http://informahealthcare.com/pog ISSN: 0167-482X (print), 1743-8942 (electronic) J Psychosom Obstet Gynaecol, 2014; 35(1): 1–7 ! 2014 Informa UK Ltd. DOI: 10.3109/0167482X.2013.866646
ORIGINAL ARTICLE
Stereotyped beliefs about male and female OB-GYNS: relationship to provider choice and patient satisfaction Katherine S. Buck and Heather L. Littleton Department of Psychology, East Carolina University, Greenville, NC, USA
Abstract
Keywords
Background: Up to 60% of women prefer a female obstetrician-gynecologist (OB-GYN), perhaps in part due to holding negative stereotypes of male providers. However, provider gender stereotypes have not been directly examined. The purpose of the current studies was to evaluate women’s stereotypes of male and female OB-GYN providers and the impact of these stereotypes on provider evaluations. Methods: First, stereotypes of male and female OB-GYNs were elicited from 96 undergraduate women who described the attributes and behaviors of a typical male or female OB-GYN. Next, 126 undergraduate women were randomized to review recordings depicting male or female OB-GYNs engaging in male or female-stereotype congruent behaviors during a well-woman visit. Results: Participants overall had positive stereotypes of female OB-GYNs (e.g. knowledgeable, easy to talk to) but some negative stereotypes of males (e.g. unable to fully understand women’s health issues). However, male and female OB-GYNs who engaged in female stereotype-congruent behaviors were similarly preferred over providers who engaged in malestereotype congruent behavior. Conclusion: Women generally regard female OB-GYNs as highly competent, whereas some believe that being male is a disadvantage in providing OB-GYN care. However, providers who engage in behaviors associated with high quality care are evaluated positively, regardless of the provider’s gender.
Gender differences, medical education, obstetrics/gynecology, patient satisfaction, stereotypes
The gender composition of U.S. obstetrician-gynecologists (OB-GYN) has changed substantially, with the proportion of OB-GYNs who are female greatly increasing [1]. Indeed, in 2011 the proportion of male senior fellows in the American College of Obstetricians and Gynecologists was 58%, whereas only 23% of junior fellows were male. Strikingly, only 17% of 2010 applicants to OB-GYN residencies were male [2]. The reduction in men entering the field of OB-GYN could reflect lack of interest in pursuing a women’s health specialty; however, there is also evidence that male medical students are being actively discouraged from choosing OB-GYN, and may be targets of gender-based discrimination in OB-GYN clerkships, such as being socially excluded and prevented from performing procedures [3–6]. An important factor that may be contributing to exclusion of male medical students during training, and the discouragement of men from pursuing
Address for correspondence: Heather Littleton, Department of Psychology, East Carolina University, 104 Rawl, Greenville, NC 27858, USA. Email: [email protected]
Received 9 April 2013 Revised 11 October 2013 Accepted 13 November 2013
OB-GYN as a medical specialty is the belief that women are unwilling to receive care from a male provider. Indeed, a sizable proportion of women (35–60%) prefer a female OBGYN [7], with consistent findings among women of diverse socioeconomic, ethnic and religious backgrounds [8–11]. Women also often list provider gender as a key part of their decision-making process when choosing an OB-GYN [11]. This preference for a female provider is somewhat surprising given that male OB-GYN providers have been found to engage in more patient-centered behaviors, such as asking questions about emotional and social issues, encouraging patients to speak about these issues, and working to form partnerships with patients [12]. Engaging in patient-centered behaviors is consistently related to greater satisfaction with providers [13,14]. However, some recent work examining the interaction between provider gender and patient-centered behaviors on patient satisfaction may shed some light on this seeming discrepancy. Roter and colleagues [15] reviewed recordings of patient OB visits and found that women were more satisfied with female providers than male providers, even though males engaged in more patient-centered behaviors. In addition, in a computerized physician analogue study,
20 14
Introduction
History
2
K. S. Buck & H. L. Littleton
Schmid-Mast and colleagues [14] found that female patients were less satisfied with male primary care providers who engaged in patient-centered behaviors, but more satisfied with female providers who did so. Taken together, these studies suggest that women have gender-based expectations for physician behaviors which influence their satisfaction. In other words, women may be most satisfied with providers whose behavior is consistent with their stereotypes for how male and female physicians should behave. Thus, women’s stereotyped ideas about male and female providers may be influential in shaping their satisfaction and provider choice. It is possible that women believe that men are less likely to possess the personal qualities necessary to provide good OB-GYN care. Indeed, research on gender stereotypes supports that characteristics that women regard as highly important for an OB-GYN to possess, such as being kind and helpful, are regarded as female characteristics [10,16]. It is also possible that male providers who do not behave in accordance with gender-based stereotypes (i.e. those who engage in high levels of patient-centered behaviors) may be viewed less positively than females who do so because they are violating gender norms. Finally, while not previously investigated, it is possible that some women believe that men are less able to provide high quality care, for example because they cannot fully understanding women’s health issues due to a lack of personal experience. The current study therefore sought to evaluate women’s stereotypes of male and female OB-GYN providers, as well as the role of provider gender and behaviors on provider evaluation and patient satisfaction. Two studies were conducted to accomplish these aims. In study one, women’s stereotypes about male and female OB-GYNs were elicited. In study two, the influence of both OB-GYN provider gender and provider behaviors (whether the provider behaved in a way consistent with stereotypes of male or female providers) on women’s evaluation of OB-GYN providers was experimentally evaluated.
Study one The goal of study one was to identify differences in women’s stereotypes of male and female OB-GYNs. It was hypothesized that female providers would be stereotyped as possessing more ‘‘caring’’ attributes (e.g. empathic, understanding), whereas male providers would be stereotyped as possessing more ‘‘dominant’’ attributes (e.g. professional, competent). It also was hypothesized that some women would hold negative stereotypes of male OB-GYN providers. Methods Participants A total of 104 women were recruited from the Psychology department participant pool at a large southeastern U.S. university. This pool consists of students taking introductory psychology, a general education requirement, and thus participants are fairly representative of enrolled students. Eight participants were excluded from analyses for not following directions, leaving a final sample of 96 participants. Their mean age was 18.6 years and 60.4% of participants
J Psychosom Obstet Gynaecol, 2014; 35(1): 1–7
self-identified as European American, 28.1% as African American, 7.3% as Latina and 4.2% as multi-ethnic. The ethnic composition of the sample was similar to the university as a whole [17]. Materials and procedures Participants were recruited to complete a study of women’s ideas about health care providers and participated in small groups. They were randomly assigned to write about the attributes of a typical male or female OB-GYN, as well as provide a script of a typical well-woman visit. Participants also provided their OB-GYN gender preference. Participants received course credit and the study was approved by the university institutional review board. Analysis plan The OB-GYN attribute data was coded by trained raters who read all responses and listed all attributes. A final list of attributes was then created and each participant’s data were coded by two raters. The visit scripts were first examined for relevant events and a coding sheet of events was created. Each participant’s script data was coded by two raters. Before conducting analyses, attributes and script events not mentioned in at least 15% of descriptions for either physician gender were eliminated [18,19]. Recruiting 96 women resulted in 48 women in each group, which allowed for sufficient power to detect medium-sized differences in proportion [20]. Results Among participants, 78% had a preference or strong preference for a female OB-GYN whereas only 4% preferred a male OB-GYN. A total of 51 provider attributes were identified, of which 15 were present in at least 15% of the provider descriptions. Inter-rater agreement averaged 96% and coding discrepancies were resolved by the first author. As summarized in Table 1, both ‘‘knowledgeable’’, and ‘‘easy to talk to’’ were significantly more frequently listed as typical attributes
Table 1. Frequency of descriptions of typical OB-GYN provider attributes stratified by OB-GYN gender.
