How Sex and Gender Impact Clinical Practice: An Evidence-Based Guide to Patient Care

14.

Section I

The importance of sex and gender in patient care

Outline

Chapter 1 Application of sex and gender health: A practical framework

Chapter 2 Clinician-patient communication: Gender influences

Chapter 1

Application of sex and gender health: A practical framework

Marjorie R. Jenkins, Catherine A. Johnson, Connie B. Newman and Alyson J. McGregor

Abstract

Sex- and gender-based medicine (SGBM) is a new and groundbreaking discipline that has immense potential to improve diagnosis, disease management, and health outcomes. It is grounded in differences in the ways both biological sex and the psychosocial context of gender representation influence disease. Further, SGBM is distinct from women’s health, as it encompasses the health and diseases of both women and men, and it is more than simply sex-specific health issues such as pregnancy, menopause, and cancers confined to either women or men. Rather, SGBM goes to the heart of the practice of holistic, individualized, evidence-based medicine. The majority of organ systems and disease conditions occur in both sexes and fall under the sex- and gender-based health category. People may have a myriad of risk factors that increase their potential for development of disease, and risk profiles vary widely. Sex and gender—two basic human variables—can impact disease occurrence, presentation, diagnosis, response to treatment, and prognosis.

Keywords

Health outcome; sex- and gender-based medicine; gender; communication; disease management; patient–clinician

Introduction

Sex- and gender-based medicine (SGBM) is a new and groundbreaking discipline that has immense potential to improve diagnosis, disease management, and health outcomes. It is grounded in differences in the ways both biological sex and the psychosocial context of gender representation influence disease. Further, SGBM is distinct from women’s health, as it encompasses the health and diseases of both women and men, and it is more than simply sex-specific health issues such as pregnancy, menopause, and cancers confined to either women or men. Rather, SGBM goes to the heart of the practice of holistic, individualized, evidence-based medicine. As Fig. 1.1 illustrates, the majority of organ systems and disease conditions occur in both sexes and fall under the sex- and gender-based health category. People may have a myriad of risk factors that increase their potential for development of disease, and risk profiles vary widely. Sex and gender—two basic human variables—can impact disease occurrence, presentation, diagnosis, response to treatment, and prognosis.

Figure 1.1 Men’s health, women’s health, and sex and gender health. (Reproduced with permission from Jenkins M. Texas Tech University Health Sciences Center, Laura W. Bush Institute for Women’s Health).

Defining sex and gender: why terminology matters

Science and society have interchanged sex and gender as if they are synonymous terms, but they are not. Sex is the classification of living things, generally as male or female, according to their reproductive organs and functions assigned by the chromosomal complement. Terms that indicate biological sex are male and female. Gender traditionally refers to a person’s self-representation as male or female; today, gender is nonbinary and some people consider themselves as neither male nor female.¹ Examples of terms that align with the social construct of gender are man, woman, boy, and girl, among many others. These terms were uniquely defined by the 2001 IOM Report, Exploring the Biological Contributions to Human Health: Does Sex Matter?, which underscored the importance of differentiating sex from gender in the practice of medicine.²

Sex and gender have multiple influences on disease (Table 1.1), and they can affect the responses of social institutions and individuals as well as healthcare delivery and outcomes. The terms, categories, and rationales delineated in Table 1.2 represent the first-of-its-kind attempt at codifying sex and gender terminology standards for the medical literature, and they are utilized throughout this book. Although this book, How Sex and Gender Impact Clinical Practice: An Evidence-Based Guide to Patient Care, aims to utilize these rules, in some cases deference is made to commonly accepted terminology—for example, using the phrase women of reproductive age. Furthermore, this book is the first to use the terms woman and man in connection with the word physician. This reflects the fact that the widespread use of female physician has unintentionally gendered that role.

Table 1.1

aMay lead to epigenetic modifications.

Table 1.2

This table, the first of its kind, indicates how sex and gender terminology should be used in the context of the literature and clinical practice, and includes rationales for each variable.

