Do patients talk differently to male and female physicians?A meta-analytic review

Judith A. Halla,*, Debra L. Roterb

aDepartment of Psychology, Northeastern University, Boston, MA 02115, USAbDepartment of Health Policy and Management, The Johns Hopkins University School

of Hygiene and Public Health, Baltimore, MD, USA

Abstract

A meta-analytic review was undertaken of seven observational studies which investigated the relation between physician gender and patient

communication in medical visits. In five of the studies the physicians were in general practice, internal medicine, or family practice and were

seeing general medical patients, and in two of the studies the physicians were in obstetrics–gynecology and were seeing women for obstetrical

or gynecological care. Significant findings revealed that, overall, patients spoke more to female physicians than to male physicians, disclosed

more biomedical and psychosocial information, and made more positive statements to female physicians. Patients also were rated as more

assertive toward female physicians and tended to interrupt them more. Several results were weaker, or even reversed, in the two obstetrics–

gynecology studies. Partnership statements were made significantly more often to female than male physicians in general medical visits but

not in obstetrical-gynecological visits.

# 2002 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Literature review; Meta-analysis; Physician gender; Physician–patient communication

1. Introduction

Speculation that physicians’ communication may be a

quality of care pathway has grown over the past decade and

has enhanced the centrality of communication to research

and training efforts [1–3]. Within the context of gender,

disparities in patient referrals for major diagnostic and

therapeutic interventions, as well as preventive services,

have drawn attention to possible differences in the content

of medical recommendations made to male versus female

patients [4,5]. More recently, however, quality of care

markers have been broadened from the content of recom-

mendations to the dynamics of the therapeutic

relationship. In this regard, debate on whether female phy-

sicians provide a more intense therapeutic milieu with their

patients than male physicians—one that would allow for

more open exchange and collaboration, and ultimately more

comprehensive diagnosis and treatment—has gained atten-

tion [6–8]. Much of our own investigation and interest in this

area has been devoted to understanding how male and

female physicians communicate, especially when with

patients of the same or different gender [9–11].

One might argue that the traditional focus on physician

communication fails to appreciate the influence of patients

in shaping the doctor-patient relationship. In fact, discus-

sions of gender effects in medical communication have

virtually ignored the question of how patients behave toward

male versus female physicians. We believe this is an impor-

tant 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.

In the present article we address how patients behave

toward male and female physicians based on the limited

amount of published evidence that we were able to locate. In

spite of the relatively small database, some clear findings

emerge.

1.1. Why expect patients to communicate differently with

male versus female physicians?

There are good reasons to expect that patients may behave

differently toward male versus female physicians. First,

there is evidence from non-clinical studies that people treat

men and women differently in conversation; for example,

people gaze and smile more at women than at men, approach

women more closely, and self-disclose more to women

Patient Education and Counseling 48 (2002) 217–224

* Corresponding author. Tel.: þ1-617-373-3790; fax: þ1-617-373-8714.

E-mail address: hall1@neu.edu (J.A. Hall).

0738-3991/02/$ – see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved.

PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 1 7 4 - X

[12–14]. Thus, women seem to be a different kind of

stimulus than men are in social interaction and this may

apply in the clinical situation as well.

Second, to the extent that male and female physicians

communicate differently, one would expect reciprocal beha-

vior patterns in patients [15,16]. Behaviors such as gazing,

smiling, posture, a variety of speech behaviors, and the

emotional tone of one’s communication are typically reci-

procated or matched in social interactions [14,17–19]. For

example, if your doctor’s voice sounds angry or anxious,

yours will tend to sound that way too [17], and if someone

smiles at you, you are likely to smile back [13,20]. The

reciprocation of affectively toned verbal and nonverbal

behaviors is one of the chief mechanisms underlying the

operation of interpersonal expectancy effects (self-fulfilling

prophecies) in interpersonal interaction [21,22]. Therefore,

behavioral differences between male and female physicians

could produce corresponding gender differences in patients’

behavior directed back at them.

It happens that there are, indeed, behavioral differences

between male and female physicians. In a meta-analysis

based on studies using objective observations, Roter et al.

