An assumption is often made in today's society that women prefer to go to female obstetrician-gynecologists.1 Although few studies have documented patients' preferences for same-gender physicians in the field of obstetrics and gynecology, the ability of men to compete in the field has been questioned.2 In this context, obstetric practices and managed care organizations tend to actively recruit female physicians, and the obstetrician and gynecology work force has dramatically changed in the last 20 years.3,4 ACOG is currently one-third female (versus 8% in the early 1970s), with greater than 60% of its junior members being female.1
Two studies have investigated preferences for gender concordance between physicians and patients in the field of obstetrics and gynecology. One study,1 a written survey conducted in a military obstetrics and gynecology clinic, found the majority of women preferred female providers. The other study,5 a mailed survey to members of a health maintenance organization asking about preferences for the type and sex of the provider of basic gynecologic services, found that the majority of patients preferred female providers for gynecology care.
In contrast to the limited number of studies in the field of obstetrics on patient preferences for same-gender physicians, many studies have investigated this topic in primary care settings.6–9 Despite the widely held lay view that women prefer to see female health professionals, these studies report varied results. One previous study9 found weak preferences for same-gender physician-patient relationships when presenting complaints were not gender specific. Studies have shown that preference for sex of physician is strengthened in specific clinical settings, however, including visits that require genitalia examinations, visits that involve discussion of personal problems, and visits for counseling.8,9 For example, a 1989 survey8 of family practice patients found that 57% of women preferred a woman physician for conditions that require genital or anal examinations.
The topic of patient preferences for health professionals has gained importance in our current health care climate because patient satisfaction is an important indicator of quality of care.10 Studies have shown that satisfied patients tend to be more adherent to medical recommendations11 and less likely to physician shop or disenroll from health plans.10,12,13 Although few studies in the field of obstetrics and gynecology have investigated this topic, our health care infrastructure currently acts as though women are the preferred gender in this field. Accordingly, we conducted a qualitative study to investigate the topic of gender preferences for obstetricians in a hospital (postpartum) setting. We asked patients open-ended questions about preferences regarding the gender of their physicians and nurses. We also asked about the impact that gender of their health care providers played in their hospital experience. Finally, we evaluated their rating of satisfaction with their physician.
MATERIALS AND METHODS
After obtaining approval from our institutional review board, and acquiring oral consent from participants, we conducted in-person interviews at Yale-New Haven Hospital between January and April 1999. Yale-New Haven Hospital is the major academic center in the greater New Haven region and has elements of a tertiary referral center as well as a primary care community hospital. Women who delivered at Yale-New Haven Hospital, spoke English, and were 18 years or older were eligible. A sample of convenience was recruited by identifying patients through census logs on the postpartum floors and approaching patients two or three mornings a week (based on the availability of the first author) during the enrollment period. All interviews were conducted by the first author and lasted approximately 30 minutes. Medical records were reviewed for infants' Apgar scores, gestational age at delivery, and hospital course.
We developed an interview guide, which included a standard script of open-ended questions constructed to determine patients' likes, dislikes, and preferences regarding the care they received, the gender of their health care providers, and other preferences they had in the obstetric setting. Similar open-ended questions have been validated in both inpatient hospital settings14 and outpatient primary care settings.15 Specifically, we asked patients “What things did you like, what things did you dislike, and what things would you like to have changed,”15 about their in-hospital obstetric experience. We also asked patients questions about their “feelings or preferences” about the sex of their physicians and whether they believed that the gender of their physician had any impact on their care. Patients were asked similar questions about the gender of other health care providers, including nurses. Patients were also asked to rate the quality of care they received from 0 to 10, with 0 being the worst and 10 being the best. The same script of open-ended questions was asked of all participants. Other than requests to clarify responses, no follow-up questions were asked. The interview also contained questions on demographic factors including age, insurance type, gravidity, parity, marital status, and race. Patients' responses were collected, transcribed, and printed. Responses were reviewed and analyzed for themes and raw data associations by two independent reviewers of the data. The Mann-Whitney U test was used to compare mean satisfaction scores between groups. All statistical analyses were done with Microsoft Excel and PC SAS 8.02 (SAS Institute, Inc., Cary, NC).
Among the 73 patients screened during the enrollment period, five were ineligible (three patients were less than 18 years old and two patients did not speak English). Among the 68 eligible women approached during the enrollment period, one patient refused to participate (response rate of 99%). Patient demographic and delivery information for the 67 patients included in this study is presented in Table 1. The women in this study had a mean age of 31 years and a mean parity of two. Most of the patients were white (67%), married (79%), and used a health maintenance organization (75%) for health insurance coverage. The majority of patients delivered vaginally, were term at delivery, had infants with high 5-minute Apgar scores, and 51% had a female physician.