Gender: Environmental, social, cultural, self-presentation.

Sex: biological, anatomical, physiological.

Source: Reprinted with permission from Marjorie R. Jenkins, MD and Connie B. Newman, MD.

Emerging scientific evidence over the past two decades has shown significant sex and gender influences on health and disease across the lifespan, and the influences of sex and gender on healthcare delivery are beginning to be appreciated. Moving forward, it is important to clearly delineate sex-specific conditions (such as prostate cancer in males or endometrial cancer in females) from sex and gender health (understanding sex differences in screening tests and gender differences in environmental exposures).

Reflecting a step in that direction, the trend is now to ask for both biological sex and gender identity when evaluating a patient. For example, a transgender woman might report birth sex as male, but gender as woman. In the United States, many electronic medical record systems ask for sex as distinct from gender. In the United Kingdom, a July 2019 recommendation from the UK’s Royal College of General Practitioners supports the documentation of both biological sex and gender identity in the medical chart to improve patient care and ensure appropriate screenings.³ While this may be an adjustment for many practitioners, understanding when and where to use sex and gender terminology is integral to delivering good evidence-based care in medical practice and to the interpretation of research.

Making sex and gender an integral part of healthcare delivery

Incorporation of sex and gender differences into daily practice involves consideration of whether there are known sex or gender differences in the disease presentation, diagnosis, treatment, and/or prognosis and then mindful avoidance of gender bias in the delivery of patient care. Initially, conscious effort may be required to consider these two variables and their impact on health and disease. However, it is anticipated that this will become a natural part of a clinician’s approach to patient care. Becoming familiar with sex and gender differences, and challenging potential biases by asking whether sex and gender matter, will contribute to providing the best evidence-based, individualized care, ultimately improving patient outcomes.

Determining how sex and gender matter

To avoid one-sex, gender-blind care delivery, the potential role of sex and gender should be forefront when taking a history, performing the physical examination, determining which diagnostic tests to order, interpreting test results, and when prescribing the most beneficial and tailored treatments. The first step to integrating SGBM is asking oneself during every patient encounter, How does the patient’s sex or gender matter? It is important to evaluate the influence of both the sex of the patient and the gender of the patient. How do they affect the presentation and the pathophysiology of disease in this individual? What about diagnostic testing, treatment, and outcome? Each of these is impacted in some way by the patient’s sex and gender.

This textbook describes diseases and public health issues affected by sex and gender, and provides a list of additional learning resources to begin to answer these questions. Additionally, the validated open-access PubMed Search Tool (available at www.sexandgenderhealth.org) can quickly provide citations for evidence-based medical literature.

Illuminating subconscious gender bias

During professional training and through societal norms, clinicians may have subconsciously incorporated gender bias and learned to associate certain diseases and disorders with men or women, males or females. It is important to avoid gendered (and medically incorrect) suppositions, such as:

• Breast cancer is a woman’s disease.

• Lung cancer is a man’s disease.

• Chronic obstructive pulmonary disease is much more common in men.

• Men are not victims of domestic violence.

• Young women do not develop cardiovascular disease.

Consciously challenging assumptions and increasing knowledge of new scientific/medical data can help to illuminate—and eliminate—such subconscious biases.

A stepwise approach to SGBM in clinical practice

Using a stepwise approach helps address SGBM considerations throughout the patient visit (see Fig. 1.2).

Figure 1.2 A stepwise approach to integrating sex and gender into daily clinical practice. (Reproduced with permission from Marjorie R. Jenkins, MD).

Patient history

Taking a history is in part about building rapport, and it marks the beginning of the majority of clinician–patient encounters. This step in the process is gendered, both by providers and patients. Patients may communicate their health needs differently based on how their communication style is gendered, as masculine or feminine. If a patient’s communication style is feminine, the clinician may hear diagnostic clues woven into a story; if masculine, a direct version of the issue is often laid out. The gender of the clinician can influence how information is heard and incorporated. Some appreciate when patients get to the point quickly (i.e., giving just the facts), while others welcome a storytelling approach. It’s important to recognize that each communication style has pros and cons. One may take longer, but the other may leave out vital information that could be invaluable in determining a diagnosis.

