DISCLOSURE INFORMATION

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1 DISCLOSURE INFORMATION Disclosure of Relevant Financial Relationships: Presenter has no financial relationships to disclose. Disclosure of Off-Label and/or Investigative Uses: Presenter will not discuss off-label use and/or investigational use in the presentation.

2 "What is it with female doctors?" Dr. Marianne Schmid Mast hec.unil.ch

3 Riddle A father and his son are driving to the drug store. Unfortunately, they have a terrible accident and the father dies immediately. The son is severely injured and needs to be transported to the next hospital. Because of his severe and complicated injuries, a surgeon specialist has to be flown in by helicopter to do the operation. The specialist enters the operation room, sees the kid and says: «I cannot operate this kid, this is my son!»

4 Why is it hard to find the solution? Cognitive network surgeon Man leader high status specialist

5 Definition of a Stereotype The effect of an activation of a cognitive network of associations related to a social group. caring empathic emotional warm

6 Implicit Stereotypes Outside of our conscious awareness Affect perception and judgement of others and our behavior towards them

7 Gender Stereotypes Affect Physicians

8 The Paradox Patients prefer patientcentered communication from their physician (Swenson et al., 2004) Female physicians show more patient-centered communication (Hall, Irish, Roter, et al., 1994; Hall, Roter, Blanch, & Frankel, 2009; Roter, Hall, & Aoki, 2002) Partnership building Empathy Encouragement Longer visits Patients prefer not to die and not to go back to the hospital once released Patients treated by female physicians have lower mortality and lower readmission rate (Tsugawaet al., 2017) hospitalizations, 30-day mortality and hospitalizations, 30-day readmission rate But: Patients are just a little bit more satisfied with female physicians (Hall, Blanch Hartigan, & Roter, 2011)

9 What is it with Female Doctors?

10 How Do Gender Stereotypes Affect Physicians? Empirical evidence Open questions Physician training

11 Gender Stereotypes Affect Physicians Which physician nonverbal behavior is related to more patient satisfaction and is it the same for female and male physicians?

Indicate satisfaction with physician after each video

12 Study 163 analogue patients Watch 2min videos of 8physicians (4 F, 4 M, general practitioners) Indicate satisfaction with physician after each video Schmid Mast, Hall, Klöckner Cronauer, & Choi (2008). Medical Care

13 Coding of 22 Nonverbal Behaviors Speaking time, eye contact, interpersonal distance, self-touch, loudness of voice, smiling, gesturing Attractiveness, formal dress, medical atmosphere

14 Significant Gender Differences Higher patient satisfaction with female physician if... Less interpersonal distance Less time reading medical record Less expansive body posture Softer voice More self-touch More medical atmosphere Higher patient satisfaction with male physician if... More interpersonal distance More time reading medical record More expansive body posture Louder voice Less self-touch Less medical atmosphere Schmid Mast, Hall, Klöckner Cronauer, & Choi (2008). Medical Care

15 Results in Line with Theories on the Effect of Gender Stereotypes Role Congruity Theory (Eagly and Karau, 2002) When people show interpersonal behavior in line with the gender stereotype, they are evaluated more favorably Patients are more satisfied with physicians who show nonverbal behavior corresponding to the genderstereotype

16 Results in Line with Theories on the Effect of Gender Stereotypes Lack of Fit Model (Heilman, 1983, 1995) Lack of fit between attributes of the job and attributes of the job holder => negative evaluation Patients expect from physicians to be competentand fromwomentobeless competent => lack of fit => less satisfaction To be satisfied, the gap needs to be filled with information about medical competence

17 Gender Stereotypes Affect Physicians When female and male physicians behave in the same way, are they evaluated differently by patients?

