Do Women Prefer Care From Female or Male Obstetrician-Gynecologists A Study of Patient Gender Preference
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《美国整骨期刊》
Objective: To determine whether men should be encouraged to enter the medical specialty of obstetrics and gynecology.
Methods: A self-administered survey was designed for and distributed to patients (N=264) in 13 obstetrics and gynecology waiting rooms in Connecticut. The survey was used to determine whether there were any patient preferences with regard to the gender of physicians providing obstetric and gynecologic care within this population. In addition, the rationale for any preferences was analyzed.
Results: The majority of patients (66.6%) had no gender bias when selecting an obstetrician-gynecologist, and an even larger majority (198, 80.8%) felt that physician gender does not influence quality of care. There was no statistical difference in patient satisfaction based on physician sex. Respondents self-reporting gender bias rarely selected obstetrician-gynecologists based solely on this factor and frequently choose physicians of the sex that was not their indicated preference, suggesting that several factors other than gender preference are more important in physician selection.
Conclusions: The majority of women surveyed did not select their obstetrician-gynecologists based solely on physician gender. Although a small percentage of survey respondents did indicate a gender preference, it rarely influenced physician selection and was only a minor consideration when compared with other desirable physician attributes.
In 1970, only 9% of enrolled medical students in the United States were women.1 From 1978 to the present, the percentage of women pursuing specialty practice in obstetrics and gynecology has more than quadrupled, leaving men in this specialty practice area in the minority (Table 1). As noted in Table 1, as of 2001, women composed 71.8% of obstetrics and gynecology residents (unpublished data, W.H. Pearse, MD, 2001). It is estimated that by the year 2014, women will outnumber men in the practice of obstetrics and gynecology.2
In 1974, an article by Neubardt, "Women's Liberation and the Male Gynecologist," discussed women's dissatisfaction with the medical profession and the need for female gynecologists.3
One year later, at a time when more than 83% of obstetrics and gynecology residents were men, Haar et al4 published a survey showing 33.9% of patients preferred women as their gynecologists. This 1975 article emphasized the "importance of increasing the number of women physicians...in order to provide a true alternative for women patients."4 While highlighting the finding that many women preferred same-gender physicians, Haar et al4 failed to point out that more than 60% of their respondents either preferred male physicians or specified no gender preference.
More recent studies5–7 have shown that there is a continued need for gender equality in the field of obstetrics and gynecology. After surveying 1544 obstetric-gynecology patients in a large California military hospital, Lund et al5 found that 60% of respondents either had no gender preferences or preferred a male provider. A Canadian study (N=405)6 demonstrated that 75% of patients surveyed reported no "strong preference concerning the gender of their obstetrician-gynecologist." This same 2002 study showed that 4% of respondents preferred male providers, while 21% had a preference for female providers.6 In a 2002 survey of postpartum patients (N=67), Howell et al7 reported similar findings for gender preferences. Overall, 34% of respondents preferred a female obstetrician, 7% a male obstetrician, and 58% expressed no gender preference.7
If the growing belief that patients primarily prefer women obstetrician-gynecologists8 were evidence-based, then the shift the discipline has experienced in the gender balance of physicians pursuing training in obstetrics and gynecology would be justified.1,2 However, current research does not support this belief.
We set out to answer the question: "Is there a role for men in the future practice of obstetrics and gynecology" and, if so, "What is the desired balance of men versus women in this specialty field"
To answer these questions, it was necessary to determine (1) patients' gender preferences for their obstetrician-gynecologists, (2) whether any gender preference among patients correlates with physician selection, and (3) if physician gender affects patient satisfaction.
Methods
The institutional review boards at the University of Connecticut School of Medicine (Farmington), Hartford Hospital (Conn), and Saint Francis Hospital and Medical Center (Hartford, Conn) approved all aspects of the study. A small pilot study was conducted in July 2001, after institutional review board approval, to test the validity of the survey instrument.
In August and September 2001, a self-administered 43-item survey that also gathered basic demographic data was distributed to patients in obstetrics and gynecology waiting rooms throughout the Hartford, Conn, area (Figure). Thirteen obstetrician-gynecologists' offices were contacted and all agreed to participate in the study. Demographic data was also collected regarding the 13 study sites.