Attribute Awkward Describes procedures Easy to talk to Knowledgeable Non-judgmental Professional Informative Experienced Good personality Comforting Kind Gentle Caring Empathic Appropriate
Male providers % (n) 20.8 10.4 4.2 8.3 8.3 25.0 6.2 20.8 16.7 42.0 18.8 12.5 14.6 10.4 16.7
yp50.10; *p50.05; **p50.01.
(10) (5) (2) (4) (4) (12) (3) (10) (8) (20) (9) (6) (7) (5) (8)
Female providers % (n) 0.0 27.1 22.9 29.2 20.8 14.6 16.7 10.4 22.9 48.0 27.1 18.8 16.7 16.7 10.4
(0) (13) (11) (14) (10) (7) (8) (5) (11) (23) (13) (9) (8) (8) (5)
2 11.2** 4.4* 7.2* 6.8* 3.0y 1.6 2.6 2.0 0.6 0.4 1.0 0.7 0.1 0.8 0.8
Gender stereotypes and satisfaction with OB-GYNS
DOI: 10.3109/0167482X.2013.866646
Table 2. Frequency of descriptions of events during a typical visit to an OB-GYN stratified by provider gender.
3
Methods Participants
Behavior Provider makes small talk There is a chaperone in room during exam Provider gives patient a sheet to cover up with Provider explains exam Breast exam is performed Provider asks questions about sexual activity Provider engages in reassuring behaviors Provider asks questions about birth control
Male provider % (n)
Female provider % (n)
2
25.0 (12) 18.8 (9)
8.3 (4) 2.1 (1)
4.6* 7.0*
12.5 (6) 22.9 (11) 1.9 27.1 (13) 20.8 (10) 0.4 20.8 (10) 29.1 (14) 1.0
A second sample of 136 women was recruited from the Psychology department participant pool at the same southeastern U.S. university. Ten participants were excluded from analyses due to a technical problem or because they did not follow directions, leaving a final sample of 126 participants. Their mean age was 19.7 years and 64.3% of participants selfidentified as European American, 23.0% as African American, 3.2% as Latina, 2.4% as multi-ethnic and 7.2% as other ethnicities.
25.0 (12) 20.8 (10) 0.2 16.7 (8) 18.8 (9) 0.1
Materials and procedures
22.9 (11) 12.8 (6)
1.7
*p50.05.
of female OB-GYNs than males. Also, descriptions of female OB-GYNs were significantly more likely to include ‘‘describes procedures’’ than males. Male OB-GYNs were significantly more likely to be described as ‘‘awkward’’ than female OB-GYNs. In addition, there was a trend for female OB-GYNs to be more likely to be described as ‘‘nonjudgmental’’. While women were somewhat more likely to describe male OB-GYNs as professional and experienced, and female OB-GYNs as informative, these differences were not statistically significant. Participants’ visit scripts were coded for 18 events, nine of which were present in at least 15% of the scripts. Inter-rater agreement of the coding averaged 93%. Visit scripts of male providers were significantly more likely to include the use of a chaperone and making small talk than those of female providers (Table 2). A negative male OB-GYN stereotype was present in 27% (13) of the attribute descriptions and scripts of male OB-GYNs. These stereotypes included the notion that males are unable to perform this role as well as a female physician, women are not able to be comfortable with male physicians, or that a male OB-GYN could behave inappropriately. The following excerpts illustrate the nature of these negative stereotypes, ‘‘with a male doctor, sometimes it can be difficult to feel like yourself;’’ ‘‘men can’t possibly understand;’’ ‘‘[the provider] should look at every patient as a patient and not his next girlfriend;’’ ‘‘he would be. . . criticizing and critiquing every body part’’.
Study two The goal of study two was to examine the influence of provider behaviors (i.e. whether providers engaged in male or female stereotype-congruent behavior) and provider gender on provider evaluation and satisfaction. It was hypothesized that female providers would receive more positive evaluations overall as would providers who engaged in female stereotypecongruent behavior. Further, it was hypothesized that there would be an interaction between provider gender and provider behaviors, where female providers who engaged in female provider stereotype-congruent behaviors would receive higher ratings than male providers.
Participants were recruited to complete a study of satisfaction with healthcare providers and participated in small groups. They were randomly assigned to listen to fictional audiorecorded well-woman visits with either male or female OBGYNs, and instructed to imagine they were the patient. The recordings were counter-balanced; in one the provider engaged in male stereotype-congruent behavior and in one he or she engaged in female stereotype-congruent behavior. Scripts for these visits included elements of a typical wellwoman visit (e.g. a breast and pelvic exam, discussion of birth control). The provider in the female stereotype-congruent script was knowledgeable about women’s health issues and comfortable discussing patient concerns. The provider also described the procedures during the visit. In the male stereotype-congruent script, the provider appeared awkward when interacting with the patient about sensitive issues, used a chaperone, and engaged in small talk. These scripts are included in the Appendix. After participants listened to each recording, they made several ratings about the provider. Specifically, participants rated the provider on nine attributes utilizing seven-point bipolar scales (e.g. knowledgeableuninformed, warm-cold and professional–unprofessional). Scores were summed with lower scores indicating more positive appraisals (possible range 9–163). To assess provider satisfaction, six 7-point items anchored by 1 (very poor) and 7 (superior) were adapted from the Health Resources and Services Administration Patient Satisfaction Survey [21]. For each item, participants rated how well the provider fulfilled that task and scores were summed with higher scores indicating greater satisfaction (possible range 6–42). To assess future provider utilization, participants were asked ‘‘If this was your OB-GYN, how likely would you be to see this provider again?’’ anchored by 1 (very unlikely) and 7 (very likely). Finally, participants completed a demographic questionnaire. Participants received course credit and the study was approved by the university institutional review board. Analysis plan To compare ratings of provider attributes, satisfaction, and provider utilization across conditions, 2 (provider gender) 2 (male stereotype-congruent or female stereotype-congruent) mixed factor ANOVAs were conducted with provider gender as a between participants factor and stereotype-congruence of the script as a within participants factor.
4
K. S. Buck & H. L. Littleton
J Psychosom Obstet Gynaecol, 2014; 35(1): 1–7
Table 3. Provider attribute, satisfaction, and future utilization ratings stratified by provider gender and provider stereotype-congruent behavior. Male stereotype congruent
Male Provider Female Provider Overall
Female stereotype congruent
Overall
Attribute* rating M (SD)
Satisfaction rating M (SD)
Utilization rating M (SD)
Attribute* rating M (SD)
Satisfaction rating M (SD)
Utilization rating M (SD)
Attribute* rating M (SD)
Satisfaction rating M (SD)
Utilization rating M (SD)
34.9 (10.7) 41.2 (11.4) 38.0 (11.1)
19.5 (8.5) 15.2 (9.4) 17.3 (9.1)
2.4 (1.7) 2.0 (1.4) 2.2 (1.6)
16.7 (8.8) 15.9 (9.7) 16.3 (9.2)
33.0 (9.1) 34.2 (8.8) 33.6 (8.9)
5.9 (1.4) 6.2 (1.6) 6.1 (1.5)
25.8 (9.8) 28.5 (10.5) –
26.2 (8.8) 24.7 (9.1) –
4.1 (1.6) 4.0 (1.5) –
*Lower scores indicate more positive evaluation of provider attributes.
