Physician gender and women's preventive services

General practitioner gender and use of diagnostic procedures: a French cross-sectional study in training practices

OBJECTIVES

The acceleration in the number of female doctors has led to questions about differences in how men and women practice medicine. The aim of this study was to assess the influence of general practitioner (GP) gender on the use of the three main categories of diagnostic procedures-clinical examinations, laboratory tests and imaging investigations.

DESIGN

Cross-sectional nationwide multicentre study.

SETTING

French training general practices.

PARTICIPANTS

The patient sample included all the voluntary patients over a cumulative period of 5 days per office between November 2011 and April 2012. The GP sample included 85 males and 43 females.

METHODS

54 interns in general practice, observing their GP supervisors, collected data about the characteristics of GPs and consultations, as well as the health problems managed during the visit and the processes of care associated with them. Using hierarchical multilevel mixed-effect logistic regression models, we performed multivariable analyses to assess differences in each of the three main categories of diagnostic procedures, and two specific multivariable analyses for each category, distinguishing screening from diagnostic or follow-up procedures. We searched for interactions between GP gender and patient gender or type of health problem managed.

RESULTS

This analysis of 45 582 health problems managed in 20 613 consultations showed that female GPs performed more clinical examinations than male GPs, both for screening (OR 1.75; 95% CI 1.19 to 2.58) and for diagnostic or follow-up purposes (OR 1.41; 95% CI 1.08 to 1.84). Female GPs also ordered laboratory tests for diagnostic or follow-up purposes more frequently (OR 1.21; 95% CI 1.03 to 1.43). Female GPs performed even more clinical examinations than male GPs to diagnose or follow-up injuries (OR 1.69; 95% CI 1.19 to 2.40).

CONCLUSION

Further research on the appropriateness of diagnostic procedures is required to determine to what extent these differences are related to underuse or overuse.

The Impact of Provider Sex and Experience on the Quality of Care Provided for Women with Urinary Incontinence

BACKGROUND

Although specialists are skilled in the management of urinary incontinence, primary care clinicians are integral in early diagnosis and initiation of management in order to decrease overuse of specialty care and improve the quality of specialist visits. We measured the quality of incontinence care provided by primary care clinicians prior to referral to a specialist and evaluated the impact of provider variables on quality of care.

METHODS

We performed a retrospective review of 200 women referred for urinary incontinence to a Female Pelvic Medicine and Reconstructive Surgery specialist between March 2017 and July 2018. We measured primary care adherence to 12 quality indicators in the 12 months prior to specialist consultation. We stratified adherence to quality indicators by clinician sex and years of experience.

RESULTS

Half of women with incontinence underwent a pelvic examination or had a urinalysis ordered. Few patients with urge urinary incontinence were recommended behavioral therapy (14%) or prescribed medication (8%). When total aggregate scores were compared, female clinicians performed the recommended care 47% ± 25% of the time, compared with 35% ± 23% for male clinicians (P = .003). Increasing years of experience was associated with worse overall urinary incontinence care (r -0.157, P = .02).

CONCLUSIONS

We found low rates of adherence to a set of quality indicators for women with urinary incontinence, with male clinicians performing significantly worse than female clinicians. Improvement of incontinence care in primary care could significantly reduce costs of care and preserve outcomes.

Does Provider Gender Affect the Quality of Primary Care?

BACKGROUND

Women providers have a more patient-centered communication style than men, and some studies have found women primary care providers are more likely to meet quality performance measures.

OBJECTIVE

To explore gender differences in the quality of primary care process and outcome measures.

DESIGN

Retrospective analysis of primary care performance data from 1 year (2018-2019).

PARTICIPANTS

A total of 586 primary care providers (311 women and 275 men) who cared for 241,428 primary care patients at 96 primary care clinics at 8 Veterans Affairs (VA) medical centers.

MAIN MEASURES

Our primary outcome was a composite quality measure that averaged all thirty-four primary care performance measures that assessed performance in cancer screening, diabetes care, cardiovascular care, tobacco counseling, risky alcohol screening, immunizations, HIV testing, opiate care, and continuity. Our secondary outcomes were performance on each of the 34 measures.

KEY RESULTS

There was no difference in the average performance on our composite measure between men and women (75.8% vs. 76.6%, p = 0.17). Among the 34 primary care quality measures collected, there was no difference between male and female providers' performance. Using a more conservative cut-point, women were more likely to screen at-risk diabetic patients for hypoglycemia and document follow-up on risky alcohol behavior noted during patient check-in. These differences were clinically small and likely due to chance, given the multiple measures evaluated in this study.

CONCLUSIONS

We found little evidence of difference in the performance on primary care quality measures between male and female providers.

How do clinicians use implementation tools to apply breast cancer screening guidelines to practice?

Background

Implementation tools (iTools) may enhance uptake of guidelines. However, little evidence exists on their use by primary care clinicians. This study explored which iTools clinicians used and how often; how satisfied clinicians were with the tools; whether tool use was associated with practice changes; and identified mediators for practice change(s) related to breast cancer screening (BCS).