18 Study 192 analogue patients (96 M, 96 F), Mage= 20 2 F and 2 M actors played a physician, verbal patientcenteredness was manipulated Emotional responsiveness (i.e., statements of empathy, concern, partnership, legitimation) Facilitation of patient disclosure (i.e., asking for patient opinion and open-ended questions) Information provision and counseling (psychosocial and lifestyle) Analogue patients Randomly assigned to watch one of 8 videos Report overall satisfaction, trust, caring etc. (positive patient outcomes) Hall, Roter, Blanch-Hartigan, Schmid Mast, & Pitegoff (2015). Health Communication

19 Result Positive patient outcomes female physicians male physicians low patient-centered high patient-centered Hall, Roter, Blanch-Hartigan, Schmid Mast, & Pitegoff (2015). Health Communication

20 Conclusions Male physicians are given more credit for using the good communication style than female physicians For women doctors, the patient-centered communication is expected, thus normal, therefore no extra credit Hall, Roter, Blanch-Hartigan, Schmid Mast, & Pitegoff (2015). Health Communication

21 Gender Stereotypes Affect Physicians Extra credit (more satisfaction) Patient-centered verbal communication No extra credit Maybe patients do not even perceive the female patient-centered style as patientcentered!

22 Study 60 analogue patients Filled in a sexism questionnaire (Ambivalent Sexism Inventory) Watch eight 2 min videos (4 F, 4 M) of general practitionners Indicated perceived physician patient-centeredness after each video Indicatedpositive consultation outcomes (satisfaction, trust, perceived physician competence) after each video Klöckner Cronauer & Schmid Mast (2014). The Patient

23 Results Klöckner Cronauer & Schmid Mast (2014). The Patient

24 Results for Male Patients Evaluating Female Physicians pr = -.80 Perceived patientcenteredness Hostile sexism pr = -.74 Positive consultation outcomes pr = -.24 Klöckner Cronauer & Schmid Mast (2014). The Patient

25 Conclusion Hostile sexist male patients perceive female physicians as less patient-centered which is why they have less positive consultation outcomes Female physician s patient-centered behavior is not perceived as such (at least by hostile sexist male patients)

26 Gender Stereotypes Affect Physicians Extra credit (more satisfaction) Patient-centered verbal communication No extra credit What about physician behavior that is less clearly positive?

27 When Female and Male Physicians Express Uncertainty Physicians expressing uncertainty is considered an element of patient-centered communication (Henry, 2006; Hewson, Kindy, VanKirk, & Day, 1996) Empirical evidence shows a negative effect on patient satisfaction (Blanch et al., 2009; Johnson et al., 1988) or no effect (Epstein et al., 2007; Gordon et al., 2000)

28 Study Physicians: 36 generalpractitioners(20 M, 16 F), Mage = 47, Myears_of_practice = 20 Patients: 69 patients (36 M, 33 F), Mage= 51, different medical problems Physiciansare filmed during2 consultations (Mduration = 31 min) Patients report satisfaction with physician after consultation (3 items, Cronbach s alpha =.74) Cousin, Schmid Mast, & Jaunin (2013). Health Communication

29 Measuring uncertainty Global impression of physician uncertainty (can be related to diagnosis, treatment, or consequences of treatment; inter-rater reliability: r =.77)

30 Results No gender difference in expressed uncertainty No difference is satisfaction with female and male physicians Significant 3-way interaction b* = -.67, p =.019 Controlled for physician caring, physician dominance, physician age, patient age, severity of medical problem Cousin, Schmid Mast, & Jaunin (2013). Health Communication

31 Conclusion Male patients are less satisfied with women doctors who express uncertainty Lower medical performance expected from female physicians => if female physicians express uncertainty => lower patient satisfaction Only male patients because they hold stronger stereotypes For male doctors, expressing uncertainty did not affect patient satisfaction

32 Gender Stereotypes Affect Physicians Extra credit (more satisfaction) Patient-centered verbal communication No extra credit No blame Expressed uncertainty Blame (less satisfaction)

33 Particular Challenge: Male Patient and Female Physician

34 Return to Physician after a First Visit

35 Return to Physician after a First Visit

36 How Do Gender Stereotypes Affect Physicians? Empirical evidence Open questions Physician training

37 What Else Do Female Physicians Do that Is Related to Better Patient Outcomes? Female physicians show more patient-centered communication One aspect of patient-centered care is to be able to change one s communication style and to adapt to different patients (no one-size-fits-all ) Female doctors show more variability in their communication (Noroa et al., 2017)