Communication

Clinicians may differ from their patients in verbal communication styles, some having more masculine, and others more feminine, styles. It is important for clinicians to understand their personal communication style, and the consequences of interacting with a patient with the same or opposite style. Without considering gendered communication in patient interactions, a mismatch of communication styles could inadvertently cause misperceptions and lead to negative outcomes. For example, women patients report a greater degree of pain when interacting with men clinicians than they do with women clinicians; men clinicians often underestimate pain when reported by women.⁴ Informing the patient about when and how sex or gender differences in communication were considered enhances the delivery of personalized medical care.

Physical examination

The physical exam is both sexed and gendered. Take, for example, the act of undressing, which can be vastly different for a woman versus a man. A man with mid-back pain might lift his shirt over his head in a second prior to an exam, while a woman might wish to partially undress in private and then be draped. The assumption that patients will conform to a clinician’s social expectations may not be accurate. A man recounted that when he visited the doctor for a skin check, the dermatologist asked him to take off his shirt and drop his pants for a full body exam. The doctor then proceeded to look over his body, bending over to look at the back of his legs, and then straightening to finish the encounter, all while the patient stood there with his pants around his ankles. Although this man chuckled as he shared the story, he also communicated a deep sense of discomfort and embarrassment. This is an example of approaching a patient based on gendered assumptions. In asking whether sex and gender matter, consider how this encounter would be different if the doctor had been a woman and the patient a man, or the doctor a man and the patient a woman.

In many cases, there are known differences in a physical exam that are dependent on the organ system and the biological sex of the patient. When examining a patient, clinicians should recall and note in the chart the normal findings for females and males, for example, in the size of the liver, or in the loudness of heart sounds, which may be obscured by breast tissue.

Diagnostic tests

Sex differences can influence the interpretation of diagnostic tests, which may or may not be validated in males and females, but are often extrapolated to both sexes. When interpreting laboratory or other diagnostic test results, it’s important to understand whether the range of normal values is sex-blind. For example, hemoglobin, high-density lipoprotein cholesterol, creatine phosphokinase, creatinine, and uric acid have sex-specific normal ranges, as do high-sensitive troponin (a biomarker) and QT intervals on electrocardiogram. In other cases, laboratory values may be the same in females and males, or research on sex differences may be lacking. Assuming that specificity and sensitivity in a diagnostic test will be the same in females and males can lead to misdiagnosis. Understanding these limitations will enable appropriate interpretation of test results and improve diagnostic accuracy, and support accurate and validating conversions with patients who may express concern if their lab values don’t match the range assigned to another sex.

Therapeutics

It is widely known that women report the majority of adverse events and adverse effects associated with medications. What is less well known is whether the therapeutic (drug, device, or biologic) has been adequately tested in both women and men. This is another area where single-sex medicine can lead to suboptimal outcomes. There are no FDA-approved treatments for male breast cancer, for example, and medications for osteoporosis have been well studied in women but less so in men. Why is this the case? Because the diseases of breast cancer and osteoporosis are sexed to women. At the same time, women are underrepresented in clinical trials for congestive heart failure, acute coronary syndrome, and myocardial infarction⁵,⁶ and in drug trials, particularly those related to bioequivalence of generic drugs. When sex-specific data are not available, accurate assessment of safety and efficacy in females and males is not possible, thus preventing selection of the best therapy, and at the most appropriate dose, for an individual patient.

Disease management may change throughout the menstrual cycle, such as with asthma and epilepsy. Although more research is needed, it’s important to consider the possible impact of physiological hormonal changes on disease presentation and management by asking women about their menstrual cycles and/or menopause when considering pharmacologic management of disease. Similarly, research is just beginning to appreciate how testosterone varies across the lifespan, and whether or how changes in testosterone levels impact disease.