[11] determined that female physicians conducted longer

visits than male physicians and engaged in significantly

more active partnership behaviors, positive talk, psycho-

social information giving and question asking, and emo-

tionally focused talk. Female physicians also displayed more

positive nonverbal behaviors than male physicians. These

effects were especially notable in studies of general med-

icine practice (internal medicine and family practice) and

were, interestingly, sometimes reversed in direction in the

two available studies of physicians specializing in obste-

trics–gynecology.

In the main, the differences between the communication

styles of male and female physicians correspond well with

gender differences in communication that are extensively

documented in non-clinical populations. Compared to men,

women have been shown to be more emotionally expressive

in both words and nonverbal behavior, to engage in more

positive and engaged nonverbal behaviors (such as smiling,

nodding, and gazing at a partner in conversation), to engage

in more self-disclosure, and to be more egalitarian in inter-

personal relations [12,14,23,24]. Thus, it appears that the

selection and socialization processes impinging on male and

female physicians are not strong enough to erase the perva-

sive effects of gender-role socialization. Because the com-

munication behaviors exhibited more often by female

physicians appear to be associated with positive patient

effects in the form of satisfaction and clinical outcomes

[25,26], it has been speculated that female physicians create

a more favorable therapeutic milieu than do male physicians

[6]. By examining how patients behave with female versus

male physicians, we can help to flesh out our understanding

of how those milieus might differ. The reciprocity principle

would lead us to expect that patients treat their male and

female physicians in much the same way as they are treated

by them, which is to say that patient behavior toward male

versus female physicians should parallel how male and

female physicians themselves behave.

2. Methods

2.1. Search procedure and criteria for study inclusion

To be included in the review, a study had to meet the

following criteria: (1) involve physicians, physicians in

training (interns or residents), or medical students; (2)

measure communication using neutral observers (including

simulated patients as observers), audiotape, or videotape; (3)

test for an association between physician gender and at least

one patient communication variable; (4) deal with non-

psychiatric medical visits; and, (5) be published in an

English-language book or journal. Studies of both actual

and simulated patients were included.

Studies were identified through the following search

methods: on-line database searches (MEDLINE 1967–

2000, AIDSLINE, PsycINFO, and BIOETHICS) using

the keywords ‘‘doctor–patient interaction; patient–patient

interaction; physician–patient interaction; doctor–patient

relationship’’. These keywords were combined with other

keywords: female; gender effects; female physicians;

female doctors; effect of sex of doctor. In addition, a hand

search was conducted of our own reprint files and the

reference sections of review articles and other publications.

One of the articles in the dataset was recently published by

one of the present authors (A3), with the relevant effects

being described simply as ‘‘nonsignificant’’; but since the

database was available the actual test statistics were run and

included in the present review. Study A2’s results were

reported in two separate publications (both shown in the

Appendix A). Studies included in the meta-analysis are

listed in Appendix A.

2.2. Description of studies

All of the studies were conducted in an outpatient setting.

The seven studies in the database had the following char-

acteristics:

Study A1: 11 internists (6 male, 5 female), 60 general

medical patients (both male and female, but gender

breakdown not reported).

Study A2: 50 internists (25 male, 25 female), 100

general medical patients (50 male, 50 female).

Study A3: 21 obstetricians (11 male, 10 female), 82

obstetrical patients.

Study A4: 127 internists and family practitioners (101

male, 26 female), 537 general medical patients (228

male, 309 female).

Study A5: 16 general practitioners (8 male, 8 female),

405 female patients in general medical visits.

218 J.A. Hall, D.L. Roter / Patient Education and Counseling 48 (2002) 217–224

Study A6: 21 gynecologists (13 male, 8 female), 303

obstetrical or gynecological patients.

Study A7: 21 family practitioners (17 male, 4 female),

20 patients in general medical visits (9 male, 11

female).

2.3. Analytic approach

2.3.1. Behavior groupings

Patient behaviors were conceptually grouped according to

principles developed in earlier meta-analyses of commu-

nication in medical visits [11,26]. Categories summarized in

the present study were total amount of talk, biomedical

information giving, psychosocial information giving, ques-

tion asking, partnership building, social conversation, posi-

tive talk, negative talk, emotional talk, interruptions,

orientations, and global ratings of affect. Five of the seven

studies used the Roter Interaction Analysis System [27] as

the instrument for coding verbal behavior (A2–A6).

