male physicians, but the other one reported morecounseling by females (58).

A more consistent picture of gender effects emerged for psychosocial discussion

by the physician. Five of ten studies addressing psychosocial discussion reported

significantly higher levels by female rather than by male physicians (5, 8, 56, 57, 65,

66). Only one study (68) reported higher (but nonsignificant) levels of psychosocial

discussion by male physicians, and this was a study of gynecologists.

Patients Disclosure of Information

Informational disclosure by patients was similarly categorized as biomedical or

psychosocial in nature. There is clear evidence that patients of female physicians

provided more of both kinds of information than did patients of male physicians

(Table 1). Four studies (8, 18, 51, 65, 66) were each statistically significant for

biomedical information, and three studies (8, 51, 65, 66) were each significant for

psychosocial information.

Interestingly, in parallel with the finding that a gynecology study was the only

one to report higher levels of psychosocial discussion for male physicians, the

two obstetrics-gynecology studies showed higher (but nonsignificant) levels ofpsychosocial disclosure to male physicians. These results were in the opposite

direction from the primary care studies.

(3) PARTNERSHIP BUILDING

Physicians Partnership Building

By our definition, partnership building occurs when the physician actively facili-

tates patient participation in the medical visit and/or attempts to equalize status by

assuming a less dominating stance within the relationship. Twelve studies included

the active, enlistment-type variables in their coding. Six of these studies reported

significantly higher levels of active enlistment on the part of female physicians (8,

18, 31, 51, 57, 68), and two studies showed the reverse (43, 52). The combined

p is statistically significant, indicating that female physicians engaged in higher

levels of partnering behaviors than did males.

Five studies coded variables reflecting the passive, lowered-dominance ap-

proach, and one of these reported a statistically significant result indicating lowereddominance for female physicians (8). The combined pwas not significant.

Patients Partnership Building

Patients may actively facilitate physician input through requests for opinion, un-

derstanding, paraphrase and interpretations, and verbal attentiveness. Five studies


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coded this type of variable, and as Table 1 shows, there was a nonsignificant over-

all tendency for patients to direct more partnership-building behaviors to female

than male physicians. However, it is interesting to note that three of the five stud-

ies reported significant findings; two studies showed more partnership directedtoward female physicians (18, 51), and the third study, conducted in obstetrics-

gynecology, showed more partnership directed toward male physicians (52). If the

primary care and obstetrics and gynecology studies are analyzed separately, the

combinedpfor each is significant (but in the opposite direction). Thus, in general

medical practice, patients were more promotive of a partnership relationship with

female than with male physicians; however, the opposite may be true for obstetrics

and gynecology.

(4) EMOTIONALLY RESPONSIVE COMMUNICATION

Physicians Emotional Talk

Emotionally focused talk included explicit inquiries about feelings and emotions,

exploration of emotional concerns, and statements of empathy and concern. This

category is distinguished from psychosocial exchange (see above) by directly

expressing feelings and emotions. Thirteen studies coded emotional talk in some

manner; four of these found significantly higher levels for female compared with

male physicians (35, 42, 58, 69), and the combined p was significant.Both gynecology studies in the review found higher levels of emotional talk

by male physicians; one of these reported a significant result (52) and the sec-

ond (68) was marginally significant. Because the studies showed a high degree

of heterogeneity that was almost entirely explained by the two obstetrics and gy-

necology studies, the analysis was repeated for the eleven primary care studies,

which yielded a strong and consistent gender effect favoring female physicians;

analysis of the two obstetrics and gynecology studies showed a significant gender

effect favoring male physicians.

Patients Emotional Talk

Four studies measured patient emotional talk, which included statements of con-

cern, worry, and personal feelings (18, 52, 65, 66, 68). There was no evidence

of a physician gender effect on patient emotional talk. This was true for both

obstetrics-gynecology studies and general medical studies.

Physicians Positive Talk

Positive talk captured the generally positive atmosphere created in the visit through

verbal behaviors such as agreements, encouragement, and reassurance. Social

conversation was not included in this category, with the exception of two stud-

ies in which it was embedded in a composite variable otherwise comprised of

positive elements. Fourteen studies included some measure of physicians positive


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talk. Six of these studies reported significantly higher levels of positive talk by

female physicians (4, 18, 35, 51, 58, 68). No studies reported higher levels of pos-

itive talk by male physicians and the combined p summarizing these studies was

significant.

Patients Positive Talk

Positive comments by the patient, including statements of agreement, were mea-

sured in five studies and all showed higher levels of positive talk directed toward

female physicians (18, 51, 52, 65, 66, 68). In this case, the findings were not differ-

ent in the obstetrics-gynecology studies; thus patients appear to be more verbally

positive when seen by female physicians regardless of visit type.

