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10.1146/annurev.publhealth.25.101802.123134

Annu. Rev. Public Health 2004. 25:497519

doi: 10.1146/annurev.publhealth.25.101802.123134
c 2004 by Annual Reviews. All rights reserved
Copyright

PHYSICIAN GENDER AND PATIENT-CENTERED

COMMUNICATION: A Critical Review of
Empirical Research
Debra L. Roter1 and Judith A. Hall2
1

Department of Health Policy and Management, Johns Hopkins Bloomberg School

of Public Health, Baltimore, Maryland 21205; email: droter@jhsph.edu
2
Department of Psychology, Northeastern University, Boston, Massachusetts 02115;
email: HALL1@neu.edu

Key Words literature review, physician-patient communication, meta-analysis,

physician-patient relationship, medical dialogue
Abstract Physician gender has stimulated a good deal of interest as a possible
source of variation in the interpersonal aspects of medical practice, with speculation
that female physicians are more patient-centered in their communication with patients.
Our objective is to synthesize the results of two meta-analytic reviews the effects of
physician gender on communication in medical visits within a communication framework that reflects patient-centeredness and the functions of the medical visit. We performed online database searches of English-language abstracts for the years 1967 to
2001 (MEDLINE, AIDSLINE, PsycINFO, and BIOETHICS), and a hand search was
conducted of reprint files and the reference sections of review articles and other publications. Studies using a communication data source such as audiotape, videotape, or
direct observation were identified through bibliographic and computerized searches.
Medical visits with female physicians were, on average, two minutes (10%) longer
than those of male physicians. During this time, female physicians engaged in significantly more communication that can be considered patient-centered. They engaged in
more active partnership behaviors, positive talk, psychosocial counseling, psychosocial question asking, and emotionally focused talk. Moreover, the patients of female
physicians spoke more overall, disclosed more biomedical and psychosocial information, and made more positive statements to their physicians than did the patients of
male physicians. Obstetrics and gynecology may present a pattern different from that
of primary care: Male physicians demonstrated higher levels of emotionally focused
talk than their female colleagues. Female primary care physicians and their patients engaged in more communication that can be considered patient-centered and had longer
visits than did their male colleagues. Limited studies exist outside of primary care, and
gender-related practice patterns might differ in some subspecialties from those evident
in primary care.

0163-7525/04/0421-0497$14.00

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INTRODUCTION
Recent national reports, including two issued by the Institute of Medicine (25,
26) and the American College of Physicians Charter on Medical Professionalism
(2) have focused attention on the centrality of patient-centered communication
to the safe delivery of quality medical care and the practice of ethical medicine.
Within this context, patient-centeredness has become the shorthand reference to the
inclusion of patients perspectives and preferences in care, as well as provision of
the information patients need if they want to participate in medical decision making
(16, 30). Supported by a growing body of literature linking these communication
skills to a host of valued outcomes, patient-centered communication is increasingly
regarded as a critical area of medical practice (26, 33). Indeed, the recent Institute
of Medicine reports have listed patient-centeredness among six key indicators
shaping the nations future quality of health care agenda. Professional medical
education has similarly embraced the goal of enhanced patient-centeredness. Key
medical accrediting and licensing bodies in the United States have established that
during the next 10 years, proficiency in patient-centered communication skills will
be demanded and assessed.
Unlike traditional areas of instruction in the medical sciences and clinical practice for which medical schools have adopted curricular conformity and agreed
on criteria for mastery, communications curricula have varied widely in content,
teaching strategies, duration, and objectives (1). Some schools devote as little
as one hour to a lecture on the topic of interpersonal communication, whereas
other schools have developed sophisticated programs of experiential instruction
throughout undergraduate and graduate medical training (1). In some measure,
these curricular differences reflect the ambivalence with which communication is
regarded within the modern practice of medicine. Although many medical educators believe communication is a skill on par with other medical sciences and
should be a part of the required curriculum, others fear that communication sensibilities lie within the intangible domain of medicines art, and, consequently,
cannot be operationally defined, directly taught, or explicitly evaluated. Within
this context, there is great interest in personal attributes and characteristics that
may be associated with variation in communication ability and receptivity to skill
instruction.
Gender is a characteristic that is associated with variation in communication
style. In routine conversation, differences in the interpersonal style of women as
compared with that of men are well documented (13, 17). Women disclose more
information about themselves in conversation (12), they have a warmer and more
engaged style of nonverbal communication (17), and they encourage and facilitate
others to talk to them more freely and in a warmer and more intimate way (17). In
contrast to mens tendency to assert status differences, there is evidence that women
take greater pains to downplay their own status in an attempt to equalize status with
a conversational partner (13). Women are also more accurate in judging others feelings expressed through nonverbal cues and in judging others personality traits (17).