Methods

Canadian primary care providers who are members of the Practice-Based Small Group Learning Program (n = 1464) were invited to participate in this mixed methods study. An educational module was discussed in a small group learning context, and data collection included an on-line survey, practice reflection tools (PRTs), and interviews. The module included both the Canadian Task Force on Preventive Health Care revised guideline on BCS and iTools for clinician and/or patient use. After discussing the module and at 3 months, participants completed PRTs identifying their planned practice change(s) and documenting implementation outcome(s). Use of the iTools was explored via online survey and individual interviews.

Results

Seventy participants agreed to participate. Of these, 48 participated in the online survey, 43 completed PRTs and 14 were interviewed. Most survey participants (77%) reported using at least one of seven tools available for implementing BCS guideline. Of these (78%) reported using more than one tool. Almost all participants used tools for clinicians (92%) and 62% also used tools for patients. As more tools were used, more practice changes were reported on the survey and PRTs. Interviews provided additional findings. Once information from an iTool was internalized, there was no further need for the tool. Participants did not use tools (23%) due to disagreements with the BCS guideline, patients’ expectations, and/or experiences with diagnosis of breast cancer.

Conclusion

This study found that clinicians use tools to implement practice changes related to BCS guideline. Tools developed for clinicians were used to understand and consolidate the recommendations before tools to be used with patients were employed to promote decision-making. Mediating factors that impacted tool use confirmed previous research. Finally, use of some iTools decreased over time because information was internalized.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0765-2) contains supplementary material, which is available to authorized users.

Disengagement of general practitioners in cervical cancer screening

In the absence of organized cervical cancer screening (CCS) programs, gynecologists remain principal actors in obtaining a Pap smear, followed by general practitioners (GPs). In France, with the growing scarcity of gynecologists and social inequalities in access to opportunistic screening, GPs are valuable resources for women's gynecologic follow-up. We aimed to investigate the characteristics of GPs who do not perform CCS, analyzing the effect of GPs' sex and their evolution over time. On the basis of data from three cross-sectional surveys conducted among representative samples of French GPs in 1998, 2002, and 2009 (n=5199), we constructed univariate and multivariate logistic mixed models (level 2: county, level 1: GP) with random intercept stratified on GPs' sex to investigate the characteristics of the GPs associated with no practice of CCS ever. Almost one-third of all GPs did not perform CCS ever and it increased with time. Male GPs were always more likely not to perform it (odds ratio=0.50, 95% confidence interval=0.42-0.59). The percentage of GPs not performing CCS increased more markedly among male than among female GPs, and increased more among the youngest age group. Increasingly fewer GPs engage in CCS when the growing scarcity of medical gynecologists calls for more participation. Female GPs remain significantly more active in CCS than male GPs. The participation in CCS is determined differently according to the practitioner's sex.

Anal Cancer Screening in an Urban HIV Clinic: Provider Perceptions and Practice

In this article, we sought to understand the perceptions and practice of providers on anal cancer screening in HIV-infected patients. Providers in an academic outpatient HIV practice were surveyed. Data were analyzed to determine the acceptability and perceptions of providers on anal Papanicolaou tests. Survey response rate was 55.3% (60.7% among male and 47.4% among female providers). One-third of the providers had received screening requests from patients. Female providers had higher self-rated comfort with anal Papanicolaou tests, with a mean score of 7.1 (95% confidence interval [CI] 4.7-9.5) compared to 3.6 (95% CI 1.5-5.7) for male providers, P = .02. Sixty-seven percent of male providers and 37.5% of female providers would like to refer their patients for screening rather than perform the test themselves. Only 54.2% of our providers have ever performed anal cytology examination. Our survey revealed that not all providers were comfortable performing anal cancer screening for their patients.

Role of physician gender in drug therapy

There is evidence that female patients receive less intensified drug therapy in many medical conditions than male patients. However, there are only limited data regarding the influence of physician gender on drug therapy. It has been shown, for example, that female physicians tend to adhere more closely to guideline-recommended pharmacotherapy compared to their male counterparts. In some medical conditions where drug therapy is only one among various components of a complex interplay of therapeutic regimes (e.g., diabetes, cardiovascular diseases, depression, pain management), female physicians seem to achieve better overall intermediate outcomes and some studies suggest that "better" drug therapy is provided by female compared to male physicians. The reasons for the overall better outcomes may be superior communication skills of female physicians, participatory decision making, and consequently improved drug adherence in addition to or in combination with more effective non-pharmacologic treatment results. It is impossible to distinguish between the individual contributions of drug- and nondrug-related influence on such improved outcomes and thus to determine whether they are due to unconfounded physician gender effects on drug therapy. There is until now in no area of medicine evidence to suggest that a patient will consistently receive higher quality of drug therapy by switching to a physician of a specific gender.