Physicians and Patients Negative Talk

There were no significant gender differences in patient or physician negative talk.

Physicians and Patients Social Communication

There was no evidence of a gender effect for either physicians or patients social

communication.

Physicians Nonverbal Communication

Six studies coded positive nonverbal behavior in some manner, and two of these

studies reported significant results showing that female physicians demonstrate

higher levels of smiling and head nods (18) and awareness of nonverbal commu-

nication (57). No studies reported higher levels of positive nonverbal behavior for

male physicians, and the combinedp was significant.

Patients Nonverbal Communication (Global Ratingsof Patient Communication)

Patients nonverbal communication was assessed most often through global ratings

made of their communication by neutral observers (8, 52, 65, 66). Observers

listened or watched the entire physician-patient interaction and then made global

ratings of the patient in all but one study. In the one exception (18) observers

listened to short clips of patients speech that had been electronically filtered to

obscure the verbal content. Four studies (8, 18, 52, 65, 66) gathered ratings of

positive affect (friendly, warm, kind). Of these, only one study (65, 66) showed a

significant tendency for patients to display more positive global affect to female

physicians and the combinedp was not significant.

Ratings of patients assertiveness-dominance were also obtained in these four

studies and the combined p was significant, indicating that patients were more

assertive with female than male physicians.


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Length of Visit

Research shows consistently that female physicians conduct longer visits than

do male physicians. Five of the ten studies that directly measured length of visit

reported that female physicians conduct significantly longer visits than males (4,

8, 41, 51, 68). Only one study, the U.S. study of obstetricians, found longer visits

for male physicians (52). Length of visit averaged 21 min (range 7.436.7 min)

for male physicians and 23 min (range 10.537 min) for female physicians.

AMOUNT OF PATIENT TALK There is consistent evidence that patients talk more

when seen by female than by male physicians. Three of four studies examining

the amount of patient talk reported significantly higher levels in visits with female

physicians (18, 51, 65, 66). Interestingly, the one result in which patients spoke

more to male than female physicians came from the U.S. obstetrics-gynecology

study (52). As indicated by the table, the combinedp was significant.

Gender Concordance and Communication

There have been relatively few studies that have directly examined the effects

of patient and physician gender simultaneously on medical communication, but

evidence suggests that same-gender dyads strengthen the effects observed in the

reviews mentioned earlier. For instance, two U.S. studies found that medical visits

between female physicians and female patients were characterized by longer en-counter length and more equal patient and physician contributions to the medical

dialogue than were visits with all other gender combinations (18, 51). Medical

visits between male physicians and male patients were characterized by the short-

est visit time and the highest level of physician verbal dominance. Hall et al. (18)

also reported more positive statements, head nodding, and interest cues in female

concordant visits compared with other gender combinations (18, 27). A recent

comparative study of medical communication in six Western European countries

also found that female concordant dyads were longer, had higher levels of psy-

chosocial discussion, emotional exchange, and eye contact, and had lower levelsof physician verbal dominance (67). Notably, the investigators found few country-

specific differences in the pattern of results, which suggests that the observed

effects of physician and patient gender on communication appear to transcend

national and cultural borders.

ARE FEMALE LEARNERS MORE SUCCESSFULIN MASTERING COMMUNICATION

CURRICULA THAN MALES?

It is evident from the earlier analysis that female physicians engage in more patient-

centered communication with their patients than do male physicians. There is also

evidence that female learners more readily acquire communication skills during


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training than do males and score higher on related indicators of training success,

including patient satisfaction ratings and empathic sensitivity (3).

Our review identified three studies that addressed the question of student gen-

der and measures of actual communication in a skills training program. Two ofthese studies reported higher skill acquisition for female than for male medical

students (35) or residents, whereas the third failed to find a training effect for

any students (29). For instance, the Marteau et al. study (35) found that simulated

patients rated female students higher than male students on empathy, warmth, and

competence, and that the videotaped interviews of female students were scored by

trained observers as achieving higher levels of communication skill than those of

males.

Following a training program focusing on adherence counseling skills, Roter

and colleagues (50) found a pattern of skill gain that suggests both the natureof the training program and student gender are predictive of the specific gains

a student may make. Although both male and female residents showed reduc-

tions in verbal dominance and increased use of open psychosocial questions and

problem-solving skills after training, additional changes appeared to be gender

linked. Female residents increased their use of open-ended questions across all

content domains (e.g., psychosocial, therapeutic regimen, medical history), state-

ments of empathy, and use of partnership building (e.g., asking for patient opinion

and use of interest cues). Communication changes that were most notable for male

residents were increased use of closed-ended questions in regard to the therapeu-tic regimen and active partnership-building techniques, such as paraphrasing and

interpreting patient statements. Note that the domains showing most gain by fe-

males were of a more socioemotional nature than those showing the most gain

by males.