To achieve adequate diversity in study results, urban and suburban patients visiting office practices or a clinic were surveyed; five general obstetrics and gynecology practices, one maternal fetal medicine practice, one urogynecologic practice, two reproductive endocrinology and infertility practices, three gynecologic oncology practices, and one general-residency–based obstetrics and gynecology clinic participated in the study.
On scheduled office days at the 13 study sites, patients who were at least 16 years of age were offered entry into the study. Patients were asked whether they would be willing to fill out an anonymous, standardized survey addressing how they decided on the provider for their most recent general obstetrics and gynecology visit (ie, not the current visit).
Surveys were consistently distributed by trained research personnel. The surveys, written in English and Spanish to allow for variations in primary or preferred language, typically took 10 minutes to complete while patients were waiting for their respective appointments.
The survey addressed the frequency with which patients received the care of female or male obstetrician-gynecologists (item 18). In addition, the survey asked whether each patient had the opportunity to choose the obstetrician-gynecologist who currently treats her (item 19)—and, if not, would they have liked the ability to make that choice for themselves (item 20). Respondents were also queried regarding their level of satisfaction regarding their most recent healthcare encounter (item 22). Patients also were asked to select and rank physician qualities that they consider when choosing an obstetrics and gynecology provider (items 32 through 35).
In addressing patient gender preferences regarding their obstetrician-gynecologists, we focused on several specific aspects of obstetric and gynecologic care, including pelvic examinations (item 26), obstetric care (item 27), health maintenance (item 28), and gynecologic surgery (item 29).
Before the study, a power analysis was performed by one of the investigators (C.M.O.) to calculate the number of respondents needed to demonstrate statistical significance for gender preference among physician qualities in selecting an obstetrician-gynecologist; the power analysis determined that 50 patients would need to respond to the survey. Using this figure, the confidence interval for gender preference would be on the order of 0.03. We decided to survey over 200 patients to improve the observed frequencies within subgroups.
Results
Although the number of women (54, 66.6%) providing obstetric and/or gynecologic care at the 13 survey sites was clearly predominant over the number of men (27, 33.1%) (Table 2), the disparity was a result of the increased number of female obstetrics and gynecology residents in the clinic setting.1,2 The female-to-male gender distribution in the private practice offices, however, was nearly balanced at 17 (48.6%) women and 18 (51.4%) men.
At the 13 survey sites, 272 patients were asked to participate in this survey-based study. Of these, 8 (2.9%) women declined to participate in the study because of "lack of time." The remaining patients (N=264) agreed to participate in the study, provided informed written consent, and completed the survey.
The survey was available in English and Spanish versions. An international translation service was also available to allow patients to take the survey in other languages, but this service was never requested by patients asked to complete the survey.
After data-collection was complete, survey results were tabulated for each of the 43 survey items. The observed percentages were described and means were calculated with 95% confidence intervals. Chi-square (2) analyses were used to compare across responding subgroups with the level of significance set at .05. Fisher's z-tests were used to examine differences in response percentages and analysis of variance models were conducted to examine differences in means.
Demographic information collected included patient age, ethnicity, marital status, number of children (if any), highest level of education attained, employment status, annual household income, healthcare insurance status, religious identification, and primary language spoken (Table 3). A diverse patient population was achieved, including a wide range of patient ages, a broad racial distribution, and various socioeconomic backgrounds (Table 3).
To establish a composite score, we averaged the responses to survey items 25 through 30 to determine that 5.9% of women surveyed preferred men to be their obstetrician-gynecologists, 27.6% preferred women, and 66.6% indicated that they had no preference regarding the sex of their obstetrician-gynecologists (Table 4 and Table 5).
When patients were asked specifically whether men or women are better obstetrician-gynecologists (item 30g), 198 (80.8%) responded that gender does not matter (Table 5). For patients who self-reported a gender bias, a cross analysis showed that preference did not correlate with physician selection.
Despite the fact that the majority of obstetrician-gynecologists who took part in this study at the 13 study sites were women, 17 (31.5%) of patients who had a choice regarding physician selection (item 19), and who stated they feel women are more understanding (item 30d), obtained care from men at their most recent obstetric-gynecologic care visit (item 21), 36 (66.7%) obtained care from women, and 1 (1.9%) respondent was unable to remember the sex of the attending physician (item 21). These findings suggest that factors other than physician sex are more important to patients when they select obstetrician-gynecologists.
