- Top of page
- SUBJECTS AND METHODS
- AUTHOR CONTRIBUTIONS
- Supporting Information
IDM has been defined as a meaningful dialog between patient and physician instead of a unidirectional, dutiful disclosure of alternatives, risks, and benefits by the physician to the patient (). With calls for more sharing of decision making (), the onus is on physicians to ensure that patients have all the information they need and that they understand their options, and then to help them to make an informed decision that corresponds with their preferences. This process is particularly important in making a decision about an elective surgical procedure such as TKA. We found that such dialog may be more problematic for women. Physicians in our study included fewer IDM elements and had poorer interpersonal skills during the consultation when the patient was a woman compared to a man. Physicians provided less medical information and less encouragement to participate in the decision to undergo TKA to the woman compared with the man, irrespective of their recommendation regarding TKA. In prior research, we demonstrated that physicians were more likely to recommend TKA to a man than to a woman (). Together, these results suggest that gender bias may be influencing both physicians' clinical decision making and physicians' interpersonal behavior, providing further support that physicians may contribute to the gender differences in the treatment of osteoarthritis ([5, 24, 25]).
This study adds to the increasing evidence that stereotyping based on patients' demographic characteristics such as race/ethnicity ([8, 9, 26, 27]), socioeconomic status (), and sometimes gender ([6, 28, 29]) affects physicians' treatment recommendations and physicians' interpersonal behavior during the clinical encounter, suggesting that physicians may contribute to disparities in health care utilization ([5, 30-34]). Although prior studies have shown that physicians provide less information and are less participatory with minority patients ([8, 9, 26]) and less educated and lower-income patients (), for gender, the data are equivocal.
Some studies have shown that women receive more medical information and have more participatory clinical encounters than men ([8, 9, 35]), whereas others have found the opposite () or clarified that women receive more information, since women ask more questions ([8, 35]). An important limitation of these observational studies is that some compared recordings of physicians' conversations with male and female patients whose chief symptom, presenting symptoms, and other medically relevant factors were not the same ([8, 35]). In our study, the physicians were blinded and presented with identical scenarios differing only in gender. Other studies relied on patients' reports of physicians' decision-making style, so we cannot be certain whether physicians varied in response to the patients' characteristics or whether patients differed in their reporting of physician style (). We too used patients to report physicians' behavior; however, our standardized patients were extensively trained, periodically monitored, and not informed of this study's purpose. Also, our statistical analysis accounted for the clustered data, which should minimize the bias from potential systematic differences in standardized patients' recording of physicians' behavior. Furthermore, standardized patient assessments have been found to be both reliable and valid ().
One possible explanation for the influence of patient gender on physicians' interpersonal behavior includes physicians' conscious beliefs or unconscious stereotypes about the patient. Physicians have been shown to exhibit stereotyping toward patients on the basis of their gender (). Physicians may make assumptions about a patient's level of social support or whether they live alone, and caregiver responsibilities. Also, because physicians ask women fewer questions, they may rely on their assumptions about women (). There is extensive research that all humans share the cognitive strategy of automatically applying beliefs and expectations about groups of people and generalizing these beliefs to all of the individuals belonging to that group ([40, 41]). This strategy is thought to simplify the vast amounts of information to which we are exposed, making our cognitive processing more efficient (). That physicians are immune to social categorization and stereotyping is unrealistic.
An alternate explanation is that patients' communicative behaviors influenced physicians' interpersonal behavior, which may or may not in turn have been influenced by the physicians' behavior ([7, 43, 44]). Four ways by which a patient can influence physicians' behavior include providing a health narrative, asking questions, expressing concerns, and being assertive ([44, 45]). However, our male and female standardized patients presented identical scenarios with the same chief symptom as their standard opening sentence to all physicians, they were trained not to ask questions (other than parroting the physician to help the encounter seem natural) or be assertive, and the only concern that was expressed was via a prompt, “Do you think I need a new knee?” at the end of the visit only if the physician had not recommended and/or freely offered TKA or referral to an orthopedic surgeon. Despite this, their manner of presentation may have been different by virtue of them being a man and a woman. However, had our female standardized patient asked more questions, as evidence shows women tend to do ([8, 35]), this should have resulted in physicians providing more information and having more participatory clinical encounters with her, not less.
A third and final explanation is that physicians are simply not aware of the elements that are important to IDM and lack the interpersonal skills necessary to be able to communicate effectively. Our findings are consistent with other studies that used the IDM scale ([18, 20, 46]) in that IDM for a complex decision was often incomplete. Our IDM scores for the male patient were similar for most elements, but were somewhat higher for discussion of the patient's role in decision making, discussion of the alternatives, and assessment of the patient's understanding of the decision, which may be explained by differences in the studies, specifically that in prior research, the majority of patients were women and most visits were not their first visit to the physician. We demonstrated that deficits in patient–physician communication were significantly greater for the woman. Many advocate communication skills programs for medical students, residents, and practicing physicians that focus on patient-centeredness ([10, 13, 18, 19, 26]) and have even used standardized patients for teaching and evaluating these skills ([13, 19]).
