Physician Communication Style and Patient Satisfaction: The Importance of Physician Gender

1. Physician Communication Style and Patient Satisfaction: The Importance of Physician Gender Prof. Dr. Marianne Schmid Mast University of Neuchâtel, Switzerland

2. Overview Physician gender • Physician communication style: • Manipulated on emotionality and dominance • Nonverbal behavior measured Patient satisfaction Patient gender

3. Goal Investigate how the communication style of women and men doctors affect patients (patient satisfaction)

4. Two Dimensions of Physician Communication • Emotionality: Physician’s taking on the perspective of the patient and expressing interest, concern, and empathy • Dominance: Physician’s control over information and services, the visit agenda, goals, and treatment decisions => Patient-centered: emotionality high and dominance low (Krupat et al., 2000)

5. Gender Difference in Communication Style Women doctors communicate more emotionally and less dominantly than men doctors (e.g., Roter, Hall, & Aoki, 2002)

6. Implications of Physician Style • Dominance in physician communication is related to low patient satisfaction (Buller & Buller, 1987) • Patient outcome is more positive when physicians communicate more emotionally (Ben-Sira, 1980; Cohen-Cole, 1991; Roter et al., 2006; Williams, Weinman, & Dale, 1998) => High physician emotionality and low dominance are both related to higher patient satisfaction

7. The Paradox! • No “net” difference in patient satisfaction with women and men doctors (Hall, Irish, & Roter, 1994) • How to explain this paradox? Maybe the same physician communication style adopted by a woman or man doctor affects patients differently

8. Research Question How does gender and physician communication style (emotionality and dominance) affect patient satisfaction?

9. The Challenge • Problem: In real-world physician-patient interactions, physician gender and physician communication style are confounded • Solution: Vary physician gender and physician communication style independently of each other and measure patient satisfaction • How?

10. Experimental Approach • Patients see a female or male doctor who communicates either high or low on emotionality and high or low on dominance • Physician is a virtual person ...

11. Method • Participants: 167 students (87 women, 80 men), age = 26.5 • Role play a patient: symptoms and reason for visit: Recurrent headaches, second visit, goal: discuss lab results from last visit and decide on treatment • Interaction with virtual physician (15 min) • Questionnaires: perceived emotionality, perceived dominance, patient satisfaction (Schmid Mast, Hall, Klöckner, & Choi, 2008)

12. Man (virtual) doctor

13. Woman (virtual) doctor

14. Communication with Virtual Doctor • 16 sequences (opening, data gathering, patient education and counseling, and decision making) • Stack of 16 cards, each with hints, e.g., “Your headaches have become more severe during the past two weeks” • Virtual physician talks on key command

15. Manipulation of Physician Communication Style

16. Manipulation Check • Perceived physician emotionality • 6 Items on emotionality, e.g. friendly, nice • Reliability: Cronbach‘s Alpha = .86 • Physicians with a high emotional communication style were perceived as more emotional than physicians with a low emotional communication style, t(164) = 4.65, p < .0001.

17. Manipulation Check • Perceived physician dominance • 3 Items on dominance, e.g. dominant, assertive • Reliability: Cronbach‘s Alpha = .82 • Physicians with a high dominant communication style were perceived as more dominant than physicians with a low dominant communication style, t(164) = 4.87, p < .0001.

18. Patient Satisfaction Questionnaire • 36 items, “I am very satisfied with the way the physician treated me” • Reliability: Cronbach‘s Alpha = .96 • Control variables: age, health status, experience with doctors, perceived realism of medical visit, felt awkwardness in experimental situation

19. Data Analysis • 2 (physician gender) X 2 (emotionality in physician communication) X 2 (dominance in physician communication) X 2 (patent gender) ANOVA • Dependent variable: Patient satisfaction

20. Results 4-way interaction: F(1, 151) = 5.32, p = .022

21. Medium level of patient-centeredness High patient- centeredness Low patient- centeredness Opposite-Gender Consultations Interaction effect: F(1, 83) = 10.63, p = .002 (same if control variables are taken into account)

22. Summary of Opposite-Gender Consultations • Low (D+E-) patient-centeredness entails low patient satisfaction • High (D-E+) patient-centeredness entails low patient satisfaction • Medium level of patent-centeredness (D+E+ and D-E-) entails high patient satisfaction • Why? Headaches is a common, everyday symptom, which does not necessitate a particularly patient-centered interaction style

23. Same-Gender Consultations

24. Male Same-Gender Consultations Emotionality and dominance in physician communication style do not affect patient satisfaction All F‘s < 1.15

25. Female Same-Gender Consultations Emotionality in physician communication style affects patient satisfaction Main effect for emotionality: F(1, 38) = 22.43, p = .0001

26. Summary and Interpretation of Same-Gender Results • Among men: Emotionality and dominance in physician communication style do not affect patient satisfaction. Maybe another aspect would, e.g. competence Male patient: “I don’t care how emotional or dominant he is, I care about whether he knows what he is doing!” • Among women: High emotionality in physician communication style entails more patient satisfaction than low emotionality: gender-role congruent communication Female patient: “Despite her (male) profession, I still want her to be a woman!”