2.3.2. Quantification of results

To quantify the direction and magnitude of the behavior

differences, we used the index of effect size called Cohen’s

d, which is defined as the difference between two means (in

this case, the mean behavior directed toward male physi-

cians subtracted from the mean behavior directed toward

female physicians) divided by the pooled within-group

standard deviation [28–30]. A positive d means that patients

engaged in more of the behavior with female physicians than

they did with male physicians, and a negative d means the

reverse. In the studies to be summarized, Cohen’s d was

never reported directly but was rather calculated by the

present authors from the published information using stan-

dard formulas (e.g. means and standard deviations, Pearson

correlations, t-test, or F-test) [30]. Average ds were calcu-

lated on an unweighted basis across those studies that

permitted calculation of d, as well as on a weighted basis

according to the sample size of patients.

In addition to Cohen’s d, a standard normal deviate (Z),

the statistic associated with a P-value (for example, the Z

associated with P ¼ 0:05, two-tail test, is 1.96) was derived

for each result, and these were used to calculate a combined

P-value [30]. If an author reported a result as ‘‘nonsignifi-

cant’’ and gave no other useful data for calculation of Z, a Z

of zero was used in the calculation of the combined prob-

ability (sum of the study Z’s divided by the square root of the

number of studies included in that analysis). In this way, our

review captures information often embedded in null results

which is generally lost, and provides us with a commonly

understood probability metric to compare results across

variables of interest.

3. Results

Altogether, seven studies reported quantitative results on

the relation of physician gender to patient communication

(A1–A7). An additional study [31] indicated that patient

behavior was objectively measured and showed no physician

effects; however, it was unclear exactly which patient beha-

viors were being referred to so this study is not included in

the summaries that follow.

3.1. Amount of patient talk

As shown in Table 1, the four studies that reported on the

total amount of patient talk (A2–A5) found that patients

talked more to female than to male physicians, as indicated

by both the unweighted and weighted average ds

(range ¼ �0:56 to 0.75) and the combined Z (significant

at P ¼ 0:001). Studies A2, A4, and A5 had statistically

significant results in this direction. Interestingly, the one

Table 1

Physician gender effects on patient communication during medical visits

Category N Unweighted average d Weighted average d Combined Z P-value Direction

Amount of talk 4 0.22 (4) 0.34 (4) 3.28 (4) 0.001 3/4 F > M

Biomedical information 6 0.40 (5) 0.36 (5) 4.47 (6) 0.0001 4/5 F > M

Psychosocial information 6 0.25 (5) 0.26 (5) 3.14 (6) 0.005 4/5 F > M

Question asking 5 0.00 (3) 0.10 (3) 0.60 (5) 0.60 2/3 F > M

Partnership building 5 0.19 (3) 0.25 (3) 1.54 (5) 0.13 3/4 F > M

Social conversation 4 �0.02 (3) �0.01 (3) �0.20 (4) 0.85 1/3 F > M

Positive talk 5 0.22 (4) 0.20 (4) 2.66 (5) 0.01 4/4 F > M

Negative talk 5 0.03 (4) 0.08 (4) 0.62 (5) 0.60 2/4 F > M

Emotional talk 4 �0.06 (2) �0.06 (2) �0.25 (4) 0.80 0/2 F > M

Global ratings of affect

Positive 4 0.10 (3) 0.15 (3) 1.30 (4) 0.20 2/3 F > M

Anxious 4 �0.03 (3) �0.13 (3) �0.74 (4) 0.46 1/2 F > M

Assertive 4 0.39 (3) 0.32 (3) 2.13 (4) 0.05 3/3 F > M

Note: P-values are two-tail. Number of studies on which a statistic is based is given in parentheses. Effect size is positive when patients directed more of the

behavior to female physicians than to male physicians, negative when the reverse. ‘‘Direction’’ refers to the number of studies showing patients to direct more

of the behavior to female physicians than to male physicians (F > M) out of all studies of known direction (regardless of P-value).