Outcomes and prognosis

When counseling a patient about disease progression and outcomes, practitioners should include sex- and gender-specific information if it is available. Implicit bias in care delivery impacts patients from diagnosis to treatment (and to discharge, in the case of hospitalization) and can impact patient outcomes. For example, it is known that women and men with chest pain may present differently, yet emergency room and hospital discharge instructions are the same. Similarly, women are less likely to be treated with evidence-based medicine in the context of cardiovascular disease,⁷ stroke,⁸ and sepsis,⁹ and men are less likely than women to be diagnosed with breast cancer,¹⁰ osteoporosis,¹¹ or depression.¹² While this is unintentional, clinicians should be aware of the potential for implicit gender bias, which has been propagated throughout medical training. Objective, rather than subjective, tools and approaches to diagnosing and treating medical conditions are more likely to ensure a patient receives the best evidence-based care.¹³

SGBM: conclusions

SGBM is a novel and evolving frontier of clinical practice. Factors related to both sex and gender influence disease development. Differences between men/women and males/females occur in many aspects of disease diagnosis, management, and prognosis, as well as in patient–clinician communication. Gender biases can affect diagnosis and treatment selection. The use of a sex- and gender-based framework in the clinical practice of medicine will improve the care of both women and men, and likely have a positive impact on health outcomes.

References

1. Coleman E. Transsexual, transgender, and gender – nonconforming people: an introduction. In: Legato MJ, ed. Principles of gender-specific medicine. 3rd ed. Academic Press/Elsevier 2017.

2. IOM. Exploring the biological contributions to human health: does sex matter; 2001.

3. Royal College of General Practitioners. The role of the GP in caring for gender-questioning and transgender patients. RCGP Position Statement; 2019. At: https://www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2019/RCGP-position-statement-providing-care-for-gender-transgender-patients-june-2019.ashx?la=en [accessed 03.01.20].

4. Liebert MA. Gender and the genome. vol. 1, Number 1 Mary Ann Liebert, Inc 2017; http://dx.doi.org/10.1089/GG.2017.0002.

5. Franconi F, Campesi I, Colombo D, Antonini P. Sex-gender variable: methodological recommendations for increasing scientific value of clinical studies. Cells. 2019;8(5):476 https://doi.org/10.3390/cells8050476.

6. Scott P, Under E, Jenkins MR, et al. Participation of women in clinical trials supporting approval of cardiovascular drugs. JACC. 2019;71(18):1960–1969.

7. Kim LK, Looser P, Swaminathan RV, et al. Sex-based disparities in incidence, treatment, and outcomes of cardiac arrest in the United States, 2003-2012. J Am Heart Assoc. 2016;5.

8. Reeves M, Bhatt A, Jajou P, et al. Sex differences in the use of intravenous rt-PA thrombolysis treatment for acute ischemic stroke: a meta-analysis. Stroke. 2009;40(5):1743–1749.

9. Madsen TE, Simmons J, Choo EK, Portelli D, McGregor AJ, Napoli AM. The DISPARITY study: do gender differences exist in Surviving Sepsis Campaign resuscitation bundle completion, completion of individual bundle elements, or sepsis mortality?. J Crit Care. 2014;29:473.e7–473.e11.

10. Harlan LC, Zujewski JA, Goodman MT, Stevens JL. Breast cancer in men in the United States: a population-based study of diagnosis, treatment, and survival. Cancer. 2010;116(15):3558–3568 https://doi.org/10.1002/cncr.25153.

11. National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center. Osteoporosis in men; 2018. Retrieved from: https://www.bones.nih.gov/health-info/bone/osteoporosis/men.

12. Call JB, Shafer K. Gendered manifestations of depression and help seeking among men. Am J Mens Health. 2018;12(1):41–51 https://doi.org/10.1177/1557988315623993.