27. Implications for Practice • Physician education in communication skills is important because it affects patient satisfaction • Especially for women physicians it might be advisable to communicate in a gender-congruent manner (high emotionality) • For a physician, it is advantageous to adopt different communication styles and to flexibly use them according to patient gender (and other patient characteristics…)

28. Overview Physician gender • Physician communication style: • Manipulated on emotionality and dominance • Nonverbal behavior measured Patient satisfaction Patient gender

29. Effects of Physician Nonverbal Behavior on Patient Satisfaction Physician nonverbal behavior Patient perception of physician (e.g., satisfaction)

30. Effects of Physician Nonverbal Behavior • Effects on patients • Increase patient satisfaction (DiMatteo, Hays, & Prince, 1986) • Increase adherence (DiMatteo, Hays, & Prince, 1986) • Improve health outcome (Ambady, Koo, Rosenthal, & Winograd, 2002) • Effects on physicians • Reduce malpractice litigations (Ambady, Laplante, Nguyen, et al., 2002) • Improve diagnosis (Bensing, Kerssens, & van der Pasch, 1995)

31. Patient Satisfaction and Physician Nonverbal Behavior • Patient satisfaction related to physician expressiveness • Less time reading medical chart, more forward lean, more nodding, more gestures, closer interpersonal distance, more gazing (Hall, Harrigan, & Rosenthal, 1995) • Smiling, eye contact, forward body lean, expressive tone of voice, expressive face, gestures, etc. (Griffith, Wilson, Langer, & Haist, 2003)

32. Moderators of Physician Nonverbal Behavior and Patient Satisfaction • Gender • M – M: physician interruptions negatively related to satisfaction, F – F: physician interruptions positively related to satisfaction (Hall, Irish, Roter,et al., 1994) • Severity or type of illness • Patient satisfaction related to physician’s emotional expressiveness regardless of the type of problem (medical, psychosocial, or counseling problem) (Griffith, Wilson, Langer, & Haist, 2003) • Age • Economic status • Personality

33. The Study What are the effects of gender on physicians’ nonverbal behavior correlates of patient satisfaction? (Schmid Mast, Hall, Klöckner, & Choi, 2008)

34. The Method • Analogue patients (163: 60 M, 103 F) • 11 different 2-min physician-patient interactions on videotape • Indicate satisfaction after each of the 11 interactions (1 = „not satisfied at all“ to 9 = „very satisfied“)

35. The 11 Target Physicians on Video • 11 general practioners in their private practice • Patients were between 36 and 67 years old • Second minute and the third last minute of the consultation

37. Nonverbal Behavior Correlates of Patient Satisfaction • 22 nonverbal behaviors • Speaking time, self-touch, gazing, interpersonal distance, loudness of voice, smiling, gesturing... • including appearance such as formal clothing, medical atmosphere, attractiveness • Coding reliability (mean r) .71 to .98 • For each analogue patient: Correlation of satisfaction with each of the behaviors across 11 targets (also separately across the female and across the male physician targets)

38. Speaking time 26 13 30 9 44 24 20 51 35 19 18 r = -.52 3.5 4.6 2.5 7.1 6.9 4.4 3.8 1.2 3.1 6.8 8.2 Satisfaction Correlation Coefficients 1 2 3 4 5 6 7 8 9 10 11 For each analogue patient: Correlation coefficient between satisfaction and speaking time

39. Analyses • 2 (physician gender) X 2 (patient gender) ANOVA for each of the behavioral satisfaction correlates

40. Results • No significant participant gender main effects • No significant participant gender by physician gender interaction effect (2 exceptions) • Many significant physician gender main effects

41. Female Physicians versus Male Physicians

42. Female Physicians versus Male Physicians

43. Overview Female Physicians • Less speaking time • (More patient speaking time) • Less talking while doing something else • More gazing • Less looking at medical chart • Less interpersonal distance • Less expansiveness • Softer voice • More self-touch • More lowered eyebrows • More formal clothing • More medical atmosphere

44. Overview Female Physicians • Less speaking time • (More patient speaking time) • Less talking while doing something else • More gazing • Less looking at medical chart • Less interpersonal distance • Less expansiveness • Softer voice • More self-touch • More lowered eyebrows (concern) • More formal clothing • More medical atmosphere

45. Overview Male Physicians • More interpersonal distance • Less orientation toward patient • More looking at medical chart • More expansiveness • Less self-touch • Louder voice • More gesturing • Less medical atmosphere • Less frowning

46. Overview Male Physicians • More interpersonal distance • Less orientation toward patient • More looking at medical chart • More expansiveness • Less self-touch • Louder voice • More gesturing • Less medical atmosphere • Less frowning

47. Interpretation of Results • Female physicians • gender-role congruent nonverbal behavior is related to more satisfaction • Environment is expected to convey competence • Male physicians • gender-role congruent nonverbal behavior especially in the realm of interpersonal distance (less oriented toward, more distant, more looking at chart, expansive) is related to more satisfaction • Environment is expected not to be „medical“

48. Conclusion • Physician communication training should take physician characteristics (e.g., gender) into account • Not one training fits all • Authenticity • Tailored communication • Personality: Affiliative patients adhere more to phyiscians who show affiliative than non-affiliative nonverbal behavior (Cousin & Schmid Mast, in prep.)

49. David Sipress, published in The New Yorker, September 4, 2000