Breast and cervical cancer screening patterns among American Indian women at IHS clinics in Montana and Wyoming

OBJECTIVES

We investigated factors associated with primary and secondary breast and cervical cancer screening among American Indian (AI) women receiving care from the Indian Health Service (IHS) in Montana and Wyoming.

METHODS

Rates of primary screening (i.e., screening without evidence of a prior abnormal) and secondary screening during a three-year period (2004-2006) were determined in an age- and clinic-stratified random sample of 1,094 women at six IHS units through medical record review.

RESULTS

Three-year mammography prevalence rates among AI women aged ≥45 years were 37.7% (95% confidence interval [CI] 34.1, 41.3) for primary and 58.7% (95% CI 43.9, 73.5) for secondary screening. Among women aged ≥18 years, three-year Pap test prevalence rates were 37.8% (95% CI 34.9, 40.6) for primary and 53.2% (95% CI 46.0, 60.4) for secondary screening. Primary mammography screening was positively associated with number of visits and receiving care at an IHS hospital (both p<0.001). Primary Pap test screening was inversely associated with age and positively associated with the number of patient visits (both p<0.001). Secondary mammography screening was inversely associated with driving distance to an IHS facility (p=0.035).

CONCLUSION

Our results are consistent with other surveys among AI women, which report that Healthy People 2010 goals for breast (90%) and cervical (70%) cancer screening have not been met. Improvements in breast and cervical cancer screening among AI women attending IHS facilities are needed.

Healthy colon, healthy life (colon sano, vida sana): colorectal cancer screening among Latinos in Santa Clara, California

Colorectal cancer (CRC) screening rates are low among Latinos. To identify factors associated with CRC screening, we conducted a telephone survey of Latino primary care patients aged 50-79 years. Among 1,013 participants, 38% were up-to-date (UTD) with fecal occult blood test (FOBT); 66% were UTD with any CRC screening (FOBT, sigmoidoscopy, or colonoscopy). Individuals less than 65, females, those less acculturated, and patients of female physicians were more likely to be UTD with FOBT. CRC screening among Latinos is low. Younger patients, women, and patients of female physicians receive more screening.

HIV screening among U.S. physicians, 1999-2000

In 2006, the Centers for Disease Control and Prevention (CDC) put forth recommendations for routine HIV screening for all individuals aged 13-64. The frequency and correlates of HIV screening among U.S. physicians in 2000 were examined to provide baseline data for evaluating the implementation of the 2006 CDC HIV testing guidelines through a survey mailed to a random sample of U.S. physicians in the American Medical Association's Masterfile. The primary outcome was self-reported HIV screening of asymptomatic male and nonpregnant female patients. A total of 4133 (adjusted completion rate of 70.2%) returned a completed survey. Overall, 1133 (28.4%) of physicians reported HIV screening. U.S. physicians, who were female, black, Hispanic, practiced in a city of more than 250,000 people, diagnosed HIV in the past 2 years, or followed up with patients to see if they notified their sexual partners, were more likely to screen their patients for HIV. Emergency medicine, internal medicine, and pediatrics specialists were less likely to screen than family/general practitioners. In 2000, only a quarter of U.S. physicians reported screening their patients for HIV and these rates varied by physician characteristics and practice settings.

Preventive services use among women seen by gynecologists, general medical physicians, or both

OBJECTIVE

To estimate how preventive services and counseling differ for women seen by general medical physicians and gynecologists, and whether seeing both types of physicians had a greater impact on delivery of gender-specific and gender-neutral preventive care than by either type of physician alone.

METHODS

Using data from the 2000 National Health Interview Survey, we studied the association of provider type with Pap tests, tobacco use screening, and exercise and diet counseling among women 18-64 years (n=7,317), and these services along with clinical breast examinations, mammograms, and colon cancer screening among women aged 50-64 years (n=1,551). We modeled care using multivariable logistic regression and used propensity score techniques to limit selection bias from choice of provider.

RESULTS

In the study sample, 15% were seen by general medical physicians, 62% by gynecologists, and 23% by both. Overall rates of gender-specific services (Pap test, clinical breast examination, mammography) were high (88-95%), whereas gender-neutral services were low (23-53%). Patients of gynecologists only were more likely to have Pap tests (adjusted relative risk [RR] 1.26, 95% confidence interval [CI] 1.24-1.27), tobacco use screening (adjusted RR 1.08, 95% CI 1.02-1.14), mammography (adjusted RR 1.25, 95% CI 1.20-1.28), and clinical breast examination (adjusted RR 1.25, 95% CI 1.19-1.29). In general, combined gynecologist and general care did not increase the likelihood of preventive care. Propensity score analyses confirmed these results.

CONCLUSION

Patients of gynecologists receive more preventive services compared with patients of general medical physicians, although rates of gender-neutral services were low regardless of provider type. These findings validate gynecologists' roles as providers of basic preventive care services but demonstrate that considerable room exists to improve delivery of preventive care to women.