Among the 232 (87.9%) women who answered survey item 18, 67 (28.9%) reported seeing male physicians 100% of the time and 36 (15.5%) reported seeing male physicians more than 50% of the time. Therefore, among all respondents, 103 (44.4%) saw a male physician more than 50% of the time. In contrast, 56 (24.1%) reported seeing female physicians 100% of the time and another 43 (18.5%) reported seeing female physicians more than 50% of the time. Thus, among all respondents, 99 (42.7%) saw a female physician more than 50% of the time.
Of the 67 women who chose (item 19) to see a male 100% of the time, 11 (17.7%) believe female physicians are more understanding of female issues (item 30d). In addition, 72 (75%) of women who believe female physicians are more understanding (item 30d) indicated that gender was not important when selecting an obstetrician-gynecologist.
When asked which qualities they look for when choosing obstetrician-gynecologists (items 32, 33, and 34), 96% of patients selected experience; 92.4%, knowledge; and 86%, ability (Table 6). Only 15.7% of respondents claimed physician gender played any role when they were choosing providers (items 32, 33, and 34), which was not statistically different from the 12% who considered physician age (items 31, 32, and 33) when selecting a provider (z=0.48).
Similarly, when respondents were asked to rank the top three most important qualities they considered when choosing obstetrician-gynecologists (items 33 and 34), only 6.1% selected physician gender (Table 6, part 2).
In this study, 91 (40.8%) of patients stated that they usually do not have a choice as to the gender of their obstetrician-gynecologists (item 19). This lack of choice may be because all the physicians in the practice of their choice are of the same gender or because these patients are arbitrarily assigned to the next available provider. Among the 91 patients who reported usually not having a choice in selecting the gender of their obstetrician-gynecologist (item 19), 73 responded to the follow-up question asking if they would like to have a choice (item 20). Of the 73 participants responding to this follow-up question, 38 (52.1%) answered Yes and 35 (47.9%) answered No. Interestingly, 38.5% of patients who are not given a choice in selecting their obstetrician-gynecologists (item 19) state that the ability to choose their own providers (item 20) is of minor importance to them.
Patients who were able to select their obstetrician-gynecologists, however, were significantly more satisfied (item 22) than those who were not able to choose (item 19) (F(1,215)=4.54, P<.05). Despite these results, patients who received care from a female provider during their last visit (item 21) were not significantly more satisfied (item 22) with their care than those who saw a male provider (item 21) (F(2,241) =1.05).
When further questioned about their preferences (or lack thereof) regarding physician gender (eg, personal embarrassment [item 30a], comfort [item 30b], provider sympathy [item 30c], knowledge [item 30f], and bedside manner [item 30i]), the majority of patients indicated that the physician's gender did not matter to them.
In a subgroup analysis of patient age and race as well as income and education levels, there was no significant effect on patient gender bias (item 30g). Patient age (item 1), however, was significantly associated with patients' perceived levels of comfort during pelvic examinations (item 30b) (F(2,242)=9.02, P<.001). More specifically, patients who reported a greater level of comfort during pelvic examinations provided by male obstetrician-gynecologists were significantly older (mean age, 42.8 years) than patients who reported greater levels of comfort while women were providing pelvic examinations (mean age, 33.7 years) (t(96)=2.16, P<.05). Respondents who specified no gender preference for their obstetrician-gynecologists while they were undergoing pelvic examinations (item 26) (mean age, 42.4 years) were significantly older than respondents preferring female physicians (t(230)=4.19, P<.001).
Patient race was also significantly related to perceived comfort levels during pelvic examinations (item 30b) (2(8)=15.45, P<.05), with white respondents being more likely to have no gender preference in comparison with black and Hispanic women. Regardless of the subgroup analyzed, however, at least half of the patients were willing to see male obstetrician-gynecologists.