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

long speculated that female physicians may find it easier than do male physicians
to engage in communication that can be considered patient-centered (70). The purpose of this chapter is to examine the contributions of physician gender to variation
in patient-centered aspects of medical care communication and the implications
of these differences for communication training and quality-of-care initiatives. We
approach this goal from several directions. First, a framework for characterizing
communication elements as patient-centered is presented and applied to the results
of two meta-analytic reviews of studies. The first of these relates physician gender
to the physicians communication during medical encounters (48, 54). One might
argue that the focus on physician communication fails to appreciate the influence
of patients in shaping the doctor-patient relationship. In fact, discussions of gender
effects in medical communication have virtually ignored the question of how patients behave toward male versus female physicians. This is an important question,
however, because it shifts a largely physician-centric view of communication to
one that better appreciates the reciprocal and dynamic elements of both patient
and physician in the medical interchange. Therefore, the results of a second metaanalytic review of physician gender in relation to patients communication are also
presented (19).
Furthermore, the few studies that have investigated the communication effects of
a same-gender compared with a different-gender patient-physician dyad are highlighted. Inasmuch as communication training enhances skill both at the medical
undergraduate and postgraduate levels, studies linking gender to student performance in communication training programs and curricula are also reviewed in
detail. Finally, policy implications and future directions in research, training, and
certification initiatives are discussed in relation to gender differences in performance and learning.

Operationalization of a Patient-Centered Framework

Patient-centeredness has been varyingly used to describe a philosophy of medicine
(15), a clinical method (33, 37), a type of therapeutic relationship (16), a quality-ofcare indicator (26), a professional and moral imperative (2), and a communication
style (6, 48). In their review of the empirical literature in this area, Mead & Bower
(38) concluded that although there is agreement on several dimensions of the concept of patient-centeredness, areas of conceptual contention are evident, and there
is little consensus on operationalization of indicators or measurement approaches.
There are two important areas of conceptual ambiguity evident in the literature on patient-centered communication. The first relates to the interpretation of
physicians communication that is not explicitly identified as patient-centered, and
the second is the role and meaning attributed to patient dialogue in measures of
patient-centeredness. Although physicians communication behaviors that encourage patients to talk (usually operationalized as open-ended questions) are empathic
and relate to the nonmedical dimensions of care common to most patient-centered

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assessment approaches (38), there has been little discussion regarding the role of
communication that falls outside of the patient-centered domain. For example,
closed-ended questions and compliance directives are almost always used during
the course of a medical interview, and few clinicians (or patients) would argue
that the data-gathering and patient-education functions of the medical interview
could be accomplished without them (32). However, these communications are not
generally considered to be patient-centered in that they tend to restrict, control, or
direct patients in some manner. The inclusion of patient education and counseling
in the biomedical realm is likewise complex; some investigators have identified
it as an important patient-centered indicator because many studies have shown
that patients value this information, whereas other investigators have maintained
that the provision of biomedical information is a controlling communication derived from a paradigm reflective of a physicians rather than a patients perspective
(45).
A somewhat similar ambivalence is evident in regard to the inclusion of patient
dialogue as an element of patient-centeredness. Medical educators have largely
limited their investigations to analysis of physician behavior, although sometimes
this analysis includes physicians responsiveness to patients cues of emotional distress, concerns, or expectations (62). Others have defined patient-centeredness as a
dialogue in which an assessment of both the patients and physicians contributions
is relevant (48). As noted above, the issues evident in the classification of physician communication are also present in the classification of patient communication.
For instance, investigators who include patient dialogue in their assessment would
agree that the patients provision of psychosocial information to the physician is
consistent with conceptions of patient-centeredness and the communication of the
patient narrative; however, classification of the patients biomedical disclosure is
less straightforward. Some have argued that biomedical disclosure, particularly in
response to a series of physician-directed, closed-ended questions, reflects physician dominance in the exchange. Closed-ended questions further the physicians
hypothesis-testing agenda for the visitoften without patients understanding the
significance of their responses. Yet, again, few clinicians or patients would maintain that the data-gathering tasks of the medical interview could be accomplished
without elicitation of this information or that the information is unimportant in the
patients construction of their illness narrative.
The question arises as to how these other-than-patient-centered behaviors should
be viewed within a communication framework. A reasonable approach may be that
of balance; no individual element of communication can be considered positive
or negative in isolation from a broader pattern of exchange established during
the visit. Furthermore, linking communication to fulfillment of the core medical
objectives of the interview enhances the relevance of communication study to the
practice of medicine.
The two meta-analyses on the subject of physician gender and communication
produced over 150 different variables abstracted from 23 studies that were sorted
into independent categories of communication, which allowed for quantitative
summarization (19, 54). For the current review, the communication variables

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TABLE 1 Categories of communication examined in relation to physician gender

Category

Other communications

Patient-centered communications

Data gathering

MD Biomedical questions
MD Closed-ended questions

MD Psychosocial questions
MD Open-ended questions
PATIENT Questions (all)

Patient education
and counseling

MD Biomedical counseling
PATIENT Biomedical disclosure

MD Psychosocial counseling
PATIENT Psychosocial disclosure

Partnership building

MD Active enlistment
MD Lowered dominance

Emotionally
responsive
communication

MD Emotional talk
PATIENT Emotional talk

Nonverbal behavior

MD Positive nonverbal

Positive exchange

MD Positive talk
PATIENT Positive talk

Social exchange

MD Social talk
PATIENT Social talk

Shows a significant effect favoring female physicians.