Predictors of self-reported discussion of cessation medications by physicians in New Jersey

Physicians play an important role in smoking cessation, especially discussing medications. This study evaluates physician characteristics associated with higher rates of discussion of smoking cessation medications. 336 primary-care physicians in New Jersey completed a cross-sectional, self-administered, mail survey including physician demographics, practice type, previous training and confidence in treating tobacco dependence, awareness of guidelines, and perceived effectiveness of treatments. Two-thirds of respondents felt confident in using cessation medications despite only 24% having previous training and only 13% having read or implemented practice guidelines. After controlling for other variables, female physicians were more likely to discuss medications compared with males (adjusted odds ratio(AOR) 2.2; 95% confidence interval(CI) 1.0-4.6); physicians who were confident were more likely to discuss (AOR 3.0;95% CI 1.7-5.3); and physicians in private practices (solo, group, or multispecialty) were more likely to discuss than those employed by an agency (hospital, state, or federal) (AOR 3.1;95% CI 1.4-6.8). Most physicians in this sample reported routinely discussing cessation medications, with female physicians, those feeling confident, and those in private practices doing so more frequently. Considering limited resources and opportunities to access physicians, interventions to increase discussion of effective cessation treatments could be targeted to specific physician groups.

Clinician gender is more important than gender concordance in quality of HIV care

BACKGROUND

Previous studies have examined the impact of physician gender and gender concordance on preventive care, satisfaction, and communication. Less is known about how physician gender and gender concordance affect care for chronic illnesses, including HIV.

OBJECTIVE

This study sought to determine whether patient-clinician gender concordance (patient and clinician are of the same gender) influences receipt of protease inhibitor (PI) therapy and ratings of care among HIV-infected patients.

METHODS

We reviewed data from 1860 patients and 397 clinicians in the HIV Cost and Services Utilization Study, a nationally representative the association between gender concordance and time to first PI use, and multivariable logistic regression was utilized to examine the association of gender concordance with patients' problems with care and their overall rating of care.

RESULTS

Patients who had a male clinician received PIs earlier than those who had a female clinician (adjusted time ratio = 0.69 for having a male vs having a female clinician; P <or= 0.01). Gender concordance was not a significant predictor of time to PI use. Gender discordance was associated with problems with feeling respected by clinicians. Female patients with a male clinician were most likely, and female patients with female clinicians were least likely, to report a problem with being treated with respect (P <or= 0.01 for the interaction term). Gender discordance was not associated with other problems with care or with overall ratings of care.

CONCLUSIONS

Gender discordance was associated with perceived problems of being treated with respect by clinicians, but not with time to receipt of PIs, overall ratings of care, coordination of care, or obtaining information. The perception of not being respected may represent a significant barrier to care that is particularly worse for women, in that most HIV-infected women receive their care from male clinicians.

Self-report of quality of medical student health care

OBJECTIVES

To summarise survey results for the quality of medical students' personal health care, characterise the results according to the demographics and career orientations of the students, and evaluate the relationship between the perceived quality of health care received and the degree of emphasis on prevention in the health care provided.

METHODS

We carried out a cross-sectional study with 2316 medical students in the class of 2003 from 16 medical schools, surveyed at 3 points during their training. We used a self-administered questionnaire designed to assess personal health care and related variables in medical students.

RESULTS

The majority (92%) reported receiving health care that was at least good, but only a minority (23%) said they received excellent health care. Half had a regular doctor. Health care quality was rated more highly at Year 1 orientation than at later timepoints by students who had a regular personal doctor, and especially by those with personal doctors who emphasised prevention.

CONCLUSIONS

The majority of medical students perceived that they had received health care that was good or better, but most did not believe it was excellent. As the provision of preventive care is important to students, increasing the amount of preventive care provided to students may both increase their personal satisfaction with their health care and model good clinical preventive practices for them.

Skin cancer prevention in the primary care setting: assessment using a standardized patient

Our objective was to utilize the standardized patient technique in assessing the ability of primary care physicians to identify and counsel primary prevention for patients at high risk for skin cancer. A secondary goal was to test the feasibility of this technique as a measure of actual physician behaviors in the outpatient setting. We used a convenience sample of 15 primary care physicians. The standardized patient was an 18-year-old woman with skin phototype I. She presented to physicians as needing a general physical examination for a summer lifeguard job at a beach. She stated a family history of skin cancer. Physician performances were rated using a standard checklist completed by the standardized patient following each visit. We found that none of the physicians asked questions specifically related to skin phototype or sun exposure habits such as childhood sunburns. Only 13% asked about mole changes. For counseling, 67% of physicians recommended sunscreen use; only 7% discussed sunscreen types or procedures for effective use. Only 13% counseled other skin protective behaviors. No significant differences by physician gender were found in these areas; however, female physicians counseled more global health behaviors than male physicians (p < or = 0.01). Our pilot data suggest that little skin cancer primary prevention counseling is performed for high-risk patients. The standardized patient technique worked well in obtaining outcome data for physicians' preventive practices.