Results As summarized in Table 3, for the attribute ratings, results supported a significant main effect for provider stereotypecongruence, F (1, 125) ¼ 211.54, p50.001, with providers receiving more positive ratings in the female stereotypecongruent condition than the male stereotype-congruent condition, d ¼ 2.1. In addition, there was a main effect for provider gender, F (1, 125) ¼ 7.04, p50.01 with ratings of male providers significantly more positive than females, d ¼ 0.3. Finally, the interaction was also significant, F (2, 124) ¼ 5.62, p50.05. Examination of simple main effects supported that female providers who engaged in male stereotype-congruent behavior were rated significantly more negatively than male providers who engaged in male stereotype-congruent behavior, F (1,125) ¼ 10.17, p50.01, d ¼ 0.6. In contrast, no difference across provider gender was observed for the female stereotype-congruent condition, F (1,125) ¼ 0.24, p ¼ 0.62, d ¼ 0.1. Examining the results for provider satisfaction ratings (Table 3), there was a significant main effect for provider stereotype congruence, F (1, 125) ¼ 143.51, p50.001, with satisfaction ratings significantly higher in the female stereotype congruent condition than the male stereotype-congruent condition, d ¼ 1.8. There was no main effect for provider gender, F (1, 125) ¼ 3.20, p ¼ 0.08, but the interaction was significant, F (2, 124) ¼ 4.18, p50.05. Examination of simple main effects supported lower satisfaction ratings for females who engaged in male stereotype-congruent behavior than male providers who did so, F (1,125) ¼ 7.19, p50.01, d ¼ 0.5. In contrast, no difference across gender was seen for providers who engaged in female stereotype-congruent behaviors, F (1,125) ¼ 0.63, p ¼ 0.43, d ¼ 0.1. Examining provider utilization ratings (Table 3), there was a significant main effect for provider stereotype-congruence, F (1, 125) ¼ 211.54, p50.001, with higher utilization ratings in the female stereotype-congruent condition than the male stereotype-congruent condition, d ¼ 2.6. There was no significant main effect for provider gender, F (1, 125) ¼ 0.32, p ¼ 0.57, d ¼ 0.1 and no significant interaction between provider gender and provider stereotype-congruence, F (2, 124) ¼ 1.67, p ¼ 0.20.
Discussion Both studies support that gender stereotypes are influential in shaping provider choice and satisfaction. Women believe that female OB-GYNs typically possess attributes that qualify them for competently performing that role, including being knowledgeable and easy to talk to about women’s health
issues. Interestingly, these particular attributes do not exactly map on to more general gender stereotypes, suggesting that women may hold specific stereotypes about female OB-GYN providers. In contrast, male OB-GYN providers are less likely to be regarded as possessing these desired attributes. Findings also support that some women have negative stereotypes of male OB-GYN providers that may not generalize to other male physicians. Specifically, some women appeared to hold strong injunctive norms against males as OB-GYNs, expressing that patients would be uncomfortable interacting with a male OB-GYN, men cannot fully understand women’s reproductive health issues, or even that male OB-GYNs may behave inappropriately. In contrast, results from study two indicated that women can be similarly satisfied with gynecologic care from male and female providers when they behave in accordance with expectations for female OB-GYN providers (i.e. as knowledgeable and comfortable in their role). This supports that at least among young adult women, holding negative stereotypes of male OB-GYN providers does not necessarily lead to a more negative evaluation of an OB-GYN provider, assuming he engages in preferred behaviors with patients. However, when female OB-GYNs acted in a manner consistent with individuals’ stereotyped ideas about male OB-GYN providers, they were viewed more negatively than male providers who did so. One possibility is that because female providers’ behaviors were discrepant from their stereotypes about female OB-GYNs, they were more likely to be attended to and recalled [17]. Another possible explanation is that female providers who behaved in male stereotype-congruent ways were ‘‘punished’’ with a negative evaluation for violating norms regarding how female OB-GYNs ought to behave. This is also consistent with prior research supporting that women are dissatisfied with female primary care providers who adopt a non-caring interaction style, but not male providers who do so [14]. Limitations of the current studies should be noted. First, the samples consisted of a fairly homogenous sample of college women and thus may not generalize to other groups. Indeed, prior research has supported that younger women show a stronger preference for female physicians than older women [13]. However, it should be noted that young women are making their first choices regarding an OB-GYN, so knowledge of their ideas and preferences is important. Another limitation is that the extent to which other provider variables, such as ethnicity, age or experience level, influenced evaluations of providers was not assessed. In addition, the current study focused on well-woman visits and thus findings may not generalize to the full range of
DOI: 10.3109/0167482X.2013.866646
gynecological and obstetrical care. Finally, individual difference variables of participants such as religiosity, experience with male and female providers, and age that may have affected provider gender preferences were not evaluated as moderators. Bearing these limitations in mind, the current studies suggest several directions for further research. First, provider gender preferences, stereotypes about male and female providers, and satisfaction with OB-GYNs should be investigated in additional populations, including the extent to which individual differences such as patient age, ethnicity and education moderate these associations. The extent to which provider differences, such as age and ethnicity, affect satisfaction and provider choice should also be assessed. In addition, the interplay between gender and caring behaviors should be further investigated. For instance, Roter and colleagues [12] found patients were less satisfied with males who engaged in more patientcentered behaviors. However, the current study found that women were satisfied with either gender when they engaged in more caring behaviors (e.g. explained procedures, asked about patient menstrual symptoms). This may suggest that, particularly during sensitive visits such as a well-woman exam, that there is a certain level of caring behavior preferred for both male and female physicians. It is also possible that, consistent with some prior work [12– 14], that there is an inverted U shaped relationship between level of physician caring behavior for male, but not female, providers. Thus, the influence of different levels of caring behaviors on provider evaluation and satisfaction of male and female providers should also be evaluated in future work. Results of the current studies also have several implications for OB-GYN practice. First, results suggest that at least in some cases, women are equally satisfied with care by male and female OB-GYN providers. Thus, OB-GYN practitioners should focus on engaging in knowledgeable, non-judgmental, and caring behaviors (e.g. explaining procedures, enquiring about symptoms and providing empathic responses) during patient encounters. Indeed, such behaviors may be particularly related to patient satisfaction during sensitive encounters such as well-woman visits. In addition, it is likely helpful for OB-GYN providers or office staff to determine if patients have a gender requirement for their provider, for example due to modesty concerns, religious beliefs or a significant trauma history, as opposed to a gender preference. The current study supported that women can be equally satisfied with gynecological care provided by male and female OB-GYNs, even though many women in the study had preexisting negative stereotypes about male OB-GYNs and/or a preference for a female provider. Thus, while some patients may initially be hesitant to see a male provider, it is possible that exposure to a skilled male OBGYN may positively influence their ideas about male OBGYN providers more generally. Overall, continued work focusing on understanding how both male and female OBGYN providers can best meet the needs of patients should increase the quality of care received by women, as well as ensure that the field of OB-GYN is open to all qualified individuals.
Gender stereotypes and satisfaction with OB-GYNS
5
Declaration of interest The authors report no declaration of interest.