The majority of women included in this study (39 of 67, 58%) had no preference for physician gender, as shown in Table 2. A theme that emerged from the qualitative analysis was that as long as patients felt a “connection” with their obstetrician, physician gender did not matter. Patients also emphasized technical expertise as an important physician characteristic. Thirty-four percent (23 of 67) of the patients preferred a female obstetrician; patients from this group believed that female obstetricians were more understanding because of going through childbirth themselves. In contrast, 7% (five of 67) of patients preferred a male obstetrician, citing that male physicians were “more compassionate” and “more gentle.” Despite the fact that 41% of patients had preferences about the gender of their physician, only seven of 67 (10%) thought that the gender of their physician had any impact on their care.
All of the patients in this study had female nurses while in the hospital for delivery of their infants. When asked about preferences concerning the gender of the nursing staff, the majority of patients (41 of 67, 61%) preferred having a female nurse while in the hospital for delivery of their infants. Patients cited numerous reasons for this preference, such as comfort, being self-conscious, and the personal nature of after care for women after delivery. Thirty-one percent (21 of 67) of women had no preference concerning gender of their nurse, and 7% (five of 67) did not know or did not answer this question.
Patient satisfaction scores according to physician gender are shown in Table 3. The mean satisfaction for the entire sample was 9.23. The 51% (n = 34) of patients who had a female obstetrician had a mean satisfaction score of 9.06, whereas the 40% (n = 27) of patients with male obstetricians had a mean score of 9.33. This difference was not statistically significant.
Only one-third of obstetric patients had a preference for a female obstetrician. This result contradicts the generally accepted assumption that women prefer female physicians in general and obstetricians in particular. In fact, 90% of the patients did not believe that physician gender had any impact on the care they received while in the hospital for delivery of their infants. What did emerge as the important theme was that women want to feel a “connection” with their obstetrician. As has been demonstrated in the primary care literature, interpersonal style and communication appear to be the most important traits in physicians (specifically obstetricians) rather than gender.
Our results differ from two previous studies in the field of obstetrics and gynecology, which found that the majority of women preferred female providers.1,5 Both of these surveys had large nonresponse rates, however, and the latter study was targeted to an older population (mean age of 56.4 years) and addressed only gynecologic care. We interviewed inpatient obstetric patients during their postpartum hospital stay, and had a very low refusal rate. Patients had just gone through one of the most personal experiences in their lives, and yet the majority of women had no preference for physician gender. Our results also differ from primary care data that suggest that gender preference is strengthened in certain situations. Studies have suggested that women prefer female providers in specific “intimate” clinical situations such as genital or anal exams.4,8 Although this finding may apply in the outpatient setting, our study suggests this preference weakens in the obstetric inpatient setting.
Our results are consistent with data from the primary care literature, which suggest that physician style is what matters most to patients. Studies have found that female physicians' communication style is different than male physicians' and partially explains higher patient satisfaction scores for female physicians.16 Others have found that women physicians conduct longer medical visits, engage in more positive talk, partnership building, question asking, and information giving.17,18 Another study focusing on physician-patient communication styles found that female physicians display more participatory decision-making styles than male physicians.19
One small obstetric study20 investigated the effects of obstetrician gender on communication and patient satisfaction by evaluating the first prenatal visit. The authors found that although male obstetricians conducted longer visits and engaged in more dialogue compared with female obstetricians, satisfaction with physicians' emotional responsiveness and informational partnership was related to female physician gender. Although our study did not investigate specific physician interpersonal or communication styles, our findings further demonstrate that patient preferences for same-gender obstetricians are likely more complex than mere physical attributes of a physician.
Despite the fact that the majority of patients included in this study did not have a stated preference for a female provider, nearly one-third of patients did indeed express a preference for a female physician. This finding may be an underestimate because patients could be influenced by positive birth outcomes and not focus on their true preferences during the postpartum period. We interviewed patients very proximate to their delivery, however, at a time when they are likely to have a vivid recollection of their experience (both positive and negative) on labor and delivery; therefore, their responses are not subject to recall bias. Furthermore, the study patients had already experienced delivering a child, and therefore their stated preference for physician gender was made knowing what the labor and delivery experience encompasses.
We conducted this qualitative study to investigate one aspect of patient preferences in the obstetric setting. Although our study is limited by a relatively small sample size, its strength lies in the conduction of in-depth personal interviews. The open-ended questions allowed patients to express the full scope of their feelings and reactions to the questions asked. We found that patient satisfaction in obstetrics is related to specific physician traits, such as communication style, participatory decision making, or interpersonal style, rather than gender.
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