Ensuring high-quality primary care for women: predictors of success

BACKGROUND

Provider gender, provider specialty, and clinic setting affect quality of primary care delivery for women, but previous research has not examined these factors in combination. The purpose of this study is to determine whether separate or combined effects of provider gender, availability of gynecologic services from the provider, and women's clinic setting improve patient ratings of primary care.

METHODS

Women veterans receiving care in women's clinics or traditional primary care at 10 Veteran's Affair (VA) medical centers completed a mailed questionnaire (N = 1321, 61%) rating four validated domains of primary care (preference for provider, communication, coordination, and accumulated knowledge). For each domain, summary scores were calculated and dichotomized into perfect score (maximum score) versus other. Multiple logistic regressions were used to estimate the probability of a perfect score in each domain while controlling for patient characteristics and site.

RESULTS

Female provider was significantly associated with perfect ratings for communication and coordination. Providing gynecologic care was significantly associated with perfect ratings for male and female providers. Patients who used a women's clinic and had a female provider who gave gynecologic care had perfect or nearly perfect ratings for preference for provider, communication, and accumulated knowledge.

CONCLUSION

Gynecologic services are linked to patient ratings of primary care separate from and in synergy with the effect of female provider. Male and female providers should consider offering routine gynecologic services or working in coordination with a setting that provides gynecologic services. Health care evaluations should assess scope of services for provider and practice.

Knowledge About Sexually Transmitted Diseases in Women Among Primary Care Physicians

OBJECTIVES

Little is known about sexually transmitted disease (STD) knowledge of primary care providers. The objectives of this study were to determine the knowledge about the management of STDs among primary care physicians and to identify physician characteristics associated with possession of STD knowledge.

STUDY

A self-administered questionnaire was mailed to a random sample of 1600 obstetrician/gynecologists, pediatricians, family physicians, and internists practicing in Pennsylvania. Information on physician and patient demographics was gathered, and we assessed knowledge and practice patterns concerning the management of STDs in young women.

RESULTS

Physician knowledge regarding the evaluation and management of women with or at risk for STDs was associated with female gender (odds ratio [OR]: 2.1; 95% confidence interval [CI]: 1.4-3.2), age < or =40 (OR: 2.3; 95% CI: 1.4-3.6), and metropolitan practice location (OR: 1.7; 95% CI: 1.1-2.6). Familiarity with the Center for Disease Control and Prevention's (CDC's) STD treatment guidelines was independently associated with STD knowledge (OR: 2.0; 95% CI: 1.2, 3.3). Physicians with good STD knowledge were more likely to report routinely screening at-risk women for Chlamydia trachomatis (OR: 3.9; 95% CI: 2.3-6.8).

CONCLUSIONS

Inadequacies in physician knowledge may serve as a barrier to the appropriate diagnosis and treatment of STDs. Interventions to improve STD management practices should include continuing medical education and distribution of CDC's STD treatment guidelines to primary care providers.

Physician and patient gender concordance and the delivery of comprehensive clinical preventive services

BACKGROUND

Understanding the role of patient- and physician-gender on delivery of preventive services has important implications for identifying strategies to increase preventive service delivery. We attempt to overcome methodological limitations of previous studies in examining the association of the patient-physician gender interaction on the delivery of preventive screening, counseling, and immunization services.

METHODS

In this cross-sectional study, research nurses directly observed 3256 consecutive adult patient visits to 138 family physicians. Delivery of gender neutral US Preventive Services Task Force (USPSTF) recommended screening, health behavior counseling, and immunization services was assessed by direct observation and medical record review. Multilevel regression analyses were used to test the interaction effect of physician and patient gender with preventive service delivery, controlling for patient age, insurance type, number of office visits in the past 2 years and physician age.

RESULTS

The interaction effect of physician and patient gender was not significantly associated with delivery of gender neutral screening, counseling, or immunizations. Patients of female physicians were more up-to-date on counseling services (P < 0.01) and immunizations (P < 0.05) than patients of male physicians. Male patients, independent of physician gender, were more up-to-date on counseling and immunizations (P < 0.01).

CONCLUSIONS

Physician-patient gender concordance is not associated with delivery of more preventive services. Rather, female physicians provide more counseling and immunization services to all of their patients. Previous research showing higher rates of gender-specific screening achieved by women physicians may have been an indication of an overall greater prevention orientation among women physicians rather than a specific benefit of gender concordance.

The role of physician gender in the evaluation of the National Centers of Excellence in Women's Health: test of an alternate hypothesis

A 2002 evaluation of the National Centers of Excellence in Women's Health (CoE) provided evidence that women receive higher-quality primary health care, as indicated by receipt of recommended preventive care and patient satisfaction, when they receive their care in comprehensive women's health centers. A potential rival explanation for the CoE evaluation findings, however, is that the higher quality of care in the CoE may be attributable to a predominance of female physicians in CoE settings. More women who receive health care in a CoE have a female regular physician and female physicians may provide more preventive health services. Additionally, women may self-select into the CoE because of their preference for female providers. This paper presents results of an analysis examining the role of physician gender in the CoE evaluation. Women seen in three CoE clinics and women seen in other settings in the same communities who had a female physician are compared to assess the CoE effect while controlled for physician gender. The findings confirm a positive CoE effect for many of the quality of care indicators that were observed in the original evaluation. Women seen in CoEs are more likely to receive physical breast examinations and mammograms (ages > or =50). In addition, positive CoE findings for counseling on domestic violence, sexually transmitted diseases, family or relationship concerns, and sexual function or concerns were upheld. The CoE model of care delivers advantages to women that are not explained by the greater number of female physicians in these settings.