Several training programs designed to increase communication skill measured

success through a variety of indirect indicators. For instance, Smith and colleagues

(59) assessed the effect of a one-month psychosocial communication training pro-

gram for medical residents by subsequent patient ratings of residents perfor-

mance on five satisfaction dimensions. After statistically adjusting for pretrainingsatisfaction scores, the investigators found that female residents received higher

scores from their patients on ratings of empathy and opportunities to disclose

information.

A Swedish study by Holm & Aspegren (23) used a measure of affect tolerance,

an awareness of ones own feelings, as an indicator of communication training suc-

cess. Holm & Aspegren argue that awareness of ones own feelings is a prerequisite

for insight into the feelings of others and empathic ability. Prior to training, male

and female medical students scored equally on a measure of affect tolerance (based

on students descriptions of their emotional reaction to videotape clips in which avariety of emotional states were exhibited by patients). Following communication

skills training, the female students were able to describe their emotional reac-

tions to the videotape clips with greater awareness of complex and ambivalent

feelings.


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SUMMARY OF FINDINGS

Despite widespread interest in the effects of physician gender on the care process,

the literature describing these effects is small. We identified a modest numberof observational studies relating the communication process to physician gender.

Nevertheless, the pattern of results was almost entirely consistent with what one

might expect from the nonmedically related literature regarding gender differences

in communication. Female physicians spend more time during a typical visit talk-

ing with their patients than do male physicians. During this time, they engage

in communication that more broadly relates to the larger life context of the pa-

tients condition by addressing psychosocial issues through related questioning

and counseling and through greater use of emotional talk, positive talk, and active

enlistment of patient input. In contrast to the higher levels of psychosocial andsocioemotional exchange, there is little evidence that physician gender is related

to the more task-specific communication elements of care. Physician gender was

not related to the provision of biomedical information (including discussion of the

diagnosis, prognosis, and medical treatment).

Behavioral differences in the communication styles of male and female physi-

cians would be especially important if they produced corresponding gender differ-

ences in patients behavior directed back to them. Indeed, the effects of physician

gender on patient communication were evident in the small number of studies in

which this was measured, and these results suggest that patient behavior largelyreciprocates gender-linked physician behaviors. Like their physicians, patients of

female doctors talk more overall, make more positive statements, discuss more

psychosocial information, and express more partnership building than do patients

of male physicians. There were some physician communication behaviors that

were indirectly reciprocated by patients. Even though male and female physicians

did not differ in how much biomedical information they provided to their patients,

patients of female physicians provided more biomedical information to them than

to male physicians. Because female physicians ask more psychosocial questions

than their male counterparts, it may be that this type of question stimulates morepatient disclosure of both a psychosocial and a biomedical nature. Higher levels of

patient disclosure may also be fostered by female physicians more active efforts

to build partnership through inviting the patients opinions and through the use of

interest cues, such as saying uh-huh and nodding. Interestingly, though female

physicians made more emotionally focused statements than did male physicians,

patients did not direct more emotional statements back to them. Patients did, how-

ever, disclose more psychosocial information to their female physicians.

Patient and physician gender concordance appears to strengthen many of the

gender effects observed. The three studies of which we are aware that havedirectly investigated the impact of gender concordance on communication found

that female concordant visits were characterized by longer length and more equal

patient and physician contributions to the medical dialogue, more positive commu-

nication, both verbal and nonverbal, and more interest cues than all other gender


15/23


combinations. In these studies, male physicians seeing male patients tended to

have the shortest visits with the greatest biomedical focus than all other gender

combinations.

In summary, the review revealed a pattern of effects associated with physi-cian gender that goes beyond a list of individual elements of medical exchange.

Taken together, the differences reflect a patient-centered communication style that

inspires patient reciprocation and is likely to reflect a more intimate therapeutic

milieu of heightened engagement, comfort, and partnership. Although the mag-

nitude of the effects attributable to gender for any given communication element

was small, the effects are comparable to those of many well-established medical,

psychological, behavioral, and educational interventions (34, 44, 47).

Finally, our review found evidence that female learners more readily acquire

communication skills during training than do males and score higher on both directand indirect indicators of training success.

IMPLICATIONS FOR POLICY AND PRACTICE

With increasing time and productivity pressures that plague all physicians, a two-

minute-per-visit increase evident for female physician visits represents a substan-

tial time burden that could easily put a female physician an hour behind her male

colleagues at the end of a busy day. Mechanic and colleagues (40) have reportedthat the average medical visit has increased by between 1 and 2 min in the last

10 years. Despite the increase in actual time, there is a widespread perception of a

shrinking visit that may be fueled by the time-pressured atmosphere within which

physicians are providing more preventive and counseling services than in the past

(7, 22, 61, 72). In this light, female physicians may be at even further risk of falling

behind their male colleagues in daily scheduling. Henderson & Weismans analysis

(22) of the Commonwealth survey of patient-reported screening and counseling

services concluded that female physicians provided more preventive counseling

to both their male and female patients, and more gender-specific screening to theirfemale patients than did male physicians.