13. Cleveland Clinic Newsroom. Heart attack protocol can improve outcomes, reduce disparities between men and women; March 10, 2018. Accessed at: https://newsroom.clevelandclinic.org/2018/03/10/heart-attack-protocol-can-improve-outcomes-reduce-disparities-between-men-and-women/.

Chapter 2

Clinician-patient communication: Gender influences

Amy Koerber and Kaye Renshaw

Abstract

This chapter reviews current research on how sex and gender factor into various forms of communication during clinician-patient interactions. To what extent is it possible to generalize about the communication styles or tendencies of women patients versus men patients? From the clinician’s perspective, do some communication styles or strategies work better to facilitate positive relationships with men or women patients? What expectations do patients bring to the healthcare encounter, and how might these expectations differ according to factors such as gender, race, age, and culture? In addressing such questions, the goal of this chapter is to offer practical, evidence-based guidelines to help clinicians harness the power of language and to develop a new awareness of the significance of gender in the context of communication with patients.

Keywords

Sex- and gender-based medicine; physician–patient communication; gender difference in medical communication; intercultural communication in healthcare; language and communication in healthcare; man/woman communication in healthcare; gender and communication styles; communication stereotyping in healthcare; gender and communication outcomes in healthcare

Introduction

This chapter reviews current research on how sex and gender factor into various forms of communication during clinician-patient interactions. To what extent is it possible to generalize about the communication styles or tendencies of women patients versus men patients? From the clinician’s perspective, do some communication styles or strategies work better to facilitate positive relationships with men or women patients? What expectations do patients bring to the healthcare encounter, and how might these expectations differ according to factors such as gender, race, age, and culture? In addressing such questions, the goal of this chapter is to offer practical, evidence-based guidelines to help clinicians harness the power of language and to develop a new awareness of the significance of gender in the context of communication with patients.

The power of language

Language is powerful and fundamental to our understanding of reality. In fact, we can’t even think without it. Healthcare professionals might believe there is no need to worry about the power of language and that it is just used to convey the scientific facts to our patients. But even in language that seems like it’s just about science or facts, it’s important to keep in mind that every time we use language, language is using us, too; it shapes our world by determining how we understand its most basic elements.

Let’s think about this example: He’s such a good guy… How many times have you heard someone say this phrase, or something similar? Probably quite a few, maybe even so often that you never even stop to think about what it means. So what does it mean? It has a literal meaning that’s pretty easy to interpret, of course, but if you start to think about the situations in which this phrase is used, it gets a little more interesting. Sometimes it means just what it says: that this person is truly a good guy. He’s a team player, he gets along, he does his fair share of the work, and so on. In other situations, though, the phrase is used almost as a cover, something along the lines of Well, he might come across as a little harsh sometimes, but he’s basically a good guy.…

Now let’s consider a related question: What language would you use if you wanted to say something comparable about a woman? She’s such a good girl… simply doesn’t have the same meaning. And regardless of what word you might substitute for girl, it will never have the same power as that seemingly innocuous phrase, He’s such a good guy.

This simple example reminds us of the power of language. It is a power that is strongest in situations like this, where we don’t even think about it. The such a good guy phrase, for example, only allows for a particular understanding of reality, one that allows for flaws in a man to be dismissed, but it doesn’t allow the same for a woman. The fact that there is no equivalent phrase for a woman further reinforces that reality. In other words, language dictates what can be understood to be true by creating certain versions of reality and foreclosing others.

Even in language that seems strictly scientific, layers of meaning can exist underneath the surface, with important implications for how we understand maleness and femaleness in the context of science and medicine as well as more generally. Consider, for example, the word hysterectomy. Its etymology can be traced to the Ancient Greek words hustéra, which means womb, and ektomia, which means cutting out. Along the way, the word hysteria also evolved from the same root word hustéra, and has taken on a complex array of meanings between Ancient Greece and the present. Hippocrates used the term to characterize a condition in which the womb was literally believed to wander around the body, subjecting women to a number of different health problems that, he believed, men would never experience. Of course in later centuries, this belief in a wandering womb was scientifically disproven. However, hysterical neurosis remained in the Diagnostic and Statistical Manual of Mental Disorders until 1994, when it was removed from the fourth edition.¹

In this chapter, we explore the power of language and how it might operate in ways we probably never think about during our daily interactions with patients. Language can mean many different things in the context of clinician-patient communication. There is the spoken language of the interaction and also the nonverbal cues, sometimes referred to as body language, which can be especially important in the context of face-to-face encounters between a patient and a clinician. As we address aspects of these topics, we pay close attention to what the latest research tells us about the ways in which gender factors into communication during clinician-patient interactions.