Review of evidence and explanations for suboptimal screening and treatment of dyslipidemia in women. A conceptual model

Screening and treatment rates for dyslipidemia in populations at high risk for cardiovascular disease (CVD) are inappropriately low and rates among women may be lower than among men. We conducted a review of the literature for possible explanations of these observed gender differences and categorized the evidence in terms of a conceptual model that we describe. Factors related to physicians' attitudes and knowledge, the patient's priorities and characteristics, and the health care systems in which they interact are all likely to play important roles in determining screening rates, but are not well understood. Research and interventions that simultaneously consider the influence of patient, clinician, and health system factors, and particularly research that focuses on modifiable mechanisms, will help us understand the causes of the observed gender differences and lead to improvements in cholesterol screening and management in high-risk women. For example, patient and physician preferences for lipid and other CVD risk factor management have not been well studied, particularly in relation to other gender-specific screening issues, costs of therapy, and by degree of CVD risk; better understanding of how available health plan benefits interact with these preferences could lead to structural changes in benefits that might improve screening and treatment.

Relationships of practitioner communications and characteristics with women's mammography use

Women have reported not seeking mammography because their practitioners do not recommend it. The purposes of this study were to delineate which dimensions of practitioner communications and characteristics predicted women's mammography use. In a longitudinal, correlational design, participants were 797 mid-western women, aged 51-80 years, who had not had mammograms in the prior 13 months. Practitioner communications and characteristics and women's subsequent mammography use were assessed through telephone interviews with participants. Controlling for pre-existing differences, communications and characteristics were entered in a hierarchical logistic regression on mammography use. Practitioner-specific communications predicted mammography use (e.g. endorsement, encouragement, and assistance with scheduling) as well as having internists as identified practitioners. Practitioners' mammography-specific communications can promote mammography among women who have not used it often in the past. Practitioners--especially those who are not internists--can examine whether their interactions are conducive to fostering mammography use.

Effect of provider status on preventive screening among Korean-American women in Alameda County, California

BACKGROUND

Previous research suggests that having a doctor of the same ethnicity may be associated with lower rates of breast and cervical cancer screening in some Asian-American women. This study analyzes the effect of having a Korean, non-Korean, or no regular doctor upon several measures of screening among Korean-American women.

METHODS

A random sample of 339 Korean-American women in Alameda County, California, were surveyed by telephone. Contingency tables and multivariable logistic regression were used to evaluate the association between provider status and six measures of recent screening, controlling for insurance and demographics.

RESULTS

Having a non-Korean doctor was associated with an increased likelihood of having a Pap smear (odds ratio = 2.19, 95% confidence interval = 1.00, 4.80), mammogram (odds ratio = 7.63, 95% confidence interval = 2.35, 24.84), and clinical breast examination (odds ratio = 3.76, 95% confidence interval = 1.54, 9.20) in the past 2 years, compared to having a Korean doctor. This relationship is less apparent for nonfemale specific screening tests like cholesterol exams and routine checkups.

CONCLUSIONS

Women who have a Korean doctor have less than optimal rates of breast and cervical cancer screening compared to women who have a non-Korean doctor. Having a Korean doctor may indicate less access to preventive health services, and programs to increase screening should target both Korean physicians and their female patients.

Provider characteristics and mammography recommendation among women in their 40s and 50s

OBJECTIVES

Healthcare provider recommendation for mammography is one of the strongest predictors of women's mammography use, but few studies have examined the association of provider characteristics with mammography recommendations. We examined the relationship of provider gender, age, medical specialty, and duration of relationship with the patient to report mammography recommendation.

METHODS

Participants were women ages 40-45 and 50-55 who were part of a larger intervention study of decision making about mammography. We examined the relationship of provider characteristics to patient-reported mammography recommendations at baseline and at 24-month follow-up.

RESULTS

At baseline, 74% of women in their 40s and 79% of women in their 50s reported provider mammography recommendations within the prior 2 years. Proportions were similar at the 24-month follow-up. In multivariate logistic regression models including both patient and provider characteristics, women in their 40s who had female providers were more likely to report mammography recommendations than those with male providers at baseline (OR=1.83, p=0.01) and follow-up (OR=1.74, p=0.03). Among women in their 50s, participants whose regular providers were primary care physicians were more likely to report recommendations at baseline than those whose regular providers were obstetrician/gynecologists (OR=1.68, p=0.03).