Time pressures to do more in limited time may amplify even further the com-

munication differences between physicians of different genders. Whereas male

physicians may respond to time pressures by dispensing with socioemotional and

psychosocial tasks, as suggested by Mechanic (39), female physicians may find

this more difficult to do (53). We suggest this because female physicians currently

record proportionately more diagnoses of a psychosocial nature than do their male

colleagues (10, 66), and the demand for diagnosis and treatment of mental health

problems in primary care is expected to grow (64).The results from the two obstetrics and gynecology studies deviate from those

of the primary care studies. As several studies have documented especially strong

patient preferences for female physicians in gynecologic and obstetric care (14, 46),

male physicians may feel pressure to meet the increasing competitive challenge


16/23

512 ROTER HALL

of growing numbers of female physicians by enhancing their own interpersonal

skills (20, 53). If this is the case, it would suggest that physicians are capable of

modifying their communication style given sufficient motivation and incentive.

The training literature is optimistic in this regard; there is ample evidence thatinstruction in communication skills is associated with improvement in skills, and

some studies show these improvements to be long lasting (11, 55, 60). In this

regard, female students again appear to have some learning advantage; neverthe-

less both male and female students benefit from training and increase their skill

levels.

What can we conclude about the consequences of these gender-related com-

munication effects in terms of the variety of patient outcomes so valued in health

services research? The reviewed studies did not systematically address patient out-

comes and no direct conclusions can be drawn. It seems likely that the effects foundare an indication of a relatively more health-promoting therapeutic milieu produced

by female physicians. Such a conclusion, however, can only be speculative because

no study has directly investigated whether patients of female physicians fare bet-

ter on clinical measures. Furthermore, whether medical care translates into better

clinical outcomes depends on much else besides simply whether the physician

seems to be doing the right things. Patients must also respect the physicians

judgment and be willing to follow through on the physicians suggestions and on

their own good intentions (regarding, for example, self-care, lifestyle, and medica-

tion adherence). Little or nothing is known about how male and female physicianscompare on these kinds of outcomes.

Moreover, because physician communication behaviors similar to those re-

viewed here have been positively related to patient satisfaction, compliance, and

recall and comprehension of information (20, 55), as well as a variety of health

outcomes (63), one might infer that female physicians have similarly favorable

outcomes. However, only for patient satisfaction is there evidence bearing on this

question, and here the literature is mixed. On average, female physicians do not

win out in popularity, as indicated by a review of studies that compare the sat-

isfaction of patients seeing male versus female physicians. Some studies showpatients to be more satisfied with male physicians, some with female physicians,

and some show no difference. It is premature to offer an explanation for this vari-

ation; we can only speculate that patients satisfaction depends both on what the

physician actually does as well as on stereotypes and expectations held by patients

or differences in patient characteristics such as health status or sociodemographics.

Future studies of physician gender and communication will need to focus greater

attention on the assessment of patient health outcomes and other indices of care

quality.

What might these results mean for male physicians? We do not suggest thatall or even most female physicians are patient-centered and male physicians are

not; there is far more common ground than difference in the communication be-

haviors of male and female physicians. Moreover, physicians, both male and fe-

male, who are skillful communicators may achieve time efficiencies that allow the


17/23


delivery of quality, patient-centered care in even-more-restricted time frames (55).

Physicians have the capacity to improve their communication skills in meaningful

ways through self-awareness, self-monitoring, and training. The potentially pow-

erful impact of patient reciprocation of both communication style and affect in themedical visit is especially important to recognize, as recognition could help create

positive exchanges and defuse negatively spiraling interaction patterns. As rec-

ognized by the Institute of Medicine and medical accreditation and credentialing

bodies, the promotion of patient-centered medicine is key to the nations future

quality-of-care agenda and to the advance of medicine, both as healing art and as

science.

APPENDIX

Below are variables abstracted from the meta-analyses of physician gender orga-

nized by the four functions of the medical visit.

Physician Communication Categories

I. Data gathering

A. Question content

1. General questions (4, 5, 41, 57, 58)Asks questions of family members, percent time taking history+,

problem-related data gathering, questions, questions on history and

nature of illness, requests information from family members, scans

other problem areas.

2. Biomedical questions (18, 65, 66, 68)

Medical questions

3. Psychosocial questions (18, 56, 57, 58, 65, 66, 68)

Asks about living situation, psychosocial questions.