were reorganized into categories consistent with the literature describing patientcenteredness and the functions of the medical visit (48).
The key communication categories organized by the functions of the medical
interview are elaborated below and displayed in Table 1. These include: (a) data
gathering and facilitation of patient disclosure, (b) patient education and counseling, (c) emotional responsiveness, and (d) partnership building. (A detailed listing
of the individual variables included in each of the categories of the framework is
presented in the appendix.)
DATA GATHERING Data gathering includes those skills that further the patients
ability to tell the story of his or her illness through disclosure of information that
the patient may deem meaningful (e.g., use of open-ended questions, particularly
in the psychosocial domain). We would also include all forms of patient question
asking as facilitating communication because it is useful in directing physician
disclosure to patient-defined areas of informational need.
PATIENT EDUCATION AND COUNSELING Patient education and counseling include
information and counseling skills (e.g., biomedical information and psychosocial counseling) that assist patients in making sense of their condition and coping with the medical regimen and lifestyle demands of treatment. Therefore,
both biomedical and psychosocial counseling can be considered patient-centered
communication.
From the patient perspective, the opportunity to relate the illness narrative
and reflect on experience, perspective, and interpretation of symptoms and

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circumstances may hold therapeutic value; consequently, we consider patients

disclosure, especially in the psychosocial realm, to be an indicator of the visits
patient-centered focus (49).
PARTNERSHIP BUILDING Partnership-building communication assists patients in
assuming a more active role in the medical dialogue, either through active enlistment of patient input [e.g., asking for the patients opinion and expectations,
using interest cues, paraphrasing and interpreting the patients statements to check
for (physician) understanding, and explicitly asking for patient understanding], or
passively by assuming a less-dominating stance within the relationship (e.g., being
less verbally dominant). All physician behavior in this category can be considered
patient-centered.
Patients participatory communication reflects components of active enlistment
including facilitation of physician input through requests for opinion, understanding, paraphrase and interpretations, and verbal attentiveness.
EMOTIONALLY RESPONSIVE COMMUNICATION Emotionally responsive communication conveys emotional content through explicitly emotional statements (e.g.,
use of empathy, reassurance, concern) and through nonverbal communication that
includes positive nonverbal behaviors (smiles, nods, friendly voice tone, relaxed
hands), and displaying a variety of behaviors that can have ambiguous, neutral,
or negative meaning depending on the context of use (e.g., touches patient, folds
hands, gestures while speaking, points at the patient, speech disturbances, voice
tone measures reflecting anxiety or boredom). To avoid the difficulties associated with ambiguous interpretation, the analysis was limited to positive nonverbal
behaviors. Negative talk, however, was analyzed and reflects disagreements and
criticisms.
Less explicitly emotional categories of communication are captured in positive
and social talk. Positive talk captures the general positive atmosphere created in the
visit through verbal behaviors such as agreements, approvals, and compliments.
Social conversation defined as nonmedical exchanges largely consist of social
pleasantries and greetings, usually functioning as a linguistic bridge from the social
opening or closing of the visit to the business of the visit. Social talk is not as emotionally charged as positive talk but does convey friendliness and personal regard.
Emotionally responsive communication may be considered as patient-centered
when expressed by either physician or patient.

METHODS
Studies were included in the original meta-analytic reviews if they: (a) involved
physicians, physicians in training (interns or residents), or medical students; (b) involved actual or standardized patients; (c) measured communication using neutral
observers (including standardized patients as observers), audiotape, or videotape,
with an exception being the inclusion of physician-reported length of the medical visit; (d) tested for an association between physician gender and at least one

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interpretable physician or patient communication variable; (e) dealt with nonpsychiatric medical visits; and (f) were published in an English-language book or
journal. The studies were identified through online database searches using a combination of keywords, including doctor-patient interaction; patient-interaction;
physician-patient interaction; doctor-patient relationship with female; gender
effects; female physicians; female doctors; effect of sex of doctor.
For the current review, additional studies are discussed that address physician
or student gender related to the evaluation of communication training programs.

Analytic Approach
In the meta-analyses, the standard normal deviate (Z), the statistic associated with
a p-value, was derived for each result and summed within categories of communication variables. The sum was then divided by the square root of the total number
of studies to obtain a combined Z and its associated probability (combined p).
The combined p is a statistical summary that captures information that is often
embedded in null results and generally lost, and it provides a commonly understood probability metric to compare results from multiple studies across variables
of interest. It is the combined p, representing the probability that physician gender
is related to particular categories of communication, that is reported in Table 1. An
effect size (ES), Cohens d, was also calculated in the meta-analysis to estimate
the magnitude of the difference between male and female physicians communication. All of the significant ES estimates were small in magnitude, ranging from
0.22 to 0.36. Because of the limited variation in the magnitude of Cohens d, these
estimates are not reported here.
Twenty-six studies were included in the meta-analytic calculations summarized
below. Most studies were conducted in primary care settings, with the exception
of two obstetrics and gynecology studies, and physicians at all levels of training
were represented. The average number of physicians was 40, with male physicians
substantially outnumbering female physicians (n = 25 and 15, respectively). The
average number of visits per study was 157; this reflected an average of 97 visits to
male physicians and 65 visits to female physicians in each study. There was wide
variation in the number of patients observed for each physician; the average was
4, and the range was 1 to 32.
Seven of these studies reported quantitative results on the relation of physician
gender to patient communication (8, 18, 51, 52, 65, 66, 68, 71), and a summary of
these results is also presented.