CONCLUSIONS

About one fourth of women in this study reported not having been advised by a healthcare provider to have a mammogram. All women in the study had health insurance. Among women in their 40s, for whom mammography guidelines were controversial at the time of data collection, provider gender was an important predictor of patient-reported mammography recommendation.

Gender bias in physicians' management of neck pain: a study of the answers in a Swedish national examination

BACKGROUND

Research has raised concerns about gender bias in medicine; that is, are women and men being treated differently because of gender stereotyped attitudes among physicians? We investigated gender differences in the diagnosis and management of neck pain as proposed in a written test. The design eliminated differences related to communication and patient behavior.

METHODS

In a national examination for Swedish interns, using modified essay questions, the examinees were allocated to suggest management of neck pain in either a male or a female bus driver with a tense family situation. The case description was identical with the exception of patient gender. The open answers were coded for analysis. Two hundred thirty-nine interns (41% women) participated. Chi-square-tests were used to measure differences in proportions, and t test was used to evaluate differences in means.

RESULTS

In certain areas, significant gender differences were detected. Proposals of nonspecific somatic diagnoses, psychosocial questions, drug prescriptions, and the expressed need of diagnostic support from a physiotherapist and an orthopedist were more common with females. Laboratory tests were requested more often in males. Both male and female physicians contributed to the gender differences. When assessing the impact of the patient-doctor relationship for health outcome, male physicians underlined the importance of patient compliance foremost in female patients, and female physicians did the opposite.

CONCLUSIONS

The results suggest that physicians' gendered expectations are involved in creating gender differences in medicine. The inclusion of gender theory and discussions about gender attitudes into medical school curricula is recommended to bring about awareness of the problem.

Determinants of women's choice of obstetrician/gynecologist

INTRODUCTION

There has been a reported increase in women's desires to have female medical providers. It is unclear if this finding extends to obstetrician/gynecologists or how important gender is relative to other factors in choosing a provider. This study seeks to address these issues.

METHODS AND MATERIALS

In community locations in Brooklyn, New York, 537 women completed a questionnaire regarding demographics, gender of their current provider, and whether they considered age, gender, experience, location, or cost to be the most important factor in choosing an obstetrician/gynecologist. They rated their current experience and the importance of gender using a 10-point Likert scale.

RESULTS

Overall, 61% of participants preferred a female provider. The proportion did not vary with gender of the interviewer or participants' age. A female provider was preferred by 56% of Protestants, 58% of Catholics, and 58% of Jews and by 74% of Hindus and 89% of Muslims (p = 0.02). Regardless of whether a woman preferred a male or a female provider, 38% of participants felt strongly (7-10 on Likert scale) that gender was important. There was no difference in satisfaction with current provider between women who preferred a male or female provider. Gender was as important in choosing an obstetrician as experience or cost. Almost as many women with a female provider indicated a preference for a male (46%) as women with a male provider who preferred a female provider (54%).

CONCLUSIONS

A slight majority of these women, particularly those who are Hindu or Moslem or currently use a female, prefer female providers. Only a minority of these women feel strongly about their preference, and women with male providers are as satisfied as are women with female providers. Gender of provider was about as important as a physician's experience in choice of clinician.

The physician as worker: what it means and why now?

Health care researchers and managers have viewed physicians traditionally through three major lenses, that is, as professionals, suppliers, and caregivers. This article makes a case for another lens, that of the physician as worker. The worker perspective complements these existing perspectives, serves as a generative metaphor in raising new assumptions and questions about physicians, and provides physicians with a dimensionality necessary because of increasing diversity within and external to the medical profession.

Physician gender effects on preventive screening and counseling: an analysis of male and female patients' health care experiences

BACKGROUND

Studies have documented that patients of female physicians receive higher levels of preventive services. However, most studies include patients of only one gender, examine mainly gender-specific screening services, and do not examine patient education and counseling.

OBJECTIVES

This study tests both physician- and patient-gender effects on screening and counseling services received in the past year and considers effects of gender-matched patient-physician pairs.

RESEARCH DESIGN

Multivariate analyses are conducted to assess direct and interactive (physician x patient) gender effects and to control for important covariates.

SUBJECTS

Data are from the 1998 Commonwealth Fund Survey of Women's Health, a nationally representative sample of U.S. adults. The analytic sample includes 1,661 men and 1,288 women ages 18 and over.

MEASURES

Dependent variables are measures of patient-reported screening and counseling services received, including gender-specific and gender-nonspecific services and counseling on general health habits and sensitive topics.

RESULTS

Female physician gender is associated with a greater likelihood of receiving preventive counseling for both male and female patients. For female patients, there is an increased likelihood of receiving more gender-specific screening (OR = 1.36, P <0.05) and counseling (OR = 1.40, P <0.05). These analyses provide no evidence that gender-matched physician-patient pairs provide an additional preventive care benefit beyond the main effect of female physician gender.

CONCLUSIONS

Female physician gender influences the provision of both screening and counseling services. These influences may reflect physicians' practice and communication styles as well as patients' preferences and expectations.