References 1. American College of Obstetrician and Gynecologists. ACOG membership. Available from http://www.acog.org/departments/ dept_notice.cfm?recno¼20&bulletin¼3568 [last accessed 19 Sep 2009]. 2. American Association of Medical Colleges. Residency applicants of U.S. medical schools by specialty and sex; 2011. Available from https://www.aamc.org/download/151890/data/table39_specialtybysex2011.pdf [last accessed 25 Feb 2012]. 3. Jiang X. The OBGYN clerkship: are students denied the opportunity to provide care and what is the role of gender? Conn Med 2012;76:231–6. 4. Rowe T. The male medical student problem. J Obstet Gynaecol Can 2008;30:873–6. 5. Stratton T, McLaughlin M, Witte F, et al. Does students’ exposure to gender discrimination and sexual harassment in medical school affect specialty choice and residency program selection? Acad Med 2005;80:400–8. 6. Witte F, Stratton T, Nora L. Stories from the field: Students’ descriptions of gender discrimination and sexual harassment during medical school. Acad Med 2006;81:648–54. 7. Emmons S, Adams K, Nichols M, Cain J. The impact of perceived gender bias on obstetrics and gynecology skills acquisition by third year medical students. Acad Med 2004;79:326–32. 8. Chandler P, Chandler C, Dabbs M. Provider gender preference in obstetrics and gynecology: a military population. Mil Med 2000; 165:938–40. 9. Kerssens JJ, Bensing JM, Andela MG. Patient preference for genders of health professionals. Soc Sci Med 1997;44:1531–40. 10. Mavis B, Vasilenko P, Schnuth R, et al. Female patients’ preferences related to interpersonal communications, clinical competence, and gender when selecting a physician. Acad Med 2005;80:1159–65. 11. Zuckerman M, Navizedeh N, Feldman J, et al. Determinants of women’s choice of obstetrician/gynecologist. J Womens Health 2002;11:175–80. 12. Roter DL, Hall DA. Physician gender and patient centered communication: a critical review of empirical research. Annu Rev Publ Health 2004;25:497–519. 13. Hall JA, Blanch-Hartigan D, Roter DL. Patients’ satisfaction with male versus female physicians: a meta-analysis. Med Care 2011;49: 611–17. 14. Schmidt-Mast M, Hall JA, Roter DL. Disentangling physician sex and physician communication style: their effects on patient satisfaction in a virtual medical visit. Patient Educ Couns 2007; 68:16–22. 15. Roter DL, Geller G, Bernhardt BA, et al. Effects of obstetrician gender on communication and patient satisfaction. Obstet Gynecol 1999;93:635–41. 16. Eagly A, Karau S. Role continuity theory of prejudice toward female leaders. Psychol Rev 2002;109:573–98. 17. East Carolina University. College portrait for ECU. Available from http://www.ecu.edu/cs-acad/admissions/upload/CollegePortrait-for-ECU.pdf [last accessed 23 Aug 2013]. 18. Bower GH, Black JB, Turner TJ. Scripts in memory for text. Cognitive Psychol 1979;11:177–220. 19. Rose S, Frieze IR. Young singles’ contemporary dating scripts. Sex Roles 1993;25:499–509. 20. Cohen, J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Earlbaum Associates; 1998. 21. Health Center Patient Satisfaction Survey. Health Resources and Services Administration. Available from http://bphc.hrsa.gov/ patientsurvey/samplesurvey.htm [last accessed 1 Aug 2010].
Appendix Audio Scripts: MALE PROVIDER STEREOTYPE CONGRUENT: Physician: Good morning, ma’am. I’m Doctor Smith. Doing ok this morning?
6
K. S. Buck & H. L. Littleton
Patient: Yes, I’m fine, thank you. Physician: Great, glad to hear you’re doing well. It sure is beautiful outside today, isn’t it? I am going to ask you some questions and then I’ll bring in my nurse and we’ll proceed with the exam. Patient: Alright. Physician: So, um, are you currently having any, um, sexual partners at the moment? Patient: Yes, one now and two in the last year. Physician: When was your last period? Patient: About 2 weeks ago. Physician: Well, uh, you need to be careful when you switch partners. That is a good way to get an STD. Well, we will do an STD test today. Ok, so I see that you are taking the birth control pill Yaz. Are you happy with your birth control options that you are using right now? Patient: Well, yes, I think so. Physician: Good, you know those commercials for birth control are everywhere nowadays. So, tell me what you like to do in your spare time. Patient: Well, I like to do yoga and watch movies. I also really like to paint. Physician: Great, that’s good to hear. Do you, um, have any other questions before I go get my nurse? Patient: No, I guess not. Physician: Ok, well I’ll go get my nurse, Sarah, and we’ll get going. Physician: Ok, Ms. Jones, lay back and I’ll go ahead and do your breast exam. I’ll, uh, make sure that there are not any abnormalities. (Pause for getting into position?) So, Ms. Jones, how are you doing in school?? Patient: Um, okay. Ouch. Physician: (Nervous laugh), Sorry the exam can hurt a little. Glad you are doing uh, okay in school. Patient: Um, thanks. Physician: Ok, go ahead and slide on down to the end of the table. Please make sure to relax. You can cover up with this sheet. Patient: Ok. Physician: Well I’m glad to hear that school is going well. Do you have a job? Patient: Um, yeah, I work at a pizza place in town. Physician: Great. I’m glad to hear it. It’s important that people are happy in their everyday lives. Ok, we are all done here. Is there anything else that you need? Patient: No, I don’t think so. Physician: Ok, well Sarah will be back with your prescriptions in just a moment. See you next year. FEMALE PROVIDER STEREOTYPE CONGRUENT: Physician: Good morning, I’m Dr. Williams. Welcome, I’m glad you’re here today. How are you doing today? Patient: I’m doing well, thanks. Physician: Great, well today we’ll talk a bit about your health first, and then we’ll move on to the exam. Is that alright? Patient: Yes, that sounds fine. Physician: So tell me, are you having any kinds of problems that you wanted to discuss with me today? Patient: Well, I guess that I am having some cramps, right before my period starts.
J Psychosom Obstet Gynaecol, 2014; 35(1): 1–7
Physician: Ok, some cramping right before your period. Has that changed at all recently? Patient: No, it’s always been like that, but I would like to see if there is anything to make that better. Physician: Sure, that sounds like something we can work on. Because of the way that birth control pills work with your hormones, sometimes when women start taking birth control, cramps may decrease. I can see in your chart that you’ve never taken the pill before. Since you don’t have any medical reasons why you shouldn’t take birth control, we can start you on a prescription if you like. What do you think? Patient: That sounds like it would be good. Physician: How many sexual partners have you had in the last year? Patient: 2 Physician: What kind of safe sex practices are you using? Patient: Well, we use condoms most of the time. Physician: When was your last period? Patient: About 2 weeks ago. Physician: Ok, well that’s a great start. However, in order for condoms to be effective against pregnancy and disease transmission, they have to be used from the start, every time that you have sex, with every partner. When was the last time you were tested for sexually transmitted diseases? Patient: About 4 months ago. Physician: Well, we can test you again today if you would like. Patient: Yeah, I think that is probably a good idea. Physician: Sure thing. That’s no problem. Anything else? Patient: No, I don’t think so. Physician: Ok, well let’s go ahead and do a breast exam. Have you noticed any changes in your breasts? Patient: No, I haven’t. Physician: I will be feeling for any lumps, abnormalities, or discharge. Is that alright? Patient: Yes Physician: Ok, lay back and raise your arm. Good. Everything feels like it is normal with your breasts. Go ahead and slide down to the end of the table so we can start the pelvic exam. If you take some deep breaths and try to relax, this will help avoid discomfort. Patient: Alright. Physician: Ok, I am going to examine you externally, then I will insert my finger and press on your tummy a little to check on your cervix and ovaries, then I will insert the speculum to do the Pap test and take some swabs to check you for any STDs. Ok, I’m going to start the exam now. You’re doing great, just make sure to try to relax. Patient: Ok Physician: (small amount of time passes) Good job. The hard part is over. You can sit back up. Well, everything looks normal. I will send off your sample and you will hear back in about 1–2 weeks with your Pap test results. The STD tests we will have in a few days. If they are normal they will be mailed, otherwise we will call. Also, we’ll make sure to get you that birth control prescription. Do you have any other questions or anything else that you need? Patient: No, I don’t think so. Thanks for all your help. Physician: You’re very welcome and we look forward to seeing you again.
DOI: 10.3109/0167482X.2013.866646
Gender stereotypes and satisfaction with OB-GYNS
ä Current knowledge There is currently a gender imbalance in new physicians entering the field of OB-GYN, with only 17% of applicants to OB-GYN residences being male. Male medical students may believe that they are not welcome in the field of OB-GYN in part because women prefer female providers. Negative stereotypes of male OB-GYNs may be fueling patient preferences for female OB-GYNs and lead to increased satisfaction with female providers. ä What this study adds Some women hold negative stereotypes of male OBGYNs and many hold positive stereotypes of female OB-GYNS. Women are similarly satisfied with care received from male and female providers when they behave in accordance with expectations for female OB-GYN providers.