J.A. Hall, D.L. Roter / Patient Education and Counseling 48 (2002) 217–224 219

negative effect (meaning that patients spoke more to male

than female physicians) came from the obstetrics–gynecol-

ogy study (A3). Without this study, the overall effect was

predictably larger (unweighted average d ¼ 0:48, weighted

average d ¼ 0:41, combined Z ¼ 4:52, P < 0:0001),

indicating that patients talked more to female than male

physicians.

3.2. Patient information giving

Information giving (measured in studies A1–A6) was

divided into biomedical information giving and psychoso-

cial information giving. There is clear evidence that patients

of female physicians provided more of both kinds of infor-

mation than patients of male physicians (Table 1), with

highly significant combined probabilities. For biomedical

information giving, ds ranged from �0.04 to 0.75, and for

psychosocial information giving, ds ranged from �0.18 to

0.52. Studies A1, A2, A4, and A5 were each statistically

significant for biomedical information, and studies A1, A4,

and A5 were each significant for psychosocial information.

Interestingly, in parallel with the findings described ear-

lier for physicians’ communication [11], the two studies on

obstetricians-gynecologists showed results far from signifi-

cance for both kinds of information. With these studies

removed from the calculation, the effects showing more

information being given to female physicians became sub-

stantially stronger: for biomedical information, unweighted

average d ¼ 0:50, weighted average d ¼ 0:40, combined

Z ¼ 5:57, P < 0:0001; for psychosocial information,

unweighted average d ¼ 0:36, weighted average d ¼0:30, combined Z ¼ 4:26, P < 0:0001.

3.3. Patient question asking

Five studies coded patient question asking; for the three

studies that separately reported biomedical and psychosocial

questions (A2, A5, and A6), these two kinds of questions

were combined before the calculations were done to be

comparable to the two studies that reported only total patient

questions (A3 and A4). As Table 1 shows, there were no

overall effects, and individually no study reached statistical

significance, though study A4 achieved P < 0:06

(d ¼ 0:18), showing patients to ask female physicians more

questions than they asked male physicians. In the aggregate,

however, it is evident that patients’ question asking was not

related to the physician’s gender.

3.4. Patient partnership building

The category of partnership building by patients reflects

components of active enlistment including facilitation of

physician input through requests for opinion, understanding,

paraphrase and interpretations, and verbal attentiveness.

Five studies coded this type of variable (A2–A6). As

Table 1 shows, there was a non-significant overall tendency

for patients to address more partnership building behaviors

to female than male physicians. The three available ds were

mixed in direction (�0.29, 0.26, and 0.61, studies A3, A4,

and A2), with an unweighted average d of 0.19 and a

weighted average d of 0.25. However, if the two obste-

trics–gynecology studies are omitted (one of which supplied

a d), the unweighted average d is 0.44, the weighted average

d is 0.31, and the combined Z is 2.78 (P < 0:01). Thus, in

general medical practice patients were more promotive

of a partnership relationship with female than with male

physicians.

3.5. Patient social conversation

Four studies measured social conversation, that is, non-

medical chitchat that usually occurs at the beginning and end

of the medical visit (A2, A3, A4, and A6). As shown in

Table 1, there was no significant difference by physician

gender. The three known ds were �0.16, 0.00, and 0.04

(A2–A4), with none coming close to statistical significance.

3.6. Patient positive talk

Positive comments by the patient, including statements of

agreement, were measured in five studies (A2–A6). As

Table 1 shows, the overall gender effect was significant,

with an unweighted average d of 0.22 and a weighted

average d of 0.20. In this case, the findings were not different

in the obstetrics–gynecology studies, and indeed the largest

effect was for an obstetrics–gynecology study (A3,

d ¼ 0:38). Thus, patients’ utterances were more positive

toward female physicians regardless of visit type.

3.7. Patient negative talk

Patient negative talk, which included disagreements, was

measured in five studies (A2–A6). Table 1 shows that there

was no significant gender effect (range of ds ¼ �0:18–

0.16). Excluding the obstetrics–gynecology studies for this

variable made no appreciable difference.

3.8. Patient emotional talk

Four studies measured patient emotional talk, which

included statements of concern, worry, and personal feelings

(A2, A3, A5, and A6). Table 1 shows that 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. None of the studies individually

approached statistical significance.

