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: [email protected] (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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