4. Compliance-related questions (57, 58)Checks for compliance.

B. Question format

1. Closed questions (51, 52, 57, 58)

Closed questions, specific questions.

2. Open questions (42, 43, 51, 52, 57, 58)

Open questions, probes for information, too few open questions

(reversed).

II. Patient education and counseling1. Biomedical (4, 8, 18, 42, 51, 52, 65, 66, 68)

Biomedical counseling, biomedical information, resolution of problem,

treatment with medications, treatment without medications, medical

advice+, information on therapeutic regimen.


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514 ROTER HALL

2. Psychosocial (5, 8, 18, 52, 53, 56, 57, 67, 68)

Considers consequence of illness, considers psychosocial status, talks

about shame/taboo, critical of technical/medical developments, detects

abuse sooner

, discusses repeat consultations, discusses impact of diagno-sis on family, discusses impact of diagnosis on patient, discusses impact

of diagnosis on patient and family, discusses personal habits, discusses

physical adjustment to pregnancy, discusses emotional adjustment to preg-

nancy, discusses social adjustment to pregnancy, focuses on psychosocial

problems, focuses on patient, gives information on personal habits, gives

psychosocial counseling, gives psychosocial information, gives informa-

tion on disadvantages of medications and referrals, makes psychosocial

intervention, makes sex abuse referral and plan, minimizes prescription,

pays attention to prevention, devotes proportion of time discussing fam-ily problems, devotes proportion of time discussing preventive services,

refers to living situation, refers to self-help groups, shows relationship of

problem to life, uses family to implement treatment.

III. Partnership building

A. Enlistment (8, 18, 31, 36, 41, 43, 51, 52, 57, 58, 65, 66, 68)

Accepts patient norms and values, uses active listening skills, allows com-

plete initial concern statement+, asks for clarification, asks for patient opin-

ion, asks for self-treatment, asks for reassurance, uses back channels,

checks+ and considers complaints seriously, elicits expectations for treat-

ment, elicits feedback, elicits patient expectations, elicits rationale for visit,

encourages patient to tell story, encourages patient paraphrase, listens atten-

tively, paraphrases, makes partnership statements+, picks up on patients

verbal leads, is patient-centered, reflects shared decision making, under-

stands perception of complaints, shows verbal attentiveness.

B. Lowered dominance (8, 21, 43, 58, 65, 66)

Egalitarian, not dominant, overall control of presentation (reversed), per-

cent MD talk to total (reversed), respectful

, too much control of interview(reversed).

IV. Responding to emotions

A. Social conversation (4, 18, 52, 53, 57, 58, 68)

Social conversation, quality of greeting.

B. Positive talk (4, 8, 18, 21, 35, 41, 42, 51, 52, 57, 58, 66, 68, 69)

Acknowledgment, agreement, approval, encouragement, encouragement/

reassurance, laughs/jokes, positive composite, positive talk, puts patient at

ease, rapport, reassurance, reinforcement, shared laughter,social behaviors,

warm.

C. Negative talk (18, 21, 42, 51, 52, 57, 58, 65, 66, 68)

Anger, anxiety, criticizes patient, disagreement, disapproval, does not avoid

criticism+, negative talk.


19/23


D. Focus on emotions (8, 18, 28, 35, 42, 43, 51, 52, 57, 58, 65, 66, 68, 69)

Asks about patients satisfaction, concern+, discusses doctor-patient

relationship, discusses own emotional response, elicits patient feelings,

emotional probes

, emotional talk, empathy

, explores emotional concern,interest/concern, legitimation, reflection, reflects patients feelings, shows

concern, stimulates patient to share problems.

E. Nonverbal communication

1. Positive nonverbal behaviors (18, 42, 57, 58, 66, 68)

Awareness of nonverbal communication, relaxed hands, friendly voice

tone (filter), nod, patient-directed gaze, smile, uses appropriate non-

verbal communication, uses eye contact.

2. Negative nonverbal behaviors (18, 21, 42)Anxious voice tone (electronically filtered speech), bored voice tone

(electronically filtered speech)+, speech disturbances, tense hands/fists.

3. Neutral nonverbal behaviors (18, 21, 42)

Touches patient, touches self, folds hands/arms, gestures while speaking,

points at patient, manipulates objects, interrupts patient, simultaneous

speech, speech pitch, speech amplitude, speech rate.

F. Length of Visit (4, 5, 8, 18, 31, 41, 51, 52, 65, 66, 68)

Observed visit time

+

Patient Communication Categories

I. Data gathering (18, 51, 52, 65, 66, 68)

Patient asks questions, asks psychological questions, asks medical questions,

asks clarifying questions.

II. Information giving

1. Biomedical (8, 18, 51, 52, 65, 66, 68)

Patient gives biomedical information.