Comment
It has been proposed that the number of men applying to obstetrics and gynecology residency programs is decreasing because of a fear of being unable to secure employment after graduation and residency training. Although a few recent studies9–11 have suggested that patients seeking obstetric and gynecologic care prefer to have women as their caregivers in this role, the impact of these studies is limited by small sample sizes, biased populations, and a failure within the study design to analyze the importance of physician gender in patients' selection of physicians and in their satisfaction levels. Chandler et al9 found that 52% of patients preferred women, 44% had no preference, and 4% preferred men. Nevertheless, in their discussion, they point out that 93% of survey respondents believed that physician reputation and personal experience were the most important factors in choosing on obstetrician-gynecologist. However, Chandler's study had two considerable limitations: (1) it was distributed only to military employees, making the results difficult to generalize; and (2) researchers did not seek to determine whether patients' stated gender preferences for physicians providing their care influenced their physician selection.
A recent study by Howell et al12 demonstrated that a majority of patients did not prefer a female obstetrician. Despite the study's small sample size and their unique subject enrollment techniques (ie, selecting only from obstetrics patients who had recent positive experiences with their physicians), their findings concurred with those of Chandler et al9 in that both studies found that physician gender was less important to patients than other physician characteristics.
In 2001, men still composed the majority of the obstetric physician and gynecologist workforce at 61% (Table 1).13,14 Because of this majority, it is logical that there will continue to be a demand for female providers, as a more even balance between men and women continues to develop. Therefore, the pertinent question becomes: What is the appropriate balance of men and women in obstetrics and gynecology And does the development of gender balance correlate with a lack of demand for male providers
Much has been written about gender differences in obstetrician-gynecologists,2–4,8,9,15–20 the projected supply of men and women in this specialty practice field,2,21 and the potential implications of a shift in gender distribution among providers.22 A literature review, however, found no studies to date addressing whether one isolated factor—namely, physician gender—bears any correlation with their selection by patients.
Although the practice of obstetrics and gynecology still has more male than female providers, the number of women in this field has been growing steadily for many years.1,2 If current trends continue, it is estimated that women will soon outnumber men in the field of obstetrics and gynecology, and a paucity of men will be in such training programs.2 Given the popular belief that most women prefer same-gender obstetrician-gynecologists,8 the common conclusion conveyed to many medical students is that it may be difficult for male obstetrician-gynecologists to secure employment in the future.8 If a majority of patients prefer to seek care from women, then the current trend should be encouraged; if it is not true, however, we may experience an unnecessary demographic "shortage" of men in obstetrics and gynecology.
With male obstetrician-gynecologists still outnumbering females by 3 to 2 in 2001,14 the demand for female physicians is readily apparent. However, the gradual influx of women into the field (Table 1) has lead to a common misinterpretation, namely that there is no longer a need for qualified male physicians in this medical specialty. In fact, a small pilot survey conducted simultaneously indicated that most obstetrics and gynecology department chairpersons believe that the majority of patients prefer to see women for care (P.F. Schnatz, DO, unpublished data, 2001). The results of the present study demonstrate that the majority of women surveyed (72.5%) are satisfied with obstetrician-gynecologists of either gender or prefer to see a male provider. Only 14.7% of respondents believe that women are better obstetrician-gynecologists.
As noted, the majority of patients indicate no gender preference in their obstetrician-gynecologists. Moreover, this finding remained unchanged throughout all the subgroups analyzed. Only 33.5% of patients surveyed revealed gender bias when queried regarding specific medical procedures, physician attributes, and their personal opinions. Among these women, four out of five had biases in favor of female providers. However, the gender bias of these patients did not dictate their final selection of physicians for their own care. More women with a stated gender preference had, in fact, seen a male obstetrician-gynecologist for their most recent physician encounter.
Of respondents who chose their own healthcare providers, 56.5% selected men, whereas 46.2% selected women. This finding, combined with responses regarding patients' perceptions of important physician qualities, strongly supports the hypothesis of this study, that physician gender is a minor factor to patients selecting obstetrician-gynecologists. Although one might suggest that patients who prefer women as their obstetrician-gynecologists might seek the care of men merely for purposes of expedience and convenience, the fact that patient satisfaction levels vis-à-vis physician gender was unchanged argues against this hypothesis.