RESULTS
As reflected in Table 1, physician gender was related to each of the four functions
of the medical interview. (The appendix identifies individual variables that have
demonstrated a significant relationship to physician gender in at least one study
for this behavior.)

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(1) DATA GATHERING

Data gathering was characterized in terms of both content (biomedical and psychosocial) and format (closed-ended and open-ended).

Physicians Question Content

As reflected in Table 1, there is evidence that female physicians ask more psychosocial questions of their patients than do male physicians. Three of six studies reported significant results indicating higher levels for female physicians (18, 56, 57),
and no studies reported higher levels of psychosocial questioning by male physicians. For biomedical questions, two of three studies reported significant results;
one reported significantly higher levels of biomedical question asking for female
physicians (18), whereas the other study found higher levels for male physicians
(68). Because the two significant results were of near equal magnitude, the pooled
combined p was nonsignificant. It is interesting to note that the study reporting
higher levels of biomedical question asking for females was conducted in primary
care, whereas higher levels for males were reported from a gynecology study.

Physicians Question Format

Only one of four studies coding closed questions reported significantly higher
levels for female physicians (51); however, none of the remaining three reported
higher levels for males. The pooled findings reflect a marginally significant combined p (<.1), which suggests that females ask more closed-ended questions than
do their male counterparts. In contrast to closed-ended questions, there is little
evidence of a gender effect for open-ended questions. Whereas one of six studies
found significantly higher levels of open-ended questions for female physicians
(58), the remaining studies were inconsistent in direction, and the combined p was
not statistically significant.

Patients Question Asking

Patient question asking was infrequently defined in terms of content or form; consequently, all patient questions were combined. Five studies coded patient question
asking and none of these studies reported a statistically significant physician gender
effect.

(2) EDUCATION AND COUNSELING

Education and counseling were characterized in terms of content, with a focus on
either biomedical topics (e.g., medical symptoms and history, diagnosis, prognosis,
and treatment) or psychosocial topics (e.g., prevention; lifestyle; quality of life and
adjustment; social, family, and work relationships; and issues related to discussion
of feelings and emotions).

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Analysis of findings in this area revealed mixed results. There was little consistent evidence that physician gender affected medically specific counseling. Two
studies reported significant results; one (65) reported significantly higher levels
of biomedical counseling by male physicians, but the other one reported more
counseling by females (58).
A more consistent picture of gender effects emerged for psychosocial discussion
by the physician. Five of ten studies addressing psychosocial discussion reported
significantly higher levels by female rather than by male physicians (5, 8, 56, 57, 65,
66). Only one study (68) reported higher (but nonsignificant) levels of psychosocial
discussion by male physicians, and this was a study of gynecologists.

Patients Disclosure of Information

Informational disclosure by patients was similarly categorized as biomedical or
psychosocial in nature. There is clear evidence that patients of female physicians
provided more of both kinds of information than did patients of male physicians
(Table 1). Four studies (8, 18, 51, 65, 66) were each statistically significant for
biomedical information, and three studies (8, 51, 65, 66) were each significant for
psychosocial information.
Interestingly, in parallel with the finding that a gynecology study was the only
one to report higher levels of psychosocial discussion for male physicians, the
two obstetrics-gynecology studies showed higher (but nonsignificant) levels of
psychosocial disclosure to male physicians. These results were in the opposite
direction from the primary care studies.

(3) PARTNERSHIP BUILDING

Physicians Partnership Building
By our definition, partnership building occurs when the physician actively facilitates patient participation in the medical visit and/or attempts to equalize status by
assuming a less dominating stance within the relationship. Twelve studies included
the active, enlistment-type variables in their coding. Six of these studies reported
significantly higher levels of active enlistment on the part of female physicians (8,
18, 31, 51, 57, 68), and two studies showed the reverse (43, 52). The combined
p is statistically significant, indicating that female physicians engaged in higher
levels of partnering behaviors than did males.
Five studies coded variables reflecting the passive, lowered-dominance approach, and one of these reported a statistically significant result indicating lowered
dominance for female physicians (8). The combined p was not significant.

Patients Partnership Building

Patients may actively facilitate physician input through requests for opinion, understanding, paraphrase and interpretations, and verbal attentiveness. Five studies

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coded this type of variable, and as Table 1 shows, there was a nonsignificant overall tendency for patients to direct more partnership-building behaviors to female
than male physicians. However, it is interesting to note that three of the five studies reported significant findings; two studies showed more partnership directed
toward female physicians (18, 51), and the third study, conducted in obstetricsgynecology, showed more partnership directed toward male physicians (52). If the
primary care and obstetrics and gynecology studies are analyzed separately, the
combined p for each is significant (but in the opposite direction). Thus, in general
medical practice, patients were more promotive of a partnership relationship with
female than with male physicians; however, the opposite may be true for obstetrics
and gynecology.

