Transcript Introduction - Sex and Gender Womens Health Collaborative

Northwestern University Feinberg School of Medicine
What we do (and don't) know about the role of gender in
influencing patient- healthcare provider communication
18 May 2010
Marla L. Clayman, PhD MPH
Division of General Internal Medicine
Why do we care about communication in
the provider-patient relationship?
Over 900 million ambulatory physician office visits each year (NAMCS
2006 summary)
Health care providers are the most trusted sources of health
information (HINTS data 2005)
Interventions increasingly implemented with the provider’s imprimatur
• Screening for cancer
• Health behaviors
• Decision aids
Why do we care about gender in the
patient-provider relationship?
• Women are the face of most health care providers
U.S. Department of Health and Human Services, Health Resources and Services Administration,
Maternal and Child Health Bureau. Women's Health USA 2007. Rockville, Maryland: U.S.
Department of Health and Human Services, 2006.
Why do we care about gender in the
patient-provider relationship?
• Women are the face of most health care providers
• Women are the face of patients
• The majority (about 60%) of outpatient visits are by women (NAMCS 2006
summary).
Annual rate of outpatient department
visits by patient age and sex: US 2005
Why do we care about gender in the
patient-provider relationship?
• Women are the face of most health care providers
• The majority (about 60%) of outpatient visits are
by women (NAMCS 2006 summary).
• Even when pregnancy and childbirth stays are
excluded, females account for more hospital stays
than men (HCUP data 2007).
• In 2007, women represented two-thirds of users of
mental health services, including inpatient and
outpatient care and prescription medications.
What beyond prevalence is
important?
How does this fit in with the bigger picture of
healthcare in America?
• Increasingly, communication is seen as important to the health care
system
• Medicine may be gendered (with an emphasis on men), but most
patients and most practitioners are women.
Crossing the Quality Chasm (IOM report)
“Patient Centered Care is Fundamental to Quality Health
Care.”
“[Patient-centered care is] health care that establishes a
partnership among practitioners, patients and their families
(where appropriate) to ensure that decisions respect
patients’ wants, needs and preferences, and solicit
patients’ input on the education and support they need to
make decisions and participate in their own care.”
Report suggests communication measures as metrics of
quality.
Professional training
In the past decade, formal recognition that
communication skills are an essential part of
medicine and healthcare
• Including accrediting bodies for:
- Medical Students
- Residents
- Nurses
- Physician Assistants
- Genetic Counselors
Does better communication really
lead to better quality care?
More informed patients have been shown to have
• Better recall of information
• Better chronic disease control
• Higher patient satisfaction
• Less anxiety
Some data suggest that patients who are more
satisfied with the provider’s communication rate
their care more highly in terms of quality
Should we expect differences by gender?
Studies in non-clinical settings show that women
and men tend to have different communication
styles.
Communication is reciprocal – we respond
differently to people depending on how they
respond to us.
The same communication behaviors can be
interpreted differently based on the gender of who
engages in them.
How can we determine if there are
differences?
• Medical encounter recordings
• Objective measure of what happens in the visit
• The interpretation might not be
• Little reactivity (response to being taped)
• Can use audio or video
• Often used in conjunction with self-report
Analysis of taped visits
Coding systems - RIAS, CANCODE
• Mutually exclusive and exhaustive categories
- Form (e.g., open-ended questions) and/or
- Content (e.g., biomedical information)
• Specific behaviors or content
- For example, education about diabetes self care
• Non-verbal communication
Patient-provider communication and
physician gender
• Female physicians engage in more:
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•
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Partnership
Positive talk
Psychosocial counseling
Psychosocial question asking
• No differences by physician gender for amount, quality, or
manner of biomedical information giving.
• Visits are 2 minutes longer, on average, for female
physicians
Roter et al. 2002 JAMA meta-analysis
Physician gender, part II
• Patients speak more to female physicians
• Patients, when talking to female physicians,
• Disclose more biomedical and psychosocial information
• Are more assertive to female physicians
• Are more likely to interrupt
• No differences in patient question asking
Hall and Roter 2002 PEC meta analysis
Patient gender
Female patients:
• give more information
• ask more questions
• use more back-channels
- Un-huh, yeah, I see
- (see Roter and Hall 2006 for a summary)
No clear relationship between communication,
patient satisfaction, and physician-patient gender
concordance (Hall et al. 1994)
Example of research using hypothetical
situations
• A study of 167 students acting as patients
• Interacting with a virtual physician
•
Physician varied only by sex
• Found that in male-male pairs, the communication style of
physician did not affect satisfaction
• But, for female-female pairs, patients were more satisfied
if the physician was more caring (Schmid Mast 2007)
• Similar to other research that people expect women (and
women physicians) to behave in certain “feminine” ways.