7
Copyright of Journal of Psychosomatic Obstetrics & Gynecology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ORIGINAL ARTICLE
Stereotyped beliefs about male and female OB-GYNS: relationship to provider choice and patient satisfaction Katherine S. Buck and Heather L. Littleton Department of Psychology, East Carolina University, Greenville, NC, USA
Abstract
Keywords
Background: Up to 60% of women prefer a female obstetrician-gynecologist (OB-GYN), perhaps in part due to holding negative stereotypes of male providers. However, provider gender stereotypes have not been directly examined. The purpose of the current studies was to evaluate women’s stereotypes of male and female OB-GYN providers and the impact of these stereotypes on provider evaluations. Methods: First, stereotypes of male and female OB-GYNs were elicited from 96 undergraduate women who described the attributes and behaviors of a typical male or female OB-GYN. Next, 126 undergraduate women were randomized to review recordings depicting male or female OB-GYNs engaging in male or female-stereotype congruent behaviors during a well-woman visit. Results: Participants overall had positive stereotypes of female OB-GYNs (e.g. knowledgeable, easy to talk to) but some negative stereotypes of males (e.g. unable to fully understand women’s health issues). However, male and female OB-GYNs who engaged in female stereotype-congruent behaviors were similarly preferred over providers who engaged in malestereotype congruent behavior. Conclusion: Women generally regard female OB-GYNs as highly competent, whereas some believe that being male is a disadvantage in providing OB-GYN care. However, providers who engage in behaviors associated with high quality care are evaluated positively, regardless of the provider’s gender.
Gender differences, medical education, obstetrics/gynecology, patient satisfaction, stereotypes
The gender composition of U.S. obstetrician-gynecologists (OB-GYN) has changed substantially, with the proportion of OB-GYNs who are female greatly increasing [1]. Indeed, in 2011 the proportion of male senior fellows in the American College of Obstetricians and Gynecologists was 58%, whereas only 23% of junior fellows were male. Strikingly, only 17% of 2010 applicants to OB-GYN residencies were male [2]. The reduction in men entering the field of OB-GYN could reflect lack of interest in pursuing a women’s health specialty; however, there is also evidence that male medical students are being actively discouraged from choosing OB-GYN, and may be targets of gender-based discrimination in OB-GYN clerkships, such as being socially excluded and prevented from performing procedures [3–6]. An important factor that may be contributing to exclusion of male medical students during training, and the discouragement of men from pursuing
Address for correspondence: Heather Littleton, Department of Psychology, East Carolina University, 104 Rawl, Greenville, NC 27858, USA. Email: [email protected]
Received 9 April 2013 Revised 11 October 2013 Accepted 13 November 2013
OB-GYN as a medical specialty is the belief that women are unwilling to receive care from a male provider. Indeed, a sizable proportion of women (35–60%) prefer a female OBGYN [7], with consistent findings among women of diverse socioeconomic, ethnic and religious backgrounds [8–11]. Women also often list provider gender as a key part of their decision-making process when choosing an OB-GYN [11]. This preference for a female provider is somewhat surprising given that male OB-GYN providers have been found to engage in more patient-centered behaviors, such as asking questions about emotional and social issues, encouraging patients to speak about these issues, and working to form partnerships with patients [12]. Engaging in patient-centered behaviors is consistently related to greater satisfaction with providers [13,14]. However, some recent work examining the interaction between provider gender and patient-centered behaviors on patient satisfaction may shed some light on this seeming discrepancy. Roter and colleagues [15] reviewed recordings of patient OB visits and found that women were more satisfied with female providers than male providers, even though males engaged in more patient-centered behaviors. In addition, in a computerized physician analogue study,
20 14
Introduction
History
2
K. S. Buck & H. L. Littleton
Schmid-Mast and colleagues [14] found that female patients were less satisfied with male primary care providers who engaged in patient-centered behaviors, but more satisfied with female providers who did so. Taken together, these studies suggest that women have gender-based expectations for physician behaviors which influence their satisfaction. In other words, women may be most satisfied with providers whose behavior is consistent with their stereotypes for how male and female physicians should behave. Thus, women’s stereotyped ideas about male and female providers may be influential in shaping their satisfaction and provider choice. It is possible that women believe that men are less likely to possess the personal qualities necessary to provide good OB-GYN care. Indeed, research on gender stereotypes supports that characteristics that women regard as highly important for an OB-GYN to possess, such as being kind and helpful, are regarded as female characteristics [10,16]. It is also possible that male providers who do not behave in accordance with gender-based stereotypes (i.e. those who engage in high levels of patient-centered behaviors) may be viewed less positively than females who do so because they are violating gender norms. Finally, while not previously investigated, it is possible that some women believe that men are less able to provide high quality care, for example because they cannot fully understanding women’s health issues due to a lack of personal experience. The current study therefore sought to evaluate women’s stereotypes of male and female OB-GYN providers, as well as the role of provider gender and behaviors on provider evaluation and patient satisfaction. Two studies were conducted to accomplish these aims. In study one, women’s stereotypes about male and female OB-GYNs were elicited. In study two, the influence of both OB-GYN provider gender and provider behaviors (whether the provider behaved in a way consistent with stereotypes of male or female providers) on women’s evaluation of OB-GYN providers was experimentally evaluated.
Study one The goal of study one was to identify differences in women’s stereotypes of male and female OB-GYNs. It was hypothesized that female providers would be stereotyped as possessing more ‘‘caring’’ attributes (e.g. empathic, understanding), whereas male providers would be stereotyped as possessing more ‘‘dominant’’ attributes (e.g. professional, competent). It also was hypothesized that some women would hold negative stereotypes of male OB-GYN providers. Methods Participants A total of 104 women were recruited from the Psychology department participant pool at a large southeastern U.S. university. This pool consists of students taking introductory psychology, a general education requirement, and thus participants are fairly representative of enrolled students. Eight participants were excluded from analyses for not following directions, leaving a final sample of 96 participants. Their mean age was 18.6 years and 60.4% of participants
J Psychosom Obstet Gynaecol, 2014; 35(1): 1–7
self-identified as European American, 28.1% as African American, 7.3% as Latina and 4.2% as multi-ethnic. The ethnic composition of the sample was similar to the university as a whole [17]. Materials and procedures Participants were recruited to complete a study of women’s ideas about health care providers and participated in small groups. They were randomly assigned to write about the attributes of a typical male or female OB-GYN, as well as provide a script of a typical well-woman visit. Participants also provided their OB-GYN gender preference. Participants received course credit and the study was approved by the university institutional review board. Analysis plan The OB-GYN attribute data was coded by trained raters who read all responses and listed all attributes. A final list of attributes was then created and each participant’s data were coded by two raters. The visit scripts were first examined for relevant events and a coding sheet of events was created. Each participant’s script data was coded by two raters. Before conducting analyses, attributes and script events not mentioned in at least 15% of descriptions for either physician gender were eliminated [18,19]. Recruiting 96 women resulted in 48 women in each group, which allowed for sufficient power to detect medium-sized differences in proportion [20]. Results Among participants, 78% had a preference or strong preference for a female OB-GYN whereas only 4% preferred a male OB-GYN. A total of 51 provider attributes were identified, of which 15 were present in at least 15% of the provider descriptions. Inter-rater agreement averaged 96% and coding discrepancies were resolved by the first author. As summarized in Table 1, both ‘‘knowledgeable’’, and ‘‘easy to talk to’’ were significantly more frequently listed as typical attributes
Table 1. Frequency of descriptions of typical OB-GYN provider attributes stratified by OB-GYN gender.
Attribute Awkward Describes procedures Easy to talk to Knowledgeable Non-judgmental Professional Informative Experienced Good personality Comforting Kind Gentle Caring Empathic Appropriate
Male providers % (n) 20.8 10.4 4.2 8.3 8.3 25.0 6.2 20.8 16.7 42.0 18.8 12.5 14.6 10.4 16.7
yp50.10; *p50.05; **p50.01.