2. Psychosocial (8, 18, 51, 52, 65, 66, 68)

Patient gives psychosocial information.

III. Partnership building (18, 51, 52, 65, 66, 68)

Partnership statements, verbal attentiveness.

IV. Responding to emotions

A. Social conversation (18, 51, 52, 68)

Nonmedical chit chat, social conversation.

B. Positive talk (18, 51, 52, 65, 66, 68)

Positive talk, social behaviors (composite).

C. Negative talk (18, 51, 52, 65, 66, 68)

Disagreement, criticism


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516 ROTER HALL

D. Focus on emotions (18, 52, 65, 66, 68)

Emotional talk, discusses MD-Patient relationship, shows concern.

E. Nonverbal communication (8, 18, 52, 65, 66)

Global ratings of the following emotions: anger+, warmth, assertive-ness, anxiety, dominance, interest, friendliness, relaxed, submissive,

bored, calmness in voice tone (filter), friendliness in voice tone (filter).

Difference shows significantly higher levels for female physicians in at least

one study for this behavior.+Difference shows higher levels for male physicians in at least one study for

this behavior.

TheAnnual Review of Public Healthis online athttp://publhealth.annualreviews.org

LITERATURE CITED

1. Am. Assoc.Med. Coll. (AAMC). 1999.Re-

port III: Contemporary Issues in Medicine:

Communication in Medicine. Medical

School Objectives Project. Washington,

DC: AAMC

2. ABIM Found., ACP-ASIM Found., Eur.Fed. Inter. Med. 2003. Charter on medical

professionalism. 2002. Ann. Intern. Med.

136:24346

3. Aspegren K. 1999. BEME Guide No.

2: teaching and learning communication

skills in medicinea review with quality

grading of articles. Med. Teach. 21:563

70

4. Bernzweig J, Takayama JI, Phibbs C, Lewis

C, Pantell RH. 1997. Gender differences

in physician-patient communication: evi-

dence from pediatric visits. Arch. Pediatr.

Adolesc. Med.151:58691

5. Bertakis KD, Helms LJ, Callahan EJ, Azari

R, Robbins JA. 1995. The influence of gen-

der on physician practice style.Med. Care

33:40716

6. Byrne JM, Long BEL. 1976.Doctors Talk-

ing to Patients. London: Her Majestys Sta-tion. Off.

7. Carr-Hill R, Jenkins-Clarke S, Dixon P,

Pringle M. 1998. Do minutes count? Con-

sultation lengths in general practice. J.

Health Serv. Res. Policy3:297313

8. Charon R, Greene MG, Adelman R. 1994.

Women readers, women doctors: a femi-

nist reader-response theory for medicine. In

The Empathic Practitioner: Empathy, Gen-

der, and Medicine, ed. ED More, MS Milli-

gan, pp. 20521. New Brunswick, NJ: Rut-gers Univ. Press

9. Colliver JA, Vu NV, Marcy ML, Travis TA,

Robbs RS. 1993. Effects of examinee gen-

der, standardized-patient gender, and their

interaction on standardized patients rat-

ings of examinees interpersonal and com-

munication skills.Acad. Med.68:15357

10. Cypress BK. 1980. Characteristics of Visits

to Female and Male Physicians. Vital and

Health Statistics 13[49]. Hyattsville, MD:

U.S. Dep. Health Hum. Serv.

11. Davis DA, Thomson MA, Oxman AD,

Haynes RB. 1995. Changing physician per-

formance: a systematic review of the effect

of continuing medical education strategies.

JAMA6:7005

12. DindiaK,AllenM.1992.Sexdifferencesin

self-disclosure: a meta-analysis. Psychol.

Bull.112:1062413. Eagly AH, Johnson BT. 1990. Gender and

leadership style: a meta-analysis. Psychol.

Bull.108:23356

14. Elstad J. 1994. Womens priorities regard-

ing physician behavior and their preference


21/23


for a female physician. Women Health

21:119

15. Engel GL. 1977. The need for a new medi-

calmodel:a challengefor biomedicine.Sci-

ence196:12936

16. Gerteis M, Edgman-Levitan S, Daley J,

Delbanco TL. 1993.Through the Patients

Eyes. San Francisco, CA: Jossey Bass

17. Hall JA. 1984.Nonverbal Sex Differences:

Communication Accuracy and Expressive

Style. Baltimore, MD: Johns Hopkins Univ.