To what extent is it possible to generalize about the communication styles or tendencies of women patients versus men patients? From the clinician’s perspective, do some communication styles or strategies work better to facilitate positive relationships with men or women patients? What expectations do patients bring to the clinician-patient encounter, and how might these differ according to factors such as gender, race, age, and culture? In addressing such questions, our goal is to offer practical, evidence-based guidance to help clinicians harness the power of language and to develop a new awareness of the significance of gender in the context of clinician-patient communication.

Gender and communication styles

Although the terms sex and gender are sometimes used interchangeably, the two terms actually have distinct meanings that are important to understand. When we talk about sex, in scientific terms, we are talking about the biological differences between the male and female of any species, including humans. When we talk about gender, we are referring to the whole set of traits that, for a variety of reasons, come to be affiliated with masculinity and femininity in a given society at a specific time. Although some of these traits may be perceived as deriving from a biological characteristic, many are not linked to biological characteristics and, in fact, are strictly a product of cultural beliefs that circulate in that society at that time.

One way that experts explain this phenomenon is through the concept of the gender spectrum (see Fig. 2.1). The gender spectrum conceptualizes gender as a nonbinary phenomenon, and as something much more fluid than we might typically believe it to be. Yes, there are biological features affiliated with maleness and femaleness, but gender means something more. For starters, we must distinguish between gender identity—the way an individual conceives his or her own gender, which may or may not be tied to the biological features their body possesses—and gender expression—the way an individual presents to the world. The latter can include aesthetic features such as dress as well as communication aspects such as the gender of pronouns by which they prefer to be addressed.

Figure 2.1 The gender spectrum. (Reproduced with permission from O′Hanlan KA, Gordon JC, Sullivan MW. Biological origins of sexual orientation and gender identity: impact on health. Gynecol Oncol 2018;149(1):33–42).

Using this fluid conception of gender as a starting place, we might think along similar lines about communication in the context of gendered interactions between patient and clinician. If we think in terms of a communication spectrum, this can help us understand that masculine and feminine communication styles exist but that they are not necessarily tied to an individual’s biological sex or gender identity. For example, in some contexts a woman might adopt a communication style that would be considered more masculine, and a man might adopt a communication style that would be considered more feminine. These choices are not always intentional, and often we become so busy that we hardly think about the manner in which we are communicating. However, as we learn to pay more attention to communication in our interactions with all individuals, we can become more conscious of how to make such choices, with the ultimate goal of using the communication style or strategy that is most appropriate to the given situation, regardless of whether or not that communication style is gendered in a way that aligns with an individual’s biological sex or their gender identity.

Throughout this chapter, when we talk about communication styles, we use terminology of masculine and feminine to make clear that individuals may use a variety of communication styles and strategies, and these are not necessarily tied to whether an individual identifies as a man or woman. However, in some cases, we refer to scientific literature that uses different terminology—such as men and women or male and female—and in those cases, it is important to honor the author’s original word choices.

Communications stereotyping in society

There is a great deal of literature available to offer us an initial idea of what may be considered a masculine or feminine communication style in the context of clinician-patient interactions. A 2002 meta-analytic review based on 26 studies published between 1967 and 2001 concluded that, in the context of primary care, women physicians tend to adopt a communication style that is more patient centered and that appointments with women physicians tend to last slightly longer than those with man physicians.² These findings are consistent with several decades of research that document, more generally, differences between men's and women’s communication styles—research that shows, for example, women are more forthcoming in their disclosure of personal information³ and that, as a result, women also encourage others to interact more freely in their interpersonal interactions.⁴ Such studies offer empirical evidence to suggest how we might expect a woman clinician to communicate with patients, and how that might differ from the way that a man clinician communicates. But we must always remember that such studies do not tell the whole story.