3.9. Patient interruptions

Two studies (A2, A7, not shown in Table 1) measured

verbal interruptions, meaning an apparently motivated intru-

sion into the other’s speaking turn with the purpose of

220 J.A. Hall, D.L. Roter / Patient Education and Counseling 48 (2002) 217–224

changing the topic and overtaking the floor. These two

studies showed very different results. Study A2 showed

no physician gender effect (no d reported) while study

A7 showed a large and significant one indicating that

patients interrupted female physicians more than male phy-

sicians (d ¼ 1:46, P < 0:01). The combined Z over both

studies was 1.91 (P < 0:06). Study A7 was, however, very

small—only 21 patients. On the other hand, study A2 had

100 patients. It is possible that study A7 is not representative

of interruptive patterns in general medical practice.

3.10. Patient orientations

Orientations indicate what is expected or what might be

coming next. Patients’ use of this category is often an

indication of items on an agenda (e.g. ‘‘I have a bunch of

questions I’d like to ask you’’) or instructions regarding

procedures (e.g. ‘‘Give me a minute to get ready’’). Only the

obstetrics–gynecology studies (A3 and A6) reported this

behavior (not shown in Table 1). Although in one of the

studies there was a significant effect such that more orienta-

tions were directed toward female physicians (A6), in the

other the effect was nonsignificant and went in the opposite

direction. Together the combined Z was 0.62 (P < 0:60).

3.11. Global ratings of patient communication

The final category of behavior to be presented consists of

global ratings made of patients’ communication by neutral

observers (A1–A3 and A5). In all but study A2, observers

listened or watched the entire physician–patient interaction

and then made global ratings of the patient; in study A2,

observers listened to short clips of patients’ speech that had

been electronically filtered to obscure the verbal content.

Anger-irritation was rated in study A5 and showed that

patients directed less anger-irritation toward female than

male physicians (d ¼ �0:22, P < 0:05). This study plus

three others (A1–A3) also gathered ratings of positive affect

(friendly, warm, kind; see Table 1). The unweighted average

d was 0.10 and the weighted average d was 0.15 (both based

on three studies, range ¼ �0:20 to 0.29) and the combined Z

was 1.30 (four studies), P < 0:20. Of the four studies, study

A5 showed a significant tendency for patients to display

more positive affect to female physicians.

Four studies reported global ratings of anxiety (or relaxa-

tion, reversed in polarity; A1–A3 and A5). There was no

trend (unweighted average d ¼ �0:03, weighted average

d ¼ �0:11, both based on three studies; range ¼ �0:22 to

0.14). Study (A5) found that female physicians were spoken

to less anxiously than male physicians were.

Ratings of assertiveness–dominance (or submissiveness,

reversed in polarity) were obtained in studies A1–A3 and

A5. The unweighted average d was 0.39 and the weighted

average d was 0.32 (both based on three studies,

range ¼ 0:11 to 0.95), combined Z ¼ 2:13, P < 0:05 (four

studies), showing that patients were more assertive with

female than male physicians. This effect was significant

(P < 0:001) in Study A1.

4. Discussion

Although based on a limited dataset, the present quanti-

tative summary was able to detect several significant trends

in the behavior of patients toward their male versus female

physicians. Female physicians received more positive state-

ments in all kinds of visits, but they received more talk

overall, more biomedical and psychosocial information, and

more partnership behaviors to a greater extent (or only) in

routine medical visits as opposed to visits to obstetricians-

gynecologists. Findings for global ratings of positive and

negative affect tended (nonsignificantly, overall) to concur

with the result for number of positive statements. As noted

earlier, a previous quantitative analysis of physician beha-

vior according to physician gender also found that the

same obstetrics–gynecology studies produced results that

deviated from studies based on general medical practice

[11]. In that review, female obstetrician-gynecologists did

not differ from their male counterparts for a number of

behaviors, and for some the trend was even reversed. It was

speculated that patient preferences for female physicians has

put male obstetricians at a competitive disadvantage, leading

male physicians to ‘‘try harder’’ with their patients to

establish a more patient-centered atmosphere than would

otherwise be expected [6]. For the present review of patient

behaviors to show similarly deviant results for the same

obstetrics–gynecology studies is consistent with the reci-

procity mechanism described above, in that the relative lack

of a difference in physicians’ behavior is mirrored back in

the behavior shown to them by patients.