Behavioral Adaptability The physician varies

and wants low patient-centered physician

38 Behavioral Adaptability The physician varies his or her communication style according to the expectations of the patient Expects and wants high patient-centered physician Expects and wants low patient-centered physician Carrard & Schmid Mast (2015). Patient Education and Counseling

39 Patients Have Different Expectations Patients harbor expectations with respect to physician communication style Fit between physician sharing behavior and patient expectations about physician sharing behavior related to more satisfaction Expectation Confirmation Theory (Jiang & Klein, 2009) Cousin, Schmid Mast, Roter & Hall (2012). Patient Education and Counseling

40 Antecedents and Consequences of Behavioral Adaptability Physician Interpersonal Accuracy Physician Behavioral Adaptability Better Patient Outcomes

41 Definition of Interpersonal Accuracy Correctly assessing others states and traits.

42 Effects of Interpersonal Accuracy Interpersonal accuracy related to empathy, prosocial behavior, or skills in negotiating, selling, teaching, and managing (Hall, Schmid Mast, & West, 2016) Related to patient satisfaction, appointmentkeeping adherence, and learning of conveyed information (Hall, 2011) Interpersonal accuracy can be trained (Blanch- Hartigan &Ruben, 2013)

43 Interpersonal Accuracy DANVA (Diagnostic Analysis of Nonverbal Accuracy; Nowicki& Duke, 1994)

44 Interpersonal Accuracy Tests Specifically for the Physician-Patient Communication

45 Interpersonal Accuracy Tests Specifically for the Physician-Patient Communication

46 Study 61 general practitioners, 34 M, 27 F, Mage = 51, Myears_of_practice = 24 Physicians take an interpersonal accuracy test 244 patients (2M, 2F), Mage = 57, Mduration = 23 min Patients indicate preference for a physician communication style prior to the consultation (PPOS, Krupat, Yeager, & Putnam; 2000) Patients indicate satisfaction and trust (aggregated) after consultation Physicians are videotaped, videos are coded with respect to verbal and nonverbal behavior Carrard & Schmid Mast, et al. (2017). Health Communication

47 Behavioral Adaptability Physician behavior Nonverbal behaviors indicative of patient-centeredness Verbal behaviors indicative of patient-centeredness (RIAS, Roter & Larson, 2002) Adaptability Correlation between expectation of patient with respect to patient-centered communication with actual patient-centered behavior of the physician across 4 patients, separately for nonverbal adaptability and verbal adaptability Carrard & Schmid Mast, et al. (2017). Health Communication

48 Results No gender difference in behavioral adaptability All physicians Verbal Adaptability Female physicians Male physicians All physicians Nonverbal Adaptability Female physicians Male physicians Variables B SE B SE B SE B SE B SE B SE Physician emotion recognition * * 0.06 R F Note. N physicians = 58 (26 F, 32 H), N patients = 232 (116 F, 116 H). Control variables: physician experience and mean per physician of patient age, patient education, years since first consultation, frequency of patient visit, severity of medical problem, and consultation duration. a Mean per physician p <.10. *p <.05. **p <.01. ***p <.001. Carrard & Schmid Mast, et al. (2017). Health Communication

49 Discussion Female physicians who are good at emotion recognition accuracy also show behavioral adaptability Negative relation between interpersonal accuracy and nonverbal behavioral adaptability for male physicians (?) Males are less knowledgeable concerning the link between behaviors and emotion (Rosip& Hall, 2004) Carrard & Schmid Mast, et al. (2017). Health Communication

50 Results for Consultation Outcomes All physicians Female physicians Male physicians Variables B SE B SE B SE Physician verbal adaptability Physician nonverbal adaptability * Physician verbal patientcenteredness Physician nonverbal patientcenteredness Wald chi *** *** 90.83*** Note. N physicians = 61 (27 F, 34 H), N patients = 244 (122 F, 122 H). Variables are unstandardized. Control variables: physician experience, patient age, patient education, years since first consultation, frequency of patient visit, severity of medical problem, and consultation duration. p <.10. *p <.05. **p <.01. ***p <.001. Carrard & Schmid Mast, et al. (2017). Health Communication