As noted earlier, gender identity is not the same as biological sex. Thus, there is no reason why a man physician could not adopt a communication style that has previously been considered feminine, or vice versa. In light of other research, which demonstrates that attention to the affective and emotional aspects of communication leads to better patient outcomes,⁵–⁷ in some situations it might be desirable for a man physician to adopt stereotypically feminine communication styles. In fact, moving outside the medical context, in a study that compared the communication effectiveness of male-only, female-only, and mixed-gender teams, linguist Judith Baxter found that the most effective teams included both men and women.⁸ Individuals in these mixed-gender teams, regardless of gender, felt free to adopt the style that was most appropriate for the situation, rather than being locked into stereotypical ways of behaving and communicating that were affiliated with their own gender identity or biological sex. Although Baxter’s study participants were graduate students in an MBA program, it is reasonable to speculate that her conclusions might apply more broadly; in short, we may all benefit from being able to consciously adapt our communication styles to accommodate the situation at hand, rather than being locked into a well-established pattern that adheres with our stereotypical understanding of how men or women should behave and communicate.

Influences on clinician-patient communication

Gender dyads and clinician-patient communication

The impact of gender dyads on communication provides food for thought as the gender dyad between the patient and clinician is relevant to the information shared during encounters.

Woman/woman dyads are more patient centered, share the most verbal exchange, occur over longer periods of time, and contain more biomedical information exchanges than other clinician/patient dyads. Further, woman clinicians in gender congruent exchanges offer more encouragement both verbally and nonverbally.²,⁹

Man/man dyads demonstrate greater calm and submissiveness in tone and volume, and men clinicians appear to interact with greater ease with patients who are also men. The content of communication focuses more on the social agenda, and more communication is exchanged in biopsychosocial information such as diet, exercise, smoking, and drug and alcohol use. A biopsychosocial pattern of communication occurs most frequently in this dyad.²,⁹

Woman/man dyads suggest less comfort than any other dyad, with the woman doctor using the least friendly tone with the most positive affect (smiling), suggesting tension around the gender role and resulting in difficulty negotiating the consultation. Further, the woman/man dyad scenarios were rated the least positive.²,⁹

Finally, man/woman dyads are the least patient-centered and more interventionist focused, with greater impact on screening services and physical examination. The interaction between clinician and patient occurs in the context of considerable nonverbal communication, and clinicians in the man/woman dyad made more assumptions than inquiries about patient medical history. Man clinicians appeared to invest more in interventions than to introducing self-management strategies into the discussion when treating woman patients.²,⁹

A recent study investigating differences in outcomes for hospitalized patients found that there were differences in outcomes for inpatients treated by man versus woman physicians. The results of this study indicated that patients treated by woman internists had lower 30-day mortality and readmission rates than those treated by man physicians. The findings also indicated that woman physicians were more likely to practice evidence-based medicine, were more deliberate in solving complex problems, and invested more in behaviors associated with patient-centered care.¹⁰

Such findings suggest the need to increase clinicians’ awareness of their personal communication styles in gender congruent and gender incongruent dyads of information exchange. They further suggest that developing an awareness and understanding of the impact of the clinician communication style on gender congruent and gender incongruent dyads in the exchange of information with the patient has application for treatment compliance, treatment outcome, and overall patient satisfaction.

Information exchange and gender

Effective communication between clinician and patient is a critical aspect of any clinical interaction. Detailed exchange of information is the basis for making accurate diagnoses and implementing effective treatment interventions. The relationship established between the clinician and patient affects the quality of care given by the clinician and the level of compliance invested by the patient. Effective communication with the patient