In interpreting the different results for obstetrics–gyne-

cology, however, one might also point to the fact that such

studies involve only female patients, and so the results could

have less to do with medical specialty than with patient

gender. However, a large study on general medical practice

in the present dataset that was also based on only female

patients (A5) had results that were typically similar to other

studies of general medical practice and not to the obstetrics–

gynecology studies.

We also found evidence, in one study at least, that female

physicians were interrupted while speaking more than male

physicians were, and global ratings from several studies

confirmed that female physicians were treated in a more

assertive manner by patients than were male physicians.

Behaviors that showed little or no difference were patient

questions, social conversation, negative statements, emo-

tional talk, orientations, and global ratings of anxiety.

As predicted on the basis of the reciprocity principle,

some of these behaviors are the same ones which an earlier

meta-analysis [11] found to differentiate the behavior of

male versus female physicians, specifically positive talk,

psychosocial information giving, and partnership building.

J.A. Hall, D.L. Roter / Patient Education and Counseling 48 (2002) 217–224 221

However, patients also provided more biomedical informa-

tion to female physicians, even though the earlier review did

not find male and female physicians to differ in how much

biomedical information they provided to their patients.

Female physicians were found, however, to ask more ques-

tions than their male counterparts [11] and it may be this

behavior, the asking of more questions, that stimulates more

patient information giving rather than more information

being provided by the physician. More patient disclosure

of biomedical information may also be fostered by female

physicians’ more active efforts to build partnership through

inviting the patients’ questions and opinions [11]. Interest-

ingly, though female physicians in the earlier review made

more emotionally focused statements than male physicians

(in primary care settings), the present review did not find that

patients directed more emotional discussion to female phy-

sicians.

Taken together, the differences that we documented in

patient behavior can be considered to reflect a heightened

level of comfort, engagement, disclosure, and assertiveness

on the part of patients speaking to female physicians.

Whether the last result stems from patients having less

respect for female physicians [32] cannot be determined

from these data. However, we think the more likely inter-

pretation, taking the entire pattern of results into account as

well as evidence for how male and female physicians

communicate with their patients, is that patients feel more

empowered in interactions with female physicians.

Considering that greater patient participation, and a more

patient-centered behavioral repertoire (such as possessed

more by female physicians), have been positively associated

with a variety of clinical outcomes [25], it seems likely that

the patient behavior effects found in the present review are

an indication of a relatively more health-promoting thera-

peutic milieu produced by female physicians. Such a con-

clusion can only be speculative at present, however, since no

study has directly investigated whether patients of female

physicians fare better on clinical measures. Indeed, such a

comparison would be fraught with methodological difficulty

considering the many variables that could confound the

comparison.

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 physician’s judgment and

must be willing to follow through on the physician’s sugges-

tions 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. However,

it is evident that, 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 [33]. 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, and we can only

speculate on how much patients’ satisfaction depends on

things the physicians actually do versus stereotypes and

expectations held by the patients, or differences in patient

characteristics such as health status or sociodemographics.

When patients are less satisfied with female physicians, the

reasons could include prejudice and skepticism toward

women in an authority role, or, paradoxically, disappoint-

ment that female physicians are not even more warm,

participatory, and approachable than they already are [33].

The case of obstetrics and gynecology is again interesting

and provides further evidence of patient expectations and

preferences influencing satisfaction assessments, regardless

of actual physician performance. In the meta-analysis

referred to earlier [11], male obstetricians conducted longer

visits and engaged in more dialogue than female obstetri-

cians. They were more likely to check that they had under-

stood the patient through paraphrase and interpretations, to

use orientations to direct the patient through the visit, and to

express concern and partnership than female physicians.

And, in the present study, it appears that these differences

were associated with much attenuated differences in how

patients treated the physicians. Nevertheless, the one obste-

trics study that monitored patient satisfaction (A3) found

male obstetricians to be rated as less satisfying by their

patients than their female counterparts, even after the expla-

natory power of particular communication variables for

satisfaction were taken into account. These lowered satis-

faction ratings seem to mimic the inconsistent evaluations of

female physicians noted above and may suggest that pre-

judice and skepticism toward male obstetricians diminishes

the positive impact of their actual performance.