51 Discussion Female physicians who show nonverbal behavioral adaptability have patients who report better consultation outcomes Above and beyond what patient-centered verbal and nonverbal communication can explain Only nonverbal: maybe the verbal channel is more scripted, less opportunity to adapt Only female physicians, but: Male and female physicians benefit from nonverbal adaptability of dominance (Carrard, Schmid Mast, & Cousin, 2016) Carrard & Schmid Mast, et al. (2017). Health Communication

52 Summary Female Physician Interpersonal Accuracy Female Physician Nonverbal Behavioral Adaptability Better Patient Outcomes Carrard & Schmid Mast, et al. (2017). Health Communication

53 Gender Stereotypes Affect Physicians Extra credit (more satisfaction) Patient-centered verbal communication No extra credit No blame Expressed uncertainty Blame (less satisfaction) Sometimes credit Nonverbal behavioral adaptability Credit (more satisfaction)

54 Congruity Theory Explains Effects for Female Physicians? Extra credit (more satisfaction) Patient-centered verbal communication No extra credit No blame Expressed uncertainty Blame (less satisfaction) Sometimes credit Nonverbal behavioral adaptability Credit (more satisfaction)

55 Blame for Negative Behavior for Female Physicians? Extra credit (more satisfaction) Patient-centered verbal communication No extra credit No blame Expressed uncertainty Blame (less satisfaction) Sometimes credit Nonverbal behavioral adaptability Credit (more satisfaction)

56 Credit for Positive Behavior for Female Physicians? Extra credit (more satisfaction) Patient-centered verbal communication No extra credit No blame Expressed uncertainty Blame (less satisfaction) Sometimes credit Nonverbal behavioral adaptability Credit (more satisfaction)

57 Credit for Positive Nonverbal Behavior for Female Physicians? Extra credit (more satisfaction) Patient-centered verbal communication No extra credit No blame Expressed uncertainty Blame (less satisfaction) Sometimes credit Nonverbal behavioral adaptability Credit (more satisfaction)

58 Conclusions and Future Research Our results suggest: incongruity is not necessarily the factor Female and male physicians sometimes do not get credit for good physician behavior For which behaviors do female physicians get credit or take the blame? Credit for nonverbal behavior (adaptability)? Blame for negative behavior? For which behaviors do male physicians get credit or take the blame? Credit for positive gender stereotype incongruent verbal behavior?

59 How Do Gender Stereotypes Affect Physicians? Empirical evidence Open questions Physician training

60 Medical Student Training in Delivering Bad News with Simulated Patients Berney, Carrard, Schmid Mast, et al. (2017). Psycho-Oncology

61 How Should We Train Physicians? Train male physicians in patient-centered verbal communication Train female physicians in nonverbal behavioral adaptability => Practice different styles with different patients

62 Physician Communication Training Application

63 Physician Communication Training Application in Breaking Bad News Questions Short consultation See instructions Choice of patient Quit simulation

64 Physician Communication Training Application in Breaking Bad News Choose a question Diagnosis Treatment Prognosis Follow-up

65 Different Patients

66 Advantages of our Training Ease of access to social interaction partner (patient) Possibility to practice and repeat Adaptability and variability of training scenarios Possibility to develop and test behavioral variability Self-administered and self-paced No social evaluation, less stress Feedback is possible Auto-evaluation, send out video for peer or expert feedback

67 How Physicians Can Overcome the Undesirable Effects of Gender Stereotypes Train interpersonal accuracy skills Train different communication styles Female and male doctors might want to train different skills Females: Nonverbal behavioral adaptability Males: Verbal patient-centeredness

68 Female physicians show nonverbal behavioral adaptability Male physicians show verbal patientcenteredness Increased patient satisfaction Physician gender becomes less salient, thus gender stereotypes play a lesser role

69 Nothing Is Done Alone Judith Hall Debra Roter Valérie Carrard Alexandre Berney

Gender, power, and nonverbal communication

1 Gender, power, and nonverbal communication Marianne Schmid Mast, Valérie Carrard, and Judith A. Hall The importance of communication in cancer care has been well documented. Communication is a challenging