(10) (5) (2) (4) (4) (12) (3) (10) (8) (20) (9) (6) (7) (5) (8)
Female providers % (n) 0.0 27.1 22.9 29.2 20.8 14.6 16.7 10.4 22.9 48.0 27.1 18.8 16.7 16.7 10.4
(0) (13) (11) (14) (10) (7) (8) (5) (11) (23) (13) (9) (8) (8) (5)
2 11.2** 4.4* 7.2* 6.8* 3.0y 1.6 2.6 2.0 0.6 0.4 1.0 0.7 0.1 0.8 0.8
Gender stereotypes and satisfaction with OB-GYNS
DOI: 10.3109/0167482X.2013.866646
Table 2. Frequency of descriptions of events during a typical visit to an OB-GYN stratified by provider gender.
3
Methods Participants
Behavior Provider makes small talk There is a chaperone in room during exam Provider gives patient a sheet to cover up with Provider explains exam Breast exam is performed Provider asks questions about sexual activity Provider engages in reassuring behaviors Provider asks questions about birth control
Male provider % (n)
Female provider % (n)
2
25.0 (12) 18.8 (9)
8.3 (4) 2.1 (1)
4.6* 7.0*
12.5 (6) 22.9 (11) 1.9 27.1 (13) 20.8 (10) 0.4 20.8 (10) 29.1 (14) 1.0
A second sample of 136 women was recruited from the Psychology department participant pool at the same southeastern U.S. university. Ten participants were excluded from analyses due to a technical problem or because they did not follow directions, leaving a final sample of 126 participants. Their mean age was 19.7 years and 64.3% of participants selfidentified as European American, 23.0% as African American, 3.2% as Latina, 2.4% as multi-ethnic and 7.2% as other ethnicities.
25.0 (12) 20.8 (10) 0.2 16.7 (8) 18.8 (9) 0.1
Materials and procedures
22.9 (11) 12.8 (6)
1.7
*p50.05.
of female OB-GYNs than males. Also, descriptions of female OB-GYNs were significantly more likely to include ‘‘describes procedures’’ than males. Male OB-GYNs were significantly more likely to be described as ‘‘awkward’’ than female OB-GYNs. In addition, there was a trend for female OB-GYNs to be more likely to be described as ‘‘nonjudgmental’’. While women were somewhat more likely to describe male OB-GYNs as professional and experienced, and female OB-GYNs as informative, these differences were not statistically significant. Participants’ visit scripts were coded for 18 events, nine of which were present in at least 15% of the scripts. Inter-rater agreement of the coding averaged 93%. Visit scripts of male providers were significantly more likely to include the use of a chaperone and making small talk than those of female providers (Table 2). A negative male OB-GYN stereotype was present in 27% (13) of the attribute descriptions and scripts of male OB-GYNs. These stereotypes included the notion that males are unable to perform this role as well as a female physician, women are not able to be comfortable with male physicians, or that a male OB-GYN could behave inappropriately. The following excerpts illustrate the nature of these negative stereotypes, ‘‘with a male doctor, sometimes it can be difficult to feel like yourself;’’ ‘‘men can’t possibly understand;’’ ‘‘[the provider] should look at every patient as a patient and not his next girlfriend;’’ ‘‘he would be. . . criticizing and critiquing every body part’’.
Study two The goal of study two was to examine the influence of provider behaviors (i.e. whether providers engaged in male or female stereotype-congruent behavior) and provider gender on provider evaluation and satisfaction. It was hypothesized that female providers would receive more positive evaluations overall as would providers who engaged in female stereotypecongruent behavior. Further, it was hypothesized that there would be an interaction between provider gender and provider behaviors, where female providers who engaged in female provider stereotype-congruent behaviors would receive higher ratings than male providers.
Participants were recruited to complete a study of satisfaction with healthcare providers and participated in small groups. They were randomly assigned to listen to fictional audiorecorded well-woman visits with either male or female OBGYNs, and instructed to imagine they were the patient. The recordings were counter-balanced; in one the provider engaged in male stereotype-congruent behavior and in one he or she engaged in female stereotype-congruent behavior. Scripts for these visits included elements of a typical wellwoman visit (e.g. a breast and pelvic exam, discussion of birth control). The provider in the female stereotype-congruent script was knowledgeable about women’s health issues and comfortable discussing patient concerns. The provider also described the procedures during the visit. In the male stereotype-congruent script, the provider appeared awkward when interacting with the patient about sensitive issues, used a chaperone, and engaged in small talk. These scripts are included in the Appendix. After participants listened to each recording, they made several ratings about the provider. Specifically, participants rated the provider on nine attributes utilizing seven-point bipolar scales (e.g. knowledgeableuninformed, warm-cold and professional–unprofessional). Scores were summed with lower scores indicating more positive appraisals (possible range 9–163). To assess provider satisfaction, six 7-point items anchored by 1 (very poor) and 7 (superior) were adapted from the Health Resources and Services Administration Patient Satisfaction Survey [21]. For each item, participants rated how well the provider fulfilled that task and scores were summed with higher scores indicating greater satisfaction (possible range 6–42). To assess future provider utilization, participants were asked ‘‘If this was your OB-GYN, how likely would you be to see this provider again?’’ anchored by 1 (very unlikely) and 7 (very likely). Finally, participants completed a demographic questionnaire. Participants received course credit and the study was approved by the university institutional review board. Analysis plan To compare ratings of provider attributes, satisfaction, and provider utilization across conditions, 2 (provider gender) 2 (male stereotype-congruent or female stereotype-congruent) mixed factor ANOVAs were conducted with provider gender as a between participants factor and stereotype-congruence of the script as a within participants factor.
4
K. S. Buck & H. L. Littleton
J Psychosom Obstet Gynaecol, 2014; 35(1): 1–7
Table 3. Provider attribute, satisfaction, and future utilization ratings stratified by provider gender and provider stereotype-congruent behavior. Male stereotype congruent
Male Provider Female Provider Overall
Female stereotype congruent
Overall
Attribute* rating M (SD)
Satisfaction rating M (SD)
Utilization rating M (SD)
Attribute* rating M (SD)
Satisfaction rating M (SD)
Utilization rating M (SD)
Attribute* rating M (SD)
Satisfaction rating M (SD)
Utilization rating M (SD)
34.9 (10.7) 41.2 (11.4) 38.0 (11.1)
19.5 (8.5) 15.2 (9.4) 17.3 (9.1)
2.4 (1.7) 2.0 (1.4) 2.2 (1.6)
16.7 (8.8) 15.9 (9.7) 16.3 (9.2)
33.0 (9.1) 34.2 (8.8) 33.6 (8.9)
5.9 (1.4) 6.2 (1.6) 6.1 (1.5)
25.8 (9.8) 28.5 (10.5) –
26.2 (8.8) 24.7 (9.1) –
4.1 (1.6) 4.0 (1.5) –
*Lower scores indicate more positive evaluation of provider attributes.