(4) EMOTIONALLY RESPONSIVE COMMUNICATION

Physicians Emotional Talk
Emotionally focused talk included explicit inquiries about feelings and emotions,
exploration of emotional concerns, and statements of empathy and concern. This
category is distinguished from psychosocial exchange (see above) by directly
expressing feelings and emotions. Thirteen studies coded emotional talk in some
manner; four of these found significantly higher levels for female compared with
male physicians (35, 42, 58, 69), and the combined p was significant.
Both gynecology studies in the review found higher levels of emotional talk
by male physicians; one of these reported a significant result (52) and the second (68) was marginally significant. Because the studies showed a high degree
of heterogeneity that was almost entirely explained by the two obstetrics and gynecology studies, the analysis was repeated for the eleven primary care studies,
which yielded a strong and consistent gender effect favoring female physicians;
analysis of the two obstetrics and gynecology studies showed a significant gender
effect favoring male physicians.

Patients Emotional Talk

Four studies measured patient emotional talk, which included statements of concern, worry, and personal feelings (18, 52, 65, 66, 68). There was no evidence
of a physician gender effect on patient emotional talk. This was true for both
obstetrics-gynecology studies and general medical studies.

Physicians Positive Talk

Positive talk captured the generally positive atmosphere created in the visit through
verbal behaviors such as agreements, encouragement, and reassurance. Social
conversation was not included in this category, with the exception of two studies in which it was embedded in a composite variable otherwise comprised of
positive elements. Fourteen studies included some measure of physicians positive

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talk. Six of these studies reported significantly higher levels of positive talk by
female physicians (4, 18, 35, 51, 58, 68). No studies reported higher levels of positive talk by male physicians and the combined p summarizing these studies was
significant.

Patients Positive Talk

Positive comments by the patient, including statements of agreement, were measured in five studies and all showed higher levels of positive talk directed toward
female physicians (18, 51, 52, 65, 66, 68). In this case, the findings were not different in the obstetrics-gynecology studies; thus patients appear to be more verbally
positive when seen by female physicians regardless of visit type.

Physicians and Patients Negative Talk

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

Physicians and Patients Social Communication

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

Physicians Nonverbal Communication

Six studies coded positive nonverbal behavior in some manner, and two of these
studies reported significant results showing that female physicians demonstrate
higher levels of smiling and head nods (18) and awareness of nonverbal communication (57). No studies reported higher levels of positive nonverbal behavior for
male physicians, and the combined p was significant.

Patients Nonverbal Communication (Global Ratings

of Patient Communication)
Patients nonverbal communication was assessed most often through global ratings
made of their communication by neutral observers (8, 52, 65, 66). Observers
listened or watched the entire physician-patient interaction and then made global
ratings of the patient in all but one study. In the one exception (18) observers
listened to short clips of patients speech that had been electronically filtered to
obscure the verbal content. Four studies (8, 18, 52, 65, 66) gathered ratings of
positive affect (friendly, warm, kind). Of these, only one study (65, 66) showed a
significant tendency for patients to display more positive global affect to female
physicians and the combined p was not significant.
Ratings of patients assertiveness-dominance were also obtained in these four
studies and the combined p was significant, indicating that patients were more
assertive with female than male physicians.

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Length of Visit
Research shows consistently that female physicians conduct longer visits than
do male physicians. Five of the ten studies that directly measured length of visit
reported that female physicians conduct significantly longer visits than males (4,
8, 41, 51, 68). Only one study, the U.S. study of obstetricians, found longer visits
for male physicians (52). Length of visit averaged 21 min (range 7.436.7 min)
for male physicians and 23 min (range 10.537 min) for female physicians.
AMOUNT OF PATIENT TALK There is consistent evidence that patients talk more
when seen by female than by male physicians. Three of four studies examining
the amount of patient talk reported significantly higher levels in visits with female
physicians (18, 51, 65, 66). Interestingly, the one result in which patients spoke
more to male than female physicians came from the U.S. obstetrics-gynecology
study (52). As indicated by the table, the combined p was significant.

Gender Concordance and Communication

There have been relatively few studies that have directly examined the effects
of patient and physician gender simultaneously on medical communication, but
evidence suggests that same-gender dyads strengthen the effects observed in the
reviews mentioned earlier. For instance, two U.S. studies found that medical visits
between female physicians and female patients were characterized by longer encounter length and more equal patient and physician contributions to the medical
dialogue than were visits with all other gender combinations (18, 51). Medical
visits between male physicians and male patients were characterized by the shortest visit time and the highest level of physician verbal dominance. Hall et al. (18)
also reported more positive statements, head nodding, and interest cues in female
concordant visits compared with other gender combinations (18, 27). A recent
comparative study of medical communication in six Western European countries
also found that female concordant dyads were longer, had higher levels of psychosocial discussion, emotional exchange, and eye contact, and had lower levels
of physician verbal dominance (67). Notably, the investigators found few countryspecific differences in the pattern of results, which suggests that the observed
effects of physician and patient gender on communication appear to transcend
national and cultural borders.