Press

18. Hall JA, Irish JT, Roter DL, Ehrlich CM,

Miller LH. 1994. Gender in medical en-counters: an analysis of physician and pa-

tient communication in a primary care set-

ting.Health Psychol.13:38492

19. Hall JA, Roter DL. 2002. Do patients

talk differently to male and female physi-

cians? A meta-analytic review. Patient

Educ. Couns.48:21724

20. Hall JA, Roter DL, Katz NR. 1988. Meta-

analysis of correlates of provider behavior

in medical encounters.Med. Care26:65775

21. Harrigan JA, Gramata JF, Lucic KS, Mar-

golis C. 1989. Its how you say it: physi-

cians vocal behavior. Soc. Sci. Med.

28:8792

22. Henderson JT, Weisman CS. 2001. Physi-

cian gender effects on preventive screening

and counseling: an analysis of male and

female patients health care experiences.

Med. Care39:12819223. Holm U, Aspegren K. 1999. Pedagogical

methods and affect tolerance in medical

students.Med. Educ.33:1418

24. HustonS,SleathB,RubinRH.2001.Physi-

cian gender and hormone replacement ther-

apy discussion. J. Womens Health Gend.

Based. Med.10:27987

25. Inst. Med. 1999. To Err is Human; Build-

ing a Safer Health System, ed. LT Kohn,

JM Corrigan, MS Donaldson. Washington,

DC: Natl. Acad. Press

26. Inst. Med. 2001. Crossing the Quality

Chasm: A New Health System. Washing-

ton, DC: Natl. Acad. Press

27. IrishJT, HallJA. 1995. Interruptive patterns

in medical visits: the effects of role, status

and gender.Soc. Sci. Med.41:87381

28. Jarski RW, Gjerde CL, Bratton BD, Brown

DD, Matthes SS. 1985. A comparison

of four empathy instruments in simu-

lated patient-medical student interactions.

J. Med. Educ.60:54551

29. Joos SK, Hickam DH, Gordon GH, Baker

LH. 1996. Effects of a physician commu-

nication intervention on patient care out-

comes.J. Gen. Intern. Med. 11:14755

30. LaineC, Davidoff F. 1996. Patient-centered

medicine: a professional evolution. JAMA275:15256

31. Law SAT, Britten N. 1995. Factors that in-

fluence the patient centeredness of a con-

sultation.Br. J. Gen. Pract. 45:52024

32. Lazare A, Putnam SM, Lipkin M. 1995.

Three functions of the medical interview.

In The Medical Interview: Clinical Care,

Education, and Research, pp. 319. New

York: Springer-Verlag

33. LipkinM,PutnamSM,LazareA.1995. TheMedical Interview: Clinical Care, Educa-

tion, and Research. New York: Springer-

Verlag

34. LipseyMW, Wilson DB.1993. Theefficacy

of psychological, educational, and behav-

ioral treatment: confirmation from meta-

analysis.Am. Psychol.48:1181211

35. Marteau TM, Humphrey C, Matoon G,

Kidd J, Lloyd M, Horder J. 1991. Fac-

tors influencing the communication skillsof first-year clinical medical students.Med.

Educ.25:12734

36. Marvel K, Epstein RM, Flowers J,

Beckman HB. 1999. Soliciting the pa-

tients agenda: Have we improved? JAMA

281:28387

37. McWhinney I. 1989. The need for a trans-

formed clinical method. In Communicating

with Medical Patients, ed. M Stewart, DL

Roter, pp. 2540. Newbury Park, CA: Sage

38. Mead N, Bower P. 2000. Patient-

centredness: a conceptual framework and

review of the empirical literature.Soc. Sci.

Med.51:1087110


22/23

518 ROTER HALL

39. Mechanic D. 1996. Changing medical or-

ganization and the erosion of trust.Milbank

Q.74:17189

40. Mechanic D, McAlpine DD, Rosenthal M.

2001. Are patients office visits with physi-

cians getting shorter? N. Engl. J. Med.

344:198204

41. Meeuwesen L, Schaap C, van der Staak

C. 1991. Verbal analysis of doctor-patient

communication.Soc. Sci. Med. 32:1143

150

42. Mendez A, Shymansky JA, Wolraich M.

1986. Verbal and non-verbal behaviour of

doctors while conveying distressing infor-mation.Med. Educ.20:43743

43. Meuleman JR, Harward MP. 1992. Assess-

ing medical interview performance: effect

of interns gender and month of training.

Arch. Intern. Med.152:167780

44. Meyer GJ, Finn SE, Eyde LD, Kay GG,

Moreland KL, et al. 2001. Psychological

testing and psychological assessment: a re-

view of evidence and issues. Am. Psychol.

56:1286545. Mishler EG. 1984. The Discourse of

Medicine: Dialectics of Medical Inter-

views.Norwood, NJ: Ablex

46. Pearse WH. 1994. The Commonwealth

Fund Womens Health Survey: selected re-

sults and comments. Womens Health Is-

sues4:3847

47. Rosenthal R. 1991. Meta-Analytic Proce-

dures for Social Research. Newbury Park,

CA: Sage48. Roter DL. 2000.Theenduring and evolving

nature of the patient-physician relationship.