The challenge for a more positive transformation in the

everyday practice of medicine includes not only promulga-

tion of medical practice norms that value communication

skills and interpersonal sensitivity, but also the generation of

gender-neutral social norms regarding patient expectations

and judgments of physician conduct. Having more women in

medicine will help contribute to societal norms that do not

inherently define ‘‘doctor’’ in gender-linked terms, but this

will not be sufficient in itself to transform medical practice.

Physician training in interpersonal skills, emphasizing those

aspects of communication identified in the growing evidence

base of medicine, can make the difference in defining quality

standards for interpersonal communication for all physi-

cians. Fortunately, there is ample evidence that training in

communication skills is effective in changing physician

performance (e.g. [1,34–36]).

4.1. Practice implications

The social psychologist Robert Rosenthal said, comment-

ing on differences in how psychological experimenters treat

male and female research subjects, that ‘‘male and female

subjects may, psychologically speaking, simply not be in the

same experiment’’ ([37], p. 56). We could say the same when

222 J.A. Hall, D.L. Roter / Patient Education and Counseling 48 (2002) 217–224

gender differences in behavior are documented in medical

visits. The present results, combined with earlier research on

male and female physicians’ behavior, suggest that the tone

and content of the medical visit can be quite different

depending on the gender of the physician. Female physi-

cians, because of patients’ preexisting stereotypes and

expectations or actual differences in physicians’ behavior,

or both, receive somewhat different communication from

patients than male physicians. It is also likely, considering

that social influence is usually mutual, that physicians, male

and female alike, are in turn influenced by how their patients

behave toward them.

In addition to the growing evidence for physician gender

effects, there is an additional body of evidence showing that

patient gender is associated with communication differences

as well [26,38]. It has been reported that women ask for more

information and talk more when with physicians than men

do [39–41]. Female patients also used more emotionally

concerned statements, disagreements, and positive state-

ments than male patients [42]. Furthermore, male and

female patients are treated differently by physicians. An

earlier meta-analysis reported a pattern of exchange in

which female patients received significantly more informa-

tion and more total communication from their physicians

than male patients [26]. Individual studies show greater

levels of partnership building and positive talk [43] and

more emotionally concerned statements (including empathy,

concern, reassurance, and legitimation) and disagreements

directed to female rather than male patients [42]. The broad

interactive pattern suggests that physicians are more

engaged with their female patients, both cognitively, pro-

viding more information, and affectively.

Recognition of these gender-related social psychological

factors in the process of care could be beneficial to physi-

cians when interacting with patients. The potentially power-

ful impact of reciprocation of behavior style and affect

between parties in the medical visit is especially important

to recognize, as such recognition could help to create

positive exchanges and defuse negatively spiraling interac-

tion patterns.

Appendix A. Studies in the meta-analysis

� A1: Charon R, Greene MG, Adelman R. Women readers,

women doctors: a feminist reader-response theory for

medicine. In: More ES, Milligan MA, editors. The

empathic practitioner: empathy, gender, and medicine.

New Brunswick, NJ: Rutgers University Press; 1994;

205–21.

� A2: Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH.

Gender in medical encounters: an analysis of physician

and patient communication in a primary care setting.

Health Psychol 1994;13:384–92, and Irish JT, Hall JA.

Interruptive patterns in medical visits: the effects of role,

status and gender. Soc Sci Med 1995;41:874–81.

� A3: Roter DL, Geller G, Bernhardt BA, Larson SM,

Doksum T. Effects of obstetrician gender on communica-

tion and patient satisfaction. Obstet Gynecol 1999;

93:635–41.

� A4: Roter D, Lipkin Jr M, Korsgaard A. Sex differences in

patients’ and physicians’ communication during primary

care medical visits. Med Care 1991;29:1083–93.

� A5: Van den Brink-Muinen A, Bensing JM, Kerssens JJ.

Gender and communication style in general practice:

differences between women’s health care and regular

health care. Med Care 1998;36:100–6.

� A6: Van Dulmen AM. Communication during gynecolo-

gical out-patient encounters. J Psychosom Obstet Gynae-

col 1999;20:119–26.

� A7: West C. Routine complications: troubles with talk

between doctors and patients. Bloomington, IN: Indiana

University Press; 1984.

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