ARE FEMALE LEARNERS MORE SUCCESSFUL

IN MASTERING COMMUNICATION
CURRICULA THAN MALES?
It is evident from the earlier analysis that female physicians engage in more patientcentered communication with their patients than do male physicians. There is also
evidence that female learners more readily acquire communication skills during

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training than do males and score higher on related indicators of training success,
including patient satisfaction ratings and empathic sensitivity (3).
Our review identified three studies that addressed the question of student gender and measures of actual communication in a skills training program. Two of
these studies reported higher skill acquisition for female than for male medical
students (35) or residents, whereas the third failed to find a training effect for
any students (29). For instance, the Marteau et al. study (35) found that simulated
patients rated female students higher than male students on empathy, warmth, and
competence, and that the videotaped interviews of female students were scored by
trained observers as achieving higher levels of communication skill than those of
males.
Following a training program focusing on adherence counseling skills, Roter
and colleagues (50) found a pattern of skill gain that suggests both the nature
of the training program and student gender are predictive of the specific gains
a student may make. Although both male and female residents showed reductions in verbal dominance and increased use of open psychosocial questions and
problem-solving skills after training, additional changes appeared to be gender
linked. Female residents increased their use of open-ended questions across all
content domains (e.g., psychosocial, therapeutic regimen, medical history), statements of empathy, and use of partnership building (e.g., asking for patient opinion
and use of interest cues). Communication changes that were most notable for male
residents were increased use of closed-ended questions in regard to the therapeutic regimen and active partnership-building techniques, such as paraphrasing and
interpreting patient statements. Note that the domains showing most gain by females were of a more socioemotional nature than those showing the most gain
by males.
Several training programs designed to increase communication skill measured
success through a variety of indirect indicators. For instance, Smith and colleagues
(59) assessed the effect of a one-month psychosocial communication training program for medical residents by subsequent patient ratings of residents performance on five satisfaction dimensions. After statistically adjusting for pretraining
satisfaction scores, the investigators found that female residents received higher
scores from their patients on ratings of empathy and opportunities to disclose
information.
A Swedish study by Holm & Aspegren (23) used a measure of affect tolerance,
an awareness of ones own feelings, as an indicator of communication training success. Holm & Aspegren argue that awareness of ones own feelings is a prerequisite
for insight into the feelings of others and empathic ability. Prior to training, male
and female medical students scored equally on a measure of affect tolerance (based
on students descriptions of their emotional reaction to videotape clips in which a
variety of emotional states were exhibited by patients). Following communication
skills training, the female students were able to describe their emotional reactions to the videotape clips with greater awareness of complex and ambivalent
feelings.

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SUMMARY OF FINDINGS
Despite widespread interest in the effects of physician gender on the care process,
the literature describing these effects is small. We identified a modest number
of observational studies relating the communication process to physician gender.
Nevertheless, the pattern of results was almost entirely consistent with what one
might expect from the nonmedically related literature regarding gender differences
in communication. Female physicians spend more time during a typical visit talking with their patients than do male physicians. During this time, they engage
in communication that more broadly relates to the larger life context of the patients condition by addressing psychosocial issues through related questioning
and counseling and through greater use of emotional talk, positive talk, and active
enlistment of patient input. In contrast to the higher levels of psychosocial and
socioemotional exchange, there is little evidence that physician gender is related
to the more task-specific communication elements of care. Physician gender was
not related to the provision of biomedical information (including discussion of the
diagnosis, prognosis, and medical treatment).
Behavioral differences in the communication styles of male and female physicians would be especially important if they produced corresponding gender differences in patients behavior directed back to them. Indeed, the effects of physician
gender on patient communication were evident in the small number of studies in
which this was measured, and these results suggest that patient behavior largely
reciprocates gender-linked physician behaviors. Like their physicians, patients of
female doctors talk more overall, make more positive statements, discuss more
psychosocial information, and express more partnership building than do patients
of male physicians. There were some physician communication behaviors that
were indirectly reciprocated by patients. Even though male and female physicians
did not differ in how much biomedical information they provided to their patients,
patients of female physicians provided more biomedical information to them than
to male physicians. Because female physicians ask more psychosocial questions
than their male counterparts, it may be that this type of question stimulates more
patient disclosure of both a psychosocial and a biomedical nature. Higher levels of
patient disclosure may also be fostered by female physicians more active efforts
to build partnership through inviting the patients opinions and through the use of
interest cues, such as saying uh-huh and nodding. Interestingly, though female
physicians made more emotionally focused statements than did male physicians,
patients did not direct more emotional statements back to them. Patients did, however, disclose more psychosocial information to their female physicians.
Patient and physician gender concordance appears to strengthen many of the
gender effects observed. The three studies of which we are aware that have
directly investigated the impact of gender concordance on communication found
that female concordant visits were characterized by longer length and more equal
patient and physician contributions to the medical dialogue, more positive communication, both verbal and nonverbal, and more interest cues than all other gender

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

have the shortest visits with the greatest biomedical focus than all other gender
combinations.
In summary, the review revealed a pattern of effects associated with physician gender that goes beyond a list of individual elements of medical exchange.
Taken together, the differences reflect a patient-centered communication style that
inspires patient reciprocation and is likely to reflect a more intimate therapeutic
milieu of heightened engagement, comfort, and partnership. Although the magnitude of the effects attributable to gender for any given communication element
was small, the effects are comparable to those of many well-established medical,
psychological, behavioral, and educational interventions (34, 44, 47).
Finally, our review found evidence that female learners more readily acquire
communication skills during training than do males and score higher on both direct
and indirect indicators of training success.