Patient Educ. Couns.39:515

49. Roter DL, Hall JA. 1992. Doctors Talking

to Patients/Patients Talking to Doctors: Im-

proving Communication in Medical Visits.

Westport, CT: Auburn House.

50. Roter D, Larson S, Shinitzky H, Chernoff

R, Serwint JR, et al. 2004. Use of an inno-

vative video feedback technique to enhance

communication skills training.Med. Educ.

In press

51. Roter D, Lipkin M Jr, Korsgaard A. 1991.

Sex differences in patients and physicians

communication during primary care medi-

cal visits.Med. Care29:108393

52. Roter DL, Geller G, Bernhardt BA, Larson

SM, Doksum T. 1999. Effects of obstetri-

cian gender on communication and patient

satisfaction.Obstet. Gynecol.93:63541

53. Roter DL, Hall JA. 1998. Why physician

gender matters in shaping the physician-

patient relationship. J. Womens Health

7:109397

54. Roter DL, Hall JA, Aoki Y. 2002. Physician

gender effects in medical communication:

a meta-analytic review. JAMA 288:756

6455. Roter DL, Hall JA, Kern DE, Barker LR,

Cole KA, Roca RP. 1995. Improving physi-

cians interviewing skills and reducing pa-

tients emotional distress: a randomized

clinical trial.Arch. Intern. Med.155:1877

84

56. Saunders DG, Kindy P Jr. 1993. Predictors

of physicians responses to woman abuse:

the role of gender, background, and brief

training.J. Gen. Intern. Med. 8:606957. Shapiro J. 1990. Patterns of psychoso-

cial performance in the doctor-patient en-

counter: a study of family practice resi-

dents.Soc. Sci. Med.31:103541

58. Shapiro J, Schiermer DD. 1991. Resident

psychosocial performance: a brief report.

Fam. Pract.8:1013

59. Smith RC, Lyles JS, Mettler JA, Marshall

AA, Van Egeren LF, et al. 1995. A strategy

for improving patient satisfaction by the in-tensive training of residents in psychosocial

medicine: a controlled, randomized study.

Acad. Med.70:72932

60. Smith RC, Lyles JS, Mettler JA, Mar-

shall AA, Van Egeren LF, et al. 2000.

Evidence-based guidelines for teach-

ing patient-centered interviewing. Patient

Educ. Couns.39:2736

61. Stafford RS, Saglam D, Causino N,

Starfield B, Culpepper L, et al. 1999.

Trends in adult visits to primary care physi-

cians in the United States.Arch. Fam. Med.

8:2632

62. Stewart M, Brown BJ, Weston WW,


23/23


McWhinney I, McWilliam CL, Freeman

TR, eds. 1995. Patient-Centered Medicine:

Transforming the Clinical Method. Thou-

sand Oaks, CA: Sage

63. Stewart MA. 1996. Effective physician-

patient communication and health out-

comes: a review. Can. Med. Assoc. J.

152:142333

64. U.S. Dep. Health Hum. Serv. 1999.Mental

Health: A Report of the Surgeon General.

Rockville, MD: U.S. Dep. Health Hum.

Serv.

65. Van den Brink-Muinen A. 1996. Gender,

Health and Health Care in General Prac-tice.Utrecht, The Neth.: NIVEL

66. Van den Brink-Muinen A, Bensing JM,

Kerssens JJ. 1998. Gender and communi-

cation style in general practice: differences

between womens health care and regular

health care.Med. Care36:1006

67. Van den Brink-Muinen A, van Dulmen S,

Messerli-Rohrbach V, Bensing J. 2002. Do

gender dyads have different communcation

patterns? A comparative study in western-

European general practices. Patient Educ.

Couns.48:25364

68. Van Dulmen AM, Bensing JM. 2000. Gen-

der differences in gynecologist communi-

cation.Women Health30:4961

69. Wasserman RC, Inui TS, Barriatua RD,

Carter WB, Lippincott P. 1984. Pedi-

atric clinicians support for parents makes

a difference: an outcome-based analysis

of clinician-parent interaction. Pediatrics

74:104753

70. Weisman CS, Teitelbaum MA. 1989.

Women and health care communication.Patient Educ. Couns.13:18399

71. West C. 1984. Routine Complications:

Troubles With Talk Between Doctors and

Patients. Bloomington, IN: Indiana Univ.

Press

72. Yarnall KSH, Pollack KI, Ostbye T, Krause

KM, Michener JL. 2003. Primary care: Is

there enough time for prevention? Am. J.

Public Health93:63541

physician gender and patient centered communication

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