Based on our data, programs such as these will benefit patients in general and women in particular. When the woman was consulted for TKA, compared with the man, physicians were less likely to discuss the nature of the decision, and seldom discussed her role in decision making, explored whether she understood the decision, or elicited her preferences. In essence, since shared decision making takes at least “two to tango” (), most physicians did not ask the woman “to dance.” Physicians also rarely discussed the recovery postsurgery, which we know to be a specific concern for women (). Physicians able to meet patients' informational needs not only satisfy patients' desire for information, but are interpreted by patients to be more concerned about them as people (). Women are more likely than men to prefer an active role in clinical decision making () and a collaborative style of communication () with their physicians. The physicians' failure to include elements or discuss items important to patients may result in them being less likely to accept physicians' recommendations (), and therefore could contribute to the gender disparity in TKA utilization. Patient preferences did not play a role in this study because standardized patients were scripted as being willing to undergo surgery.
A patient-centered approach may be part of the remedy to address the physicians' contribution to the gender disparity in TKA utilization. However, regardless of physicians' recommendation regarding TKA, patient gender influenced physicians' interpersonal behavior. Physicians recommending TKA still included 1.6 fewer IDM elements on average (P = 0.001) and had poorer interpersonal skills (P < 0.001) when the patient was a woman compared to a man. For a complex decision such as arthroplasty surgery or referral to an orthopedic surgeon, all 7 IDM elements should be present for the consultation to be considered complete (). Only for the man did the mean number of IDM elements meet the minimum of 5 for the consultation to be considered adequate for a patient to be able to weigh their increased mobility and decreased pain against the risks of morbidity and mortality of the procedure (). We also found that physicians who include more IDM elements during the consultation are more likely to recommend TKA, suggesting that IDM may be a potential confounder in the model used to assess the effect of patient gender on physicians' recommendations for TKA (). However, regardless of the extent of IDM present in the consultation, physicians remained less likely to recommend TKA to a female patient than to a male patient (OR 2.3 [95% CI 1.2, 4.3], P = 0.03). Therefore, an educational intervention designed to improve IDM and interpersonal skills may not completely address physicians' gender biases and the gender disparity in total joint arthroplasty. In addition to including gender sensitivity in medical curricula (), perhaps what is needed is an additional skills component to patient-based care that provides physicians with the capacity to consciously replace automatically activated stereotypes ([40, 52, 53]).
Contrary to other research findings ([8, 54]), we found that physicians spent less time with the woman than the man during the consultation. IDM increased as the duration of the visit increased. Indeed, for those physicians with mean IDM scores between 0 and 3 compared with physicians with mean IDM scores between 4 and 7, the length of the visit was, on average, 15 minutes and 22 minutes, respectively (P < 0.001). Based on audiotapes of actual orthopedic practice, Braddock et al () also found a greater extent of IDM with an increased duration of the visit. The Medical Outcomes Study also reported the same relationship and proposed that visits of at least 20 minutes may be needed to involve patients effectively in treatment decisions (). Changes in the way physicians are remunerated may alleviate the time pressures and demands of medical practice, thereby reducing cognitive resources and discouraging stereotyping ().
Our study has several potential limitations. First, standardized patients visited only those physicians who agreed to be visited. Our volunteer participants are probably more likely to have a greater interest in improving medical care and may have more skill in assessing and treating patients. If bias were found in these physicians, then probably similar or greater bias would be found in the wider community. Second, we relied on patients to report physicians' interpersonal behavior. However, our standardized patients underwent extensive training and monitoring. Third, since this was a cross-sectional study, we did not have the benefit of observing the patient–physician relationship develop over time. However, even at the first visit, we maintain that at minimum the physician should have included the requisite elements for a basic clinical decision: a discussion of the clinical issue or nature of the decision and elicitation of the patients' preference. Fourth, the study was performed in a single province in Canada. However, because universal health care reduces access barriers to the procedure, Ontario was an excellent setting for this study. Furthermore, because disparities in access to health care have also been found in the US, our results are likely not specific to physicians in Ontario alone. Finally, this was a study of a single surgical procedure. We chose this procedure because of the known gender disparity () and have no reason to believe the results would differ for other procedures or treatment.
In conclusion, physicians included fewer IDM elements and had poorer interpersonal behavior during the consultation when the patient was a woman compared to a man. Although physicians recommending TKA were more participatory, they still included significantly fewer IDM elements when the patient was a woman compared to a man. Also, regardless of physicians' participatory decision-making style and communication skills, physicians were less likely to recommend TKA to a female patient than to a male patient. Our findings suggest that in addition to directly influencing clinical decision making, gender bias may also influence physicians' interpersonal behavior. Because educational interventions designed to improve patient–physician communication are not likely to target physicians' unconscious stereotypes about patients, they are probably not sufficient to address the physicians' contribution to treatment disparities.