IMPLICATIONS FOR POLICY AND PRACTICE

With increasing time and productivity pressures that plague all physicians, a twominute-per-visit increase evident for female physician visits represents a substantial time burden that could easily put a female physician an hour behind her male
colleagues at the end of a busy day. Mechanic and colleagues (40) have reported
that the average medical visit has increased by between 1 and 2 min in the last
10 years. Despite the increase in actual time, there is a widespread perception of a
shrinking visit that may be fueled by the time-pressured atmosphere within which
physicians are providing more preventive and counseling services than in the past
(7, 22, 61, 72). In this light, female physicians may be at even further risk of falling
behind their male colleagues in daily scheduling. Henderson & Weismans analysis
(22) of the Commonwealth survey of patient-reported screening and counseling
services concluded that female physicians provided more preventive counseling
to both their male and female patients, and more gender-specific screening to their
female patients than did male physicians.
Time pressures to do more in limited time may amplify even further the communication differences between physicians of different genders. Whereas male
physicians may respond to time pressures by dispensing with socioemotional and
psychosocial tasks, as suggested by Mechanic (39), female physicians may find
this more difficult to do (53). We suggest this because female physicians currently
record proportionately more diagnoses of a psychosocial nature than do their male
colleagues (10, 66), and the demand for diagnosis and treatment of mental health
problems in primary care is expected to grow (64).
The results from the two obstetrics and gynecology studies deviate from those
of the primary care studies. As several studies have documented especially strong
patient preferences for female physicians in gynecologic and obstetric care (14, 46),
male physicians may feel pressure to meet the increasing competitive challenge

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of growing numbers of female physicians by enhancing their own interpersonal

skills (20, 53). If this is the case, it would suggest that physicians are capable of
modifying their communication style given sufficient motivation and incentive.
The training literature is optimistic in this regard; there is ample evidence that
instruction in communication skills is associated with improvement in skills, and
some studies show these improvements to be long lasting (11, 55, 60). In this
regard, female students again appear to have some learning advantage; nevertheless both male and female students benefit from training and increase their skill
levels.
What can we conclude about the consequences of these gender-related communication effects in terms of the variety of patient outcomes so valued in health
services research? The reviewed studies did not systematically address patient outcomes and no direct conclusions can be drawn. It seems likely that the effects found
are an indication of a relatively more health-promoting therapeutic milieu produced
by female physicians. Such a conclusion, however, can only be speculative because
no study has directly investigated whether patients of female physicians fare better on clinical measures. Furthermore, whether medical care translates into better
clinical outcomes depends on much else besides simply whether the physician
seems to be doing the right things. Patients must also respect the physicians
judgment and be willing to follow through on the physicians suggestions and on
their own good intentions (regarding, for example, self-care, lifestyle, and medication adherence). Little or nothing is known about how male and female physicians
compare on these kinds of outcomes.
Moreover, because physician communication behaviors similar to those reviewed here have been positively related to patient satisfaction, compliance, and
recall and comprehension of information (20, 55), as well as a variety of health
outcomes (63), one might infer that female physicians have similarly favorable
outcomes. However, only for patient satisfaction is there evidence bearing on this
question, and here the literature is mixed. On average, female physicians do not
win out in popularity, as indicated by a review of studies that compare the satisfaction of patients seeing male versus female physicians. Some studies show
patients to be more satisfied with male physicians, some with female physicians,
and some show no difference. It is premature to offer an explanation for this variation; we can only speculate that patients satisfaction depends both on what the
physician actually does as well as on stereotypes and expectations held by patients
or differences in patient characteristics such as health status or sociodemographics.
Future studies of physician gender and communication will need to focus greater
attention on the assessment of patient health outcomes and other indices of care
quality.
What might these results mean for male physicians? We do not suggest that
all or even most female physicians are patient-centered and male physicians are
not; there is far more common ground than difference in the communication behaviors of male and female physicians. Moreover, physicians, both male and female, who are skillful communicators may achieve time efficiencies that allow the

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

Physicians have the capacity to improve their communication skills in meaningful
ways through self-awareness, self-monitoring, and training. The potentially powerful impact of patient reciprocation of both communication style and affect in the
medical visit is especially important to recognize, as recognition could help create
positive exchanges and defuse negatively spiraling interaction patterns. As recognized by the Institute of Medicine and medical accreditation and credentialing
bodies, the promotion of patient-centered medicine is key to the nations future
quality-of-care agenda and to the advance of medicine, both as healing art and as
science.

APPENDIX
Below are variables abstracted from the meta-analyses of physician gender organized by the four functions of the medical visit.

Physician Communication Categories

I. Data gathering
A. Question content
1. General questions (4, 5, 41, 57, 58)
Asks questions of family members, percent time taking history+,
problem-related data gathering, questions, questions on history and
nature of illness , requests information from family members , scans
other problem areas.
2. Biomedical questions (18, 65, 66, 68)
Medical questions
3. Psychosocial questions (18, 56, 57, 58, 65, 66, 68)
Asks about living situation, psychosocial questions.
4. Compliance-related questions (57, 58)
Checks for compliance.
B. Question format
1. Closed questions (51, 52, 57, 58)
Closed questions , specific questions.
2. Open questions (42, 43, 51, 52, 57, 58)
Open questions , probes for information, too few open questions
(reversed).
II. Patient education and counseling
1. Biomedical (4, 8, 18, 42, 51, 52, 65, 66, 68)
Biomedical counseling, biomedical information , resolution of problem,
treatment with medications, treatment without medications, medical
advice+, information on therapeutic regimen.