Results As summarized in Table 3, for the attribute ratings, results supported a significant main effect for provider stereotypecongruence, F (1, 125) ¼ 211.54, p50.001, with providers receiving more positive ratings in the female stereotypecongruent condition than the male stereotype-congruent condition, d ¼ 2.1. In addition, there was a main effect for provider gender, F (1, 125) ¼ 7.04, p50.01 with ratings of male providers significantly more positive than females, d ¼ 0.3. Finally, the interaction was also significant, F (2, 124) ¼ 5.62, p50.05. Examination of simple main effects supported that female providers who engaged in male stereotype-congruent behavior were rated significantly more negatively than male providers who engaged in male stereotype-congruent behavior, F (1,125) ¼ 10.17, p50.01, d ¼ 0.6. In contrast, no difference across provider gender was observed for the female stereotype-congruent condition, F (1,125) ¼ 0.24, p ¼ 0.62, d ¼ 0.1. Examining the results for provider satisfaction ratings (Table 3), there was a significant main effect for provider stereotype congruence, F (1, 125) ¼ 143.51, p50.001, with satisfaction ratings significantly higher in the female stereotype congruent condition than the male stereotype-congruent condition, d ¼ 1.8. There was no main effect for provider gender, F (1, 125) ¼ 3.20, p ¼ 0.08, but the interaction was significant, F (2, 124) ¼ 4.18, p50.05. Examination of simple main effects supported lower satisfaction ratings for females who engaged in male stereotype-congruent behavior than male providers who did so, F (1,125) ¼ 7.19, p50.01, d ¼ 0.5. In contrast, no difference across gender was seen for providers who engaged in female stereotype-congruent behaviors, F (1,125) ¼ 0.63, p ¼ 0.43, d ¼ 0.1. Examining provider utilization ratings (Table 3), there was a significant main effect for provider stereotype-congruence, F (1, 125) ¼ 211.54, p50.001, with higher utilization ratings in the female stereotype-congruent condition than the male stereotype-congruent condition, d ¼ 2.6. There was no significant main effect for provider gender, F (1, 125) ¼ 0.32, p ¼ 0.57, d ¼ 0.1 and no significant interaction between provider gender and provider stereotype-congruence, F (2, 124) ¼ 1.67, p ¼ 0.20.
Discussion Both studies support that gender stereotypes are influential in shaping provider choice and satisfaction. Women believe that female OB-GYNs typically possess attributes that qualify them for competently performing that role, including being knowledgeable and easy to talk to about women’s health
issues. Interestingly, these particular attributes do not exactly map on to more general gender stereotypes, suggesting that women may hold specific stereotypes about female OB-GYN providers. In contrast, male OB-GYN providers are less likely to be regarded as possessing these desired attributes. Findings also support that some women have negative stereotypes of male OB-GYN providers that may not generalize to other male physicians. Specifically, some women appeared to hold strong injunctive norms against males as OB-GYNs, expressing that patients would be uncomfortable interacting with a male OB-GYN, men cannot fully understand women’s reproductive health issues, or even that male OB-GYNs may behave inappropriately. In contrast, results from study two indicated that women can be similarly satisfied with gynecologic care from male and female providers when they behave in accordance with expectations for female OB-GYN providers (i.e. as knowledgeable and comfortable in their role). This supports that at least among young adult women, holding negative stereotypes of male OB-GYN providers does not necessarily lead to a more negative evaluation of an OB-GYN provider, assuming he engages in preferred behaviors with patients. However, when female OB-GYNs acted in a manner consistent with individuals’ stereotyped ideas about male OB-GYN providers, they were viewed more negatively than male providers who did so. One possibility is that because female providers’ behaviors were discrepant from their stereotypes about female OB-GYNs, they were more likely to be attended to and recalled [17]. Another possible explanation is that female providers who behaved in male stereotype-congruent ways were ‘‘punished’’ with a negative evaluation for violating norms regarding how female OB-GYNs ought to behave. This is also consistent with prior research supporting that women are dissatisfied with female primary care providers who adopt a non-caring interaction style, but not male providers who do so [14]. Limitations of the current studies should be noted. First, the samples consisted of a fairly homogenous sample of college women and thus may not generalize to other groups. Indeed, prior research has supported that younger women show a stronger preference for female physicians than older women [13]. However, it should be noted that young women are making their first choices regarding an OB-GYN, so knowledge of their ideas and preferences is important. Another limitation is that the extent to which other provider variables, such as ethnicity, age or experience level, influenced evaluations of providers was not assessed. In addition, the current study focused on well-woman visits and thus findings may not generalize to the full range of
DOI: 10.3109/0167482X.2013.866646
gynecological and obstetrical care. Finally, individual difference variables of participants such as religiosity, experience with male and female providers, and age that may have affected provider gender preferences were not evaluated as moderators. Bearing these limitations in mind, the current studies suggest several directions for further research. First, provider gender preferences, stereotypes about male and female providers, and satisfaction with OB-GYNs should be investigated in additional populations, including the extent to which individual differences such as patient age, ethnicity and education moderate these associations. The extent to which provider differences, such as age and ethnicity, affect satisfaction and provider choice should also be assessed. In addition, the interplay between gender and caring behaviors should be further investigated. For instance, Roter and colleagues [12] found patients were less satisfied with males who engaged in more patientcentered behaviors. However, the current study found that women were satisfied with either gender when they engaged in more caring behaviors (e.g. explained procedures, asked about patient menstrual symptoms). This may suggest that, particularly during sensitive visits such as a well-woman exam, that there is a certain level of caring behavior preferred for both male and female physicians. It is also possible that, consistent with some prior work [12– 14], that there is an inverted U shaped relationship between level of physician caring behavior for male, but not female, providers. Thus, the influence of different levels of caring behaviors on provider evaluation and satisfaction of male and female providers should also be evaluated in future work. Results of the current studies also have several implications for OB-GYN practice. First, results suggest that at least in some cases, women are equally satisfied with care by male and female OB-GYN providers. Thus, OB-GYN practitioners should focus on engaging in knowledgeable, non-judgmental, and caring behaviors (e.g. explaining procedures, enquiring about symptoms and providing empathic responses) during patient encounters. Indeed, such behaviors may be particularly related to patient satisfaction during sensitive encounters such as well-woman visits. In addition, it is likely helpful for OB-GYN providers or office staff to determine if patients have a gender requirement for their provider, for example due to modesty concerns, religious beliefs or a significant trauma history, as opposed to a gender preference. The current study supported that women can be equally satisfied with gynecological care provided by male and female OB-GYNs, even though many women in the study had preexisting negative stereotypes about male OB-GYNs and/or a preference for a female provider. Thus, while some patients may initially be hesitant to see a male provider, it is possible that exposure to a skilled male OBGYN may positively influence their ideas about male OBGYN providers more generally. Overall, continued work focusing on understanding how both male and female OBGYN providers can best meet the needs of patients should increase the quality of care received by women, as well as ensure that the field of OB-GYN is open to all qualified individuals.
Gender stereotypes and satisfaction with OB-GYNS
5
Declaration of interest The authors report no declaration of interest.