[Variability in preventive activities among primary care teams in Catalonia. Application of a multilevel analysis]

OBJECTIVES

To determine whether variability exists among primary care teams (PCTs) in Catalonia in opportunistic screening activities (screening for smoking, drinking, hypertension and tetanus vaccination) and to analyze the explanatory factors in the individual characteristics of the population treated and the characteristics of the PCT.

METHODS

A multilevel analysis with individual and PCT explanatory variables was performed. The data were draw from a sample of 3,000 clinical histories from the adult population treated in 1995 in 30 PCTs from the restructured primary care network in Catalonia and from PCT characteristics.

RESULTS

The recording of preventive activities in the clinical histories increased with the number of risk factors and/or diseases diagnosed, the number of other preventive activities recorded, and age. Recording of arterial pressure was more frequent in women while the remaining preventive activities were more frequent in men. Workload impeded opportunistic detection. Greater recording of antitetanus vaccination was associated with the number of years that the PCT had been functioning and with wider geographical area. Recording of smoking was higher in urban areas.

CONCLUSIONS

Variability in opportunistic detection exists among PCTs in Catalonia. The characteristics of the PCT and the population treated that explain part of this variability are identified. Lower workload favors preventive activities in primary care.

Does provider prevention orientation influence female patients' preventive practices?

BACKGROUND

Health care provider encouragement for particular preventive behaviors is associated with patient adherence, but it is unclear whether a provider's overall prevention approach influences whether patients engage in recommended preventive measures. We examined whether older women who perceived that their health care provider encouraged a particular preventive behavior were more likely to follow that recommendation if they also perceived that the provider encouraged other preventive behaviors.

DATA AND METHODS

The sample included 1119 women aged 50 to 79 enrolled in a health maintenance organization. We examined associations of reported provider encouragement for post-menopausal hormone use, physical activity, fecal occult blood testing (FOBT), and flexible sigmoidoscopy with one another and with adherence to these measures according to recommended guidelines.

RESULTS

Among women reporting provider encouragement for physical activity, the likelihood of reporting regular physical activity was greater among women who reported encouragement for one other (odds ratio [OR]=1.99; confidence interval [CI]=1.35 to 2.95) and at least two other (OR=2. 38; 95% CI=1.62 to 3.48) preventive measures compared with women who reported no other encouragement. The likelihood of reporting adequate counseling for post-menopausal hormone use was greater among women reporting encouragement for at least two other preventive measures compared with those reporting no other encouragement. The likelihood of having had an FOBT or sigmoidoscopic examination was related to encouragement for those procedures, but not with greater encouragement for other preventive measures.

CONCLUSIONS

Patient perceptions of a provider's overall preventive practice approach may influence whether patients engage in recommended preventive practices, particularly for lifestyle factors.

The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review

OBJECTIVE

To critically review the literature concerning the accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease among the general population.

METHOD

A literature search was conducted on three major health research databases: MEDLINE, HealthPLAN, and PsychLit. The bibliographies of located articles were also checked for additional relevant references. Studies meeting the following five inclusion criteria were included in the review: They were investigating the accuracy of self-report among the general population, as opposed to among clinical populations. They employed an adequate and appropriate gold standard. At least 70% of respondents consented to validation, where validation imposed minimal demands on the respondent; and 60% consent to validation was considered acceptable where validation imposed a greater burden. They had a sample size capable of estimating sensitivity and specificity rates with 95% confidence intervals of width +/-10%. The time lag between collection of the self-report and validation data for physical measures did not exceed one month.

RESULTS

Twenty-four of 66 identified studies met all the inclusion criteria described above. In the vast majority, self-report data consistently underestimated the proportion of individuals considered "at-risk." Similarly, community prevalences of risk factors were considerably higher according to gold standard data sources than they were according to self-report data.

CONCLUSIONS

This review casts serious doubts on the wisdom of relying exclusively on self-reported health information. It suggests that caution should be exercised both when trying to identify at-risk individuals and when estimating the prevalence of risk factors among the general population. The review also suggests a number of ways in which the accuracy of individuals' self-reported health information can be maximized.

Variation in recommendations for cancer screening among primary care physicians in New Mexico

The acceptance of age-appropriate cancer screening as an integral part of primary care has grown among physicians over the past decade. We conducted a mailed survey of all primary care physicians in New Mexico in order to better understand their current cancer screening practices. We found a high rate of self-reported screening, particularly for prostate and colorectal cancer. The screening rates were influenced only slightly by the introduction of evidence-based guidelines, with younger physicians and those with university affiliations more likely to follow recommendations. Female physicians and obstetrician-gynecologists endorsed breast and cervical cancer screening among all age groups and were less likely to follow recommendations for less frequent screening in women as they age. Since a physician's practice beliefs influence his/her attitude toward testing, tailoring education by physician specialty may be more effective than using generic messages in encouraging compliance with the most recent evidence-based guidelines.