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

Considers consequence of illness, considers psychosocial status, talks
about shame/taboo , critical of technical/medical developments, detects
abuse sooner , discusses repeat consultations, discusses impact of diagnosis on family, discusses impact of diagnosis on patient, discusses impact
of diagnosis on patient and family, discusses personal habits, discusses
physical adjustment to pregnancy, discusses emotional adjustment to pregnancy, discusses social adjustment to pregnancy, focuses on psychosocial
problems, focuses on patient, gives information on personal habits , gives
psychosocial counseling, gives psychosocial information , gives information on disadvantages of medications and referrals, makes psychosocial
intervention, makes sex abuse referral and plan , minimizes prescription,
pays attention to prevention, devotes proportion of time discussing family problems , devotes proportion of time discussing preventive services ,
refers to living situation, refers to self-help groups, shows relationship of
problem to life, uses family to implement treatment.
III. Partnership building
A. Enlistment (8, 18, 31, 36, 41, 43, 51, 52, 57, 58, 65, 66, 68)
Accepts patient norms and values , uses active listening skills, allows complete initial concern statement+, asks for clarification, asks for patient opinion, asks for self-treatment, asks for reassurance, uses back channels ,
checks+ and considers complaints seriously, elicits expectations for treatment, elicits feedback, elicits patient expectations, elicits rationale for visit ,
encourages patient to tell story, encourages patient paraphrase, listens attentively, paraphrases , makes partnership statements+, picks up on patients
verbal leads, is patient-centered , reflects shared decision making , understands perception of complaints, shows verbal attentiveness.
B. Lowered dominance (8, 21, 43, 58, 65, 66)
Egalitarian , not dominant, overall control of presentation (reversed), percent MD talk to total (reversed), respectful , too much control of interview
(reversed).
IV. Responding to emotions
A. Social conversation (4, 18, 52, 53, 57, 58, 68)
Social conversation , quality of greeting.
B. Positive talk (4, 8, 18, 21, 35, 41, 42, 51, 52, 57, 58, 66, 68, 69)
Acknowledgment, agreement , approval, encouragement, encouragement/
reassurance , laughs/jokes, positive composite, positive talk , puts patient at
ease, rapport, reassurance , reinforcement, shared laughter, social behaviors,
warm .
C. Negative talk (18, 21, 42, 51, 52, 57, 58, 65, 66, 68)
Anger, anxiety, criticizes patient, disagreement , disapproval, does not avoid
criticism+, negative talk.

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D. Focus on emotions (8, 18, 28, 35, 42, 43, 51, 52, 57, 58, 65, 66, 68, 69)
Asks about patients satisfaction, concern+, discusses doctor-patient
relationship, discusses own emotional response, elicits patient feelings,
emotional probes , emotional talk, empathy , explores emotional concern,
interest/concern, legitimation, reflection, reflects patients feelings , shows
concern, stimulates patient to share problems.
E. Nonverbal communication
1. Positive nonverbal behaviors (18, 42, 57, 58, 66, 68)
Awareness of nonverbal communication , relaxed hands, friendly voice
tone (filter), nod , patient-directed gaze, smile , uses appropriate nonverbal communication, uses eye contact.
2. Negative nonverbal behaviors (18, 21, 42)
Anxious voice tone (electronically filtered speech) , bored voice tone
(electronically filtered speech)+, speech disturbances, tense hands/fists.
3. Neutral nonverbal behaviors (18, 21, 42)
Touches patient, touches self, folds hands/arms, gestures while speaking,
points at patient, manipulates objects, interrupts patient, simultaneous
speech, speech pitch, speech amplitude, speech rate.
F. Length of Visit (4, 5, 8, 18, 31, 41, 51, 52, 65, 66, 68)
Observed visit time+

Patient Communication Categories

I. Data gathering (18, 51, 52, 65, 66, 68)
Patient asks questions, asks psychological questions, asks medical questions,
asks clarifying questions.
II. Information giving
1. Biomedical (8, 18, 51, 52, 65, 66, 68)
Patient gives biomedical information .
2. Psychosocial (8, 18, 51, 52, 65, 66, 68)
Patient gives psychosocial information .
III. Partnership building (18, 51, 52, 65, 66, 68)
Partnership statements , verbal attentiveness.
IV. Responding to emotions
A. Social conversation (18, 51, 52, 68)
Nonmedical chit chat, social conversation.
B. Positive talk (18, 51, 52, 65, 66, 68)
Positive talk , social behaviors (composite).
C. Negative talk (18, 51, 52, 65, 66, 68)
Disagreement, criticism

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

Emotional talk, discusses MD-Patient relationship, shows concern.
E. Nonverbal communication (8, 18, 52, 65, 66)
Global ratings of the following emotions: anger+, warmth , assertiveness , anxiety , dominance, interest, friendliness, relaxed, submissive,
bored, calmness in voice tone (filter), friendliness in voice tone (filter).

Difference shows significantly higher levels for female physicians in at least

one study for this behavior.
+
Difference shows higher levels for male physicians in at least one study for
this behavior.
The Annual Review of Public Health is online at
http://publhealth.annualreviews.org

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