If gender bias (or lack thereof) were the most important factor in physician selection for patients seeking obstetric and gynecologic care, approximately 6% of patients would seek care only from men, 27%, only from women, and the remainder, who indicate no gender preference, would be divided randomly between providers of both sexes. This theoretical demand would result in a 60% to 40% demand in favor of women as providers of obstetric and gynecologic care. The results of the present study, however, demonstrate that many patients who prefer that their obstetrician-gynecologists are women actually receive their obstetric and gynecologic care from male providers.
Because the qualities important to patients can be found in both men and women in the practice of obstetrics and gynecology, patient demand for obstetrician-gynecologists can easily be satisfied with an equal distribution between the sexes. According to the results of this survey, patients desire that the specialty be composed of well-qualified physicians, whether male or female.
Instead of asking if there will be a role for men in this specialty practice in the future, perhaps physicians of both sexes should ask, "What qualities do our patients most appreciate" and "What skills can I acquire to become the best physician I can for my future patients"
It is important for people entering this medical subspecialty to realize there will always be some patients with a definite gender bias. The findings of the present study are extremely important for men in medical school who might otherwise be discouraged from entering obstetrics and gynecology for fear of a lack of employment opportunities.
Conclusion
Based on the data reported in this study, an equal distribution of male and female obstetrics and gynecologic providers is clearly well justified. Obstetrician-gynecologists who are qualified, reputable, compassionate, and are viewed by their patients as being knowledgeable, experienced, and personable are in demand. The sex of the physician is of minor importance to his or her patients when compared to these other characteristics.
Instead of promoting a specific gender as more qualified (or unqualified) for certain medical specialties, colleges and schools of medicine should fully support any candidates who exhibit the personal and professional qualities that are most important to patients.
The continued encouragement and active recruitment of interested, motivated, and qualified men who are called to enter the practice of obstetrics and gynecology will result in an optimal balance—and an equal distribution of men and women in this specialty field.
Acknowledgment
This study was conducted through the Department of Obstetrics and Gynecology at Hartford Hospital and the University of Connecticut with the support and approval of the University of Connecticut General Clinical Research Center (GCRC) and a research grant from the National Institutes of Health (#M01RR06192).
The authors thank the physicians and staff at all 13 survey study sites for their help with study recruitment and data gathering. The authors also thank Theresa George for her assistance with data entry, and Carlos Holden for his assistance with translation. Finally, the authors gratefully acknowledge the following individuals for their assistance in the preparation of this manuscript: Stephen Curry, MD; John F. Greene, MD; David M. O'Sullivan; J. David Schnatz, MD; and Susan R. Schnatz, RN.
the Johns Hopkins University School of Medicine (Johnson) in Baltimore, Md; the University of Connecticut School of Medicine (Schnatz, Kelsey, Ohannessian) in Farmington, Conn; and Hartford Hospital (Schnatz) and Saint Francis Hospital (Kelsey), both in Hartford, Conn. Dr Ohannessian is now in the Department of Individual Family Studies at the University of Delaware in Newark.
References
1. AAMC [Association of American Medical Colleges] Data Book: Statistical Information Related to Medical Education. Association of American Medical Colleges: Washington DC; l997. Tables B7–B8.
2. Jacoby I, Meyer GS, Haffner W, Cheng EY, Potter AL, Pearse WH. Modeling the future workforce of obstetrics and gynecology. Obstet Gynecol. 1998;92:450 –456.
3. Neubardt SB, moderator. Women's liberation and the male gynecologist [Roundtable]. Med Aspect Hum Sex.1974; 8:158 –199.
4. Haar E, Halitsky V, Stricker G. Factors related to the preference for a female gynecologist. Med Care.1975; 13:782 –790.
5. Lund JD, Rohrer JE, Goldfarb S. Patient gender preferences in a large military teaching hospital. Obstet Gynecol.2005; 105:747 –750.
6. Fisher WA, Bryan A, Dervaitis KL, Silcox J, Kohn H. It ain't necessarily so: most women do not strongly prefer female obstetrician-gynaecologists. J Obstet Gynaecol Can.2002; 24:885 –888.
7. Howell EA, Gardiner B, Concato J. Do women prefer female obstetricians Obstet Gynecol.2002; 99:1031 –1035.
8. Lyon DS. Where have all the young men gone Keeping men in obstetrics and gynecology. Obstet Gynecol.1997; 90(4 Pt 1):634 –636.