References 1. American College of Obstetrician and Gynecologists. ACOG membership. Available from http://www.acog.org/departments/ dept_notice.cfm?recno¼20&bulletin¼3568 [last accessed 19 Sep 2009]. 2. American Association of Medical Colleges. Residency applicants of U.S. medical schools by specialty and sex; 2011. Available from https://www.aamc.org/download/151890/data/table39_specialtybysex2011.pdf [last accessed 25 Feb 2012]. 3. Jiang X. The OBGYN clerkship: are students denied the opportunity to provide care and what is the role of gender? Conn Med 2012;76:231–6. 4. Rowe T. The male medical student problem. J Obstet Gynaecol Can 2008;30:873–6. 5. Stratton T, McLaughlin M, Witte F, et al. Does students’ exposure to gender discrimination and sexual harassment in medical school affect specialty choice and residency program selection? Acad Med 2005;80:400–8. 6. Witte F, Stratton T, Nora L. Stories from the field: Students’ descriptions of gender discrimination and sexual harassment during medical school. Acad Med 2006;81:648–54. 7. Emmons S, Adams K, Nichols M, Cain J. The impact of perceived gender bias on obstetrics and gynecology skills acquisition by third year medical students. Acad Med 2004;79:326–32. 8. Chandler P, Chandler C, Dabbs M. Provider gender preference in obstetrics and gynecology: a military population. Mil Med 2000; 165:938–40. 9. Kerssens JJ, Bensing JM, Andela MG. Patient preference for genders of health professionals. Soc Sci Med 1997;44:1531–40. 10. Mavis B, Vasilenko P, Schnuth R, et al. Female patients’ preferences related to interpersonal communications, clinical competence, and gender when selecting a physician. Acad Med 2005;80:1159–65. 11. Zuckerman M, Navizedeh N, Feldman J, et al. Determinants of women’s choice of obstetrician/gynecologist. J Womens Health 2002;11:175–80. 12. Roter DL, Hall DA. Physician gender and patient centered communication: a critical review of empirical research. Annu Rev Publ Health 2004;25:497–519. 13. Hall JA, Blanch-Hartigan D, Roter DL. Patients’ satisfaction with male versus female physicians: a meta-analysis. Med Care 2011;49: 611–17. 14. Schmidt-Mast M, Hall JA, Roter DL. Disentangling physician sex and physician communication style: their effects on patient satisfaction in a virtual medical visit. Patient Educ Couns 2007; 68:16–22. 15. Roter DL, Geller G, Bernhardt BA, et al. Effects of obstetrician gender on communication and patient satisfaction. Obstet Gynecol 1999;93:635–41. 16. Eagly A, Karau S. Role continuity theory of prejudice toward female leaders. Psychol Rev 2002;109:573–98. 17. East Carolina University. College portrait for ECU. Available from http://www.ecu.edu/cs-acad/admissions/upload/CollegePortrait-for-ECU.pdf [last accessed 23 Aug 2013]. 18. Bower GH, Black JB, Turner TJ. Scripts in memory for text. Cognitive Psychol 1979;11:177–220. 19. Rose S, Frieze IR. Young singles’ contemporary dating scripts. Sex Roles 1993;25:499–509. 20. Cohen, J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Earlbaum Associates; 1998. 21. Health Center Patient Satisfaction Survey. Health Resources and Services Administration. Available from http://bphc.hrsa.gov/ patientsurvey/samplesurvey.htm [last accessed 1 Aug 2010].
Appendix Audio Scripts: MALE PROVIDER STEREOTYPE CONGRUENT: Physician: Good morning, ma’am. I’m Doctor Smith. Doing ok this morning?
6
K. S. Buck & H. L. Littleton
Patient: Yes, I’m fine, thank you. Physician: Great, glad to hear you’re doing well. It sure is beautiful outside today, isn’t it? I am going to ask you some questions and then I’ll bring in my nurse and we’ll proceed with the exam. Patient: Alright. Physician: So, um, are you currently having any, um, sexual partners at the moment? Patient: Yes, one now and two in the last year. Physician: When was your last period? Patient: About 2 weeks ago. Physician: Well, uh, you need to be careful when you switch partners. That is a good way to get an STD. Well, we will do an STD test today. Ok, so I see that you are taking the birth control pill Yaz. Are you happy with your birth control options that you are using right now? Patient: Well, yes, I think so. Physician: Good, you know those commercials for birth control are everywhere nowadays. So, tell me what you like to do in your spare time. Patient: Well, I like to do yoga and watch movies. I also really like to paint. Physician: Great, that’s good to hear. Do you, um, have any other questions before I go get my nurse? Patient: No, I guess not. Physician: Ok, well I’ll go get my nurse, Sarah, and we’ll get going. Physician: Ok, Ms. Jones, lay back and I’ll go ahead and do your breast exam. I’ll, uh, make sure that there are not any abnormalities. (Pause for getting into position?) So, Ms. Jones, how are you doing in school?? Patient: Um, okay. Ouch. Physician: (Nervous laugh), Sorry the exam can hurt a little. Glad you are doing uh, okay in school. Patient: Um, thanks. Physician: Ok, go ahead and slide on down to the end of the table. Please make sure to relax. You can cover up with this sheet. Patient: Ok. Physician: Well I’m glad to hear that school is going well. Do you have a job? Patient: Um, yeah, I work at a pizza place in town. Physician: Great. I’m glad to hear it. It’s important that people are happy in their everyday lives. Ok, we are all done here. Is there anything else that you need? Patient: No, I don’t think so. Physician: Ok, well Sarah will be back with your prescriptions in just a moment. See you next year. FEMALE PROVIDER STEREOTYPE CONGRUENT: Physician: Good morning, I’m Dr. Williams. Welcome, I’m glad you’re here today. How are you doing today? Patient: I’m doing well, thanks. Physician: Great, well today we’ll talk a bit about your health first, and then we’ll move on to the exam. Is that alright? Patient: Yes, that sounds fine. Physician: So tell me, are you having any kinds of problems that you wanted to discuss with me today? Patient: Well, I guess that I am having some cramps, right before my period starts.
J Psychosom Obstet Gynaecol, 2014; 35(1): 1–7
Physician: Ok, some cramping right before your period. Has that changed at all recently? Patient: No, it’s always been like that, but I would like to see if there is anything to make that better. Physician: Sure, that sounds like something we can work on. Because of the way that birth control pills work with your hormones, sometimes when women start taking birth control, cramps may decrease. I can see in your chart that you’ve never taken the pill before. Since you don’t have any medical reasons why you shouldn’t take birth control, we can start you on a prescription if you like. What do you think? Patient: That sounds like it would be good. Physician: How many sexual partners have you had in the last year? Patient: 2 Physician: What kind of safe sex practices are you using? Patient: Well, we use condoms most of the time. Physician: When was your last period? Patient: About 2 weeks ago. Physician: Ok, well that’s a great start. However, in order for condoms to be effective against pregnancy and disease transmission, they have to be used from the start, every time that you have sex, with every partner. When was the last time you were tested for sexually transmitted diseases? Patient: About 4 months ago. Physician: Well, we can test you again today if you would like. Patient: Yeah, I think that is probably a good idea. Physician: Sure thing. That’s no problem. Anything else? Patient: No, I don’t think so. Physician: Ok, well let’s go ahead and do a breast exam. Have you noticed any changes in your breasts? Patient: No, I haven’t. Physician: I will be feeling for any lumps, abnormalities, or discharge. Is that alright? Patient: Yes Physician: Ok, lay back and raise your arm. Good. Everything feels like it is normal with your breasts. Go ahead and slide down to the end of the table so we can start the pelvic exam. If you take some deep breaths and try to relax, this will help avoid discomfort. Patient: Alright. Physician: Ok, I am going to examine you externally, then I will insert my finger and press on your tummy a little to check on your cervix and ovaries, then I will insert the speculum to do the Pap test and take some swabs to check you for any STDs. Ok, I’m going to start the exam now. You’re doing great, just make sure to try to relax. Patient: Ok Physician: (small amount of time passes) Good job. The hard part is over. You can sit back up. Well, everything looks normal. I will send off your sample and you will hear back in about 1–2 weeks with your Pap test results. The STD tests we will have in a few days. If they are normal they will be mailed, otherwise we will call. Also, we’ll make sure to get you that birth control prescription. Do you have any other questions or anything else that you need? Patient: No, I don’t think so. Thanks for all your help. Physician: You’re very welcome and we look forward to seeing you again.
DOI: 10.3109/0167482X.2013.866646
Gender stereotypes and satisfaction with OB-GYNS
ä Current knowledge There is currently a gender imbalance in new physicians entering the field of OB-GYN, with only 17% of applicants to OB-GYN residences being male. Male medical students may believe that they are not welcome in the field of OB-GYN in part because women prefer female providers. Negative stereotypes of male OB-GYNs may be fueling patient preferences for female OB-GYNs and lead to increased satisfaction with female providers. ä What this study adds Some women hold negative stereotypes of male OBGYNs and many hold positive stereotypes of female OB-GYNS. Women are similarly satisfied with care received from male and female providers when they behave in accordance with expectations for female OB-GYN providers.
7
Copyright of Journal of Psychosomatic Obstetrics & Gynecology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