Family members/companions
Companions tend to be women (~80% of the time)
Less studied than the doctor-patient dyad
Family members often present in geriatric primary
care, prenatal, and cancer visits
Family members are often studied as caregivers
rather than interested parties
Some have expressed concern that they dominate
the visit
Research on companions
Companions can facilitate patients’ involvement in the visit
• Asking the patient questions
• Prompting the patient to talk
• Asking for the patient's opinion
In these cases, patients were more than four times as likely to be active
in decision-making as patients whose companions did not assist in this
manner (Clayman et al. 2005 Soc Sci Med)
Medicare beneficiaries with companions were more satisfied with their
physician's technical skills, information giving, and interpersonal skills
than unaccompanied beneficiaries (Wolff & Roter 2008 Arch Int Med)
Let’s go back for a minute....
“[Patient-centered care is] health care that establishes a
partnership among practitioners, patients and their
families (where appropriate) to ensure that decisions
respect patients’ wants, needs and preferences, and
solicit patients’ input on the education and support
they need to make decisions and participate in their own
care.”
OK, but I can’t change the fact
that I’m a woman
 As a patient
 As a healthcare provider
What do I do about it?
Where can we intervene?
 How people talk
 What they talk about
 How well they understand
 The systems we have in place
 Note – this isn’t about GENDER
How people talk
Interrupting
• How long until patients are interrupted?
- Beckman and Frankel 1984
• 18 seconds
- Marvel et al. 1999
• 23 seconds
•Patients allowed to complete their statement of concerns
used only 6 seconds more on average
•Late-arising concerns were more common when physicians
did not solicit patient concerns
•Physicians with training in communication
- More likely to solicit patient concerns
- Allow patients to complete their initial statement of concerns
Teach back
Structure Verbal Instructions, Confirm Understanding
• “Now, I’m going to tell you what I think is wrong, the
tests I’m going to order, the medicine I want you to
take, and when I will see you back.”
• Increases recall
• “Any questions? OK, just to make sure I explained the
plan clearly, tell me what you are going to do after you
go home?”
• If incorrect, explain again, and repeat teach-back
Improving Prescription Instructions
• Take one tablet twice daily + “take with food”
•Take 1 tablet with breakfast and 1 with dinner
• Take one tablet daily on an empty stomach
•Take 1 tablet 30 minutes before breakfast
• Apply to affected area twice daily
•Rub on rash in the morning and the evening
What they talk about
Patients can be influenced by:
Friends and family
Information on the Web
Direct to Consumer advertising
Providers shape what gets discussed
How decisions are made, how information is given
How well they understand
Use plain language in explanations and instructions
Think about how risks are presented
• Most people (including many clinicians) are not good at probabilistic
thinking
• Recognize that terms like “high risk” and “low risk” are arbitrary and
mean different things in different contexts
Electronic prescribing
Although guidelines* recommend not using Latin
terms or abbreviations to avoid medication errors,
handwritten prescriptions often include Latin (Bailey
et al. 2009)
Electronic prescribing can be written clearly for both
pharmacy and patient
*Joint Commission and the National Coordinating Council for Medication Error Reporting
and Prevention
Fostering insight
From Gigerenzer and Edwards BMJ 2003
Single event probabilities
"You have a 30% chance of a side effect from this drug"
A frequency statement:
"Three out of every 10 patients have a side effect from this drug"
Conditional probabilities
Two ways of representing the same statistical information
The probability that a woman has breast cancer is 0.8%. If she has
breast cancer, the probability that a mammogram will show a positive
result is 90%. If a woman does not have breast cancer the probability of a
positive result is 7%. Take, for example, a woman who has a positive
result. What is the probability that she actually has breast cancer?
As natural frequencies
Eight out of every 1000 women have breast cancer. Of these
eight women with breast cancer, seven will have a positive
result on mammography.
Of the 992 women who do not have breast cancer some 70
will still have a positive mammogram. Take, for example, a
sample of women who have positive mammograms.
How many of these women actually have breast cancer?
(Answer: of 77 with a positive result, 7 (~9%) have cancer)
Doctors' estimates of the probability of breast cancer in women with a positive result on
mammography, according to whether the doctors were given the statistical information as
conditional probabilities or natural frequencies (each point represents one doctor)
Gigerenzer, G. et al. BMJ 2003;327:741-744
Copyright ©2003 BMJ Publishing Group Ltd.
Best practices
Use teach-back. Define learning goals.
Use plain language for instructions
Give numbers in natural frequencies – try to avoid
jargon.
1 out of 100 instead of 1 percent
Should we give up on providers?
No.
•Some communication skills can be taught and learned
- Giving bad news, communicating risk
But, we need to think about when to place burden on
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•
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physicians vs.
patients vs.
both vs.
Other health care professionals or lay health educators
•Some miscommunication is inevitable. Some is not...