9. Chandler P, Chandler C, Dabbs M. Provider gender preference in obstetrics and gynecology: a military population. Mil Med. 2000;165:938 –940.
10. Plunkett BA, Kohli P, Milad MP. The importance of physician gender in the selection of an obstetrician or a gynecologist. Am J Obstet Gynecol. 2002;186:926 –928.
11. Schmittdiel J, Selby JV, Grumbach K, Quesenberry CP Jr. Women's provider preferences for basic gynecology care in a large health maintenance organization. J Womens Health Gend Based Med.1999; 8:825 –833.
12. Howell EA, Gardiner B, Concato J. Do women prefer female obstetricians Obstet Gynecol.2002; 99:1031 –1035.
13. American Medical Association. Membership. Physician Characteristics and Distribution in the US. Chicago, Ill: American Medical Association; 1998.
14. American College of Obstetrics and Gynecology. Membership. Washington DC, American College of Obstetrics and Gynecology;2001 .
15. Roter DL, Geller G, Bernhardt BA, Larson SM, Doksum T. Effects of obstetrician gender on communication and patient satisfaction. Obstet Gynecol.1999; 93(5 Pt 1):635 –641.
16. Kelly JM. Sex preference in patient selection of a family physician. J Fam Pract.1980; 11:427 –433.
17. Moettus A, Sklar D, Tandberg D. The effect of physician gender on women's perceived pain and embarrassment during pelvic examination. Am J Emerg Med.1999; 17:635 –637.
18. van Dulmen A, Bensing J. Gender differences in gynecologist communication. Women Health.2000; 30:49 –61.
19. Kapphahn CJ, Wilson K, Klein J. Adolescent girls' and boys' preferences for provider gender and confidentiality in their health care. J Adolesc Health.1999; 25:131 –142.
20. Engstrom S, Madlon-Kay DJ. Choosing a family physician. What do patients want to know Minn Med.1998; 81:22 –26.
21. Pearse WH, Gant NF, Hagner AP. Workforce projections for subspecialists in obstetrics and gynecology. Obstet Gynecol. 2000;95:312 –314.
22. Pearse WH, Haffner WH, Primack A. Effect of gender on the obstetric-gynecologic work force. Obstet Gynecol.2001; 97(5 Pt 1):794 –797.(Amy M. Johnson, MD; Peter)
Methods: A self-administered survey was designed for and distributed to patients (N=264) in 13 obstetrics and gynecology waiting rooms in Connecticut. The survey was used to determine whether there were any patient preferences with regard to the gender of physicians providing obstetric and gynecologic care within this population. In addition, the rationale for any preferences was analyzed.
Results: The majority of patients (66.6%) had no gender bias when selecting an obstetrician-gynecologist, and an even larger majority (198, 80.8%) felt that physician gender does not influence quality of care. There was no statistical difference in patient satisfaction based on physician sex. Respondents self-reporting gender bias rarely selected obstetrician-gynecologists based solely on this factor and frequently choose physicians of the sex that was not their indicated preference, suggesting that several factors other than gender preference are more important in physician selection.
Conclusions: The majority of women surveyed did not select their obstetrician-gynecologists based solely on physician gender. Although a small percentage of survey respondents did indicate a gender preference, it rarely influenced physician selection and was only a minor consideration when compared with other desirable physician attributes.
In 1970, only 9% of enrolled medical students in the United States were women.1 From 1978 to the present, the percentage of women pursuing specialty practice in obstetrics and gynecology has more than quadrupled, leaving men in this specialty practice area in the minority (Table 1). As noted in Table 1, as of 2001, women composed 71.8% of obstetrics and gynecology residents (unpublished data, W.H. Pearse, MD, 2001). It is estimated that by the year 2014, women will outnumber men in the practice of obstetrics and gynecology.2
In 1974, an article by Neubardt, "Women's Liberation and the Male Gynecologist," discussed women's dissatisfaction with the medical profession and the need for female gynecologists.3
One year later, at a time when more than 83% of obstetrics and gynecology residents were men, Haar et al4 published a survey showing 33.9% of patients preferred women as their gynecologists. This 1975 article emphasized the "importance of increasing the number of women physicians...in order to provide a true alternative for women patients."4 While highlighting the finding that many women preferred same-gender physicians, Haar et al4 failed to point out that more than 60% of their respondents either preferred male physicians or specified no gender preference.
More recent studies5–7 have shown that there is a continued need for gender equality in the field of obstetrics and gynecology. After surveying 1544 obstetric-gynecology patients in a large California military hospital, Lund et al5 found that 60% of respondents either had no gender preferences or preferred a male provider. A Canadian study (N=405)6 demonstrated that 75% of patients surveyed reported no "strong preference concerning the gender of their obstetrician-gynecologist." This same 2002 study showed that 4% of respondents preferred male providers, while 21% had a preference for female providers.6 In a 2002 survey of postpartum patients (N=67), Howell et al7 reported similar findings for gender preferences. Overall, 34% of respondents preferred a female obstetrician, 7% a male obstetrician, and 58% expressed no gender preference.7
If the growing belief that patients primarily prefer women obstetrician-gynecologists8 were evidence-based, then the shift the discipline has experienced in the gender balance of physicians pursuing training in obstetrics and gynecology would be justified.1,2 However, current research does not support this belief.
We set out to answer the question: "Is there a role for men in the future practice of obstetrics and gynecology" and, if so, "What is the desired balance of men versus women in this specialty field"
To answer these questions, it was necessary to determine (1) patients' gender preferences for their obstetrician-gynecologists, (2) whether any gender preference among patients correlates with physician selection, and (3) if physician gender affects patient satisfaction.
Methods
The institutional review boards at the University of Connecticut School of Medicine (Farmington), Hartford Hospital (Conn), and Saint Francis Hospital and Medical Center (Hartford, Conn) approved all aspects of the study. A small pilot study was conducted in July 2001, after institutional review board approval, to test the validity of the survey instrument.
In August and September 2001, a self-administered 43-item survey that also gathered basic demographic data was distributed to patients in obstetrics and gynecology waiting rooms throughout the Hartford, Conn, area (Figure). Thirteen obstetrician-gynecologists' offices were contacted and all agreed to participate in the study. Demographic data was also collected regarding the 13 study sites.
To achieve adequate diversity in study results, urban and suburban patients visiting office practices or a clinic were surveyed; five general obstetrics and gynecology practices, one maternal fetal medicine practice, one urogynecologic practice, two reproductive endocrinology and infertility practices, three gynecologic oncology practices, and one general-residency–based obstetrics and gynecology clinic participated in the study.
On scheduled office days at the 13 study sites, patients who were at least 16 years of age were offered entry into the study. Patients were asked whether they would be willing to fill out an anonymous, standardized survey addressing how they decided on the provider for their most recent general obstetrics and gynecology visit (ie, not the current visit).
Surveys were consistently distributed by trained research personnel. The surveys, written in English and Spanish to allow for variations in primary or preferred language, typically took 10 minutes to complete while patients were waiting for their respective appointments.
The survey addressed the frequency with which patients received the care of female or male obstetrician-gynecologists (item 18). In addition, the survey asked whether each patient had the opportunity to choose the obstetrician-gynecologist who currently treats her (item 19)—and, if not, would they have liked the ability to make that choice for themselves (item 20). Respondents were also queried regarding their level of satisfaction regarding their most recent healthcare encounter (item 22). Patients also were asked to select and rank physician qualities that they consider when choosing an obstetrics and gynecology provider (items 32 through 35).
In addressing patient gender preferences regarding their obstetrician-gynecologists, we focused on several specific aspects of obstetric and gynecologic care, including pelvic examinations (item 26), obstetric care (item 27), health maintenance (item 28), and gynecologic surgery (item 29).
Before the study, a power analysis was performed by one of the investigators (C.M.O.) to calculate the number of respondents needed to demonstrate statistical significance for gender preference among physician qualities in selecting an obstetrician-gynecologist; the power analysis determined that 50 patients would need to respond to the survey. Using this figure, the confidence interval for gender preference would be on the order of 0.03. We decided to survey over 200 patients to improve the observed frequencies within subgroups.
Results
Although the number of women (54, 66.6%) providing obstetric and/or gynecologic care at the 13 survey sites was clearly predominant over the number of men (27, 33.1%) (Table 2), the disparity was a result of the increased number of female obstetrics and gynecology residents in the clinic setting.1,2 The female-to-male gender distribution in the private practice offices, however, was nearly balanced at 17 (48.6%) women and 18 (51.4%) men.
At the 13 survey sites, 272 patients were asked to participate in this survey-based study. Of these, 8 (2.9%) women declined to participate in the study because of "lack of time." The remaining patients (N=264) agreed to participate in the study, provided informed written consent, and completed the survey.
The survey was available in English and Spanish versions. An international translation service was also available to allow patients to take the survey in other languages, but this service was never requested by patients asked to complete the survey.
After data-collection was complete, survey results were tabulated for each of the 43 survey items. The observed percentages were described and means were calculated with 95% confidence intervals. Chi-square (2) analyses were used to compare across responding subgroups with the level of significance set at .05. Fisher's z-tests were used to examine differences in response percentages and analysis of variance models were conducted to examine differences in means.
Demographic information collected included patient age, ethnicity, marital status, number of children (if any), highest level of education attained, employment status, annual household income, healthcare insurance status, religious identification, and primary language spoken (Table 3). A diverse patient population was achieved, including a wide range of patient ages, a broad racial distribution, and various socioeconomic backgrounds (Table 3).
To establish a composite score, we averaged the responses to survey items 25 through 30 to determine that 5.9% of women surveyed preferred men to be their obstetrician-gynecologists, 27.6% preferred women, and 66.6% indicated that they had no preference regarding the sex of their obstetrician-gynecologists (Table 4 and Table 5).
When patients were asked specifically whether men or women are better obstetrician-gynecologists (item 30g), 198 (80.8%) responded that gender does not matter (Table 5). For patients who self-reported a gender bias, a cross analysis showed that preference did not correlate with physician selection.
Despite the fact that the majority of obstetrician-gynecologists who took part in this study at the 13 study sites were women, 17 (31.5%) of patients who had a choice regarding physician selection (item 19), and who stated they feel women are more understanding (item 30d), obtained care from men at their most recent obstetric-gynecologic care visit (item 21), 36 (66.7%) obtained care from women, and 1 (1.9%) respondent was unable to remember the sex of the attending physician (item 21). These findings suggest that factors other than physician sex are more important to patients when they select obstetrician-gynecologists.
Among the 232 (87.9%) women who answered survey item 18, 67 (28.9%) reported seeing male physicians 100% of the time and 36 (15.5%) reported seeing male physicians more than 50% of the time. Therefore, among all respondents, 103 (44.4%) saw a male physician more than 50% of the time. In contrast, 56 (24.1%) reported seeing female physicians 100% of the time and another 43 (18.5%) reported seeing female physicians more than 50% of the time. Thus, among all respondents, 99 (42.7%) saw a female physician more than 50% of the time.
Of the 67 women who chose (item 19) to see a male 100% of the time, 11 (17.7%) believe female physicians are more understanding of female issues (item 30d). In addition, 72 (75%) of women who believe female physicians are more understanding (item 30d) indicated that gender was not important when selecting an obstetrician-gynecologist.
When asked which qualities they look for when choosing obstetrician-gynecologists (items 32, 33, and 34), 96% of patients selected experience; 92.4%, knowledge; and 86%, ability (Table 6). Only 15.7% of respondents claimed physician gender played any role when they were choosing providers (items 32, 33, and 34), which was not statistically different from the 12% who considered physician age (items 31, 32, and 33) when selecting a provider (z=0.48).
Similarly, when respondents were asked to rank the top three most important qualities they considered when choosing obstetrician-gynecologists (items 33 and 34), only 6.1% selected physician gender (Table 6, part 2).
In this study, 91 (40.8%) of patients stated that they usually do not have a choice as to the gender of their obstetrician-gynecologists (item 19). This lack of choice may be because all the physicians in the practice of their choice are of the same gender or because these patients are arbitrarily assigned to the next available provider. Among the 91 patients who reported usually not having a choice in selecting the gender of their obstetrician-gynecologist (item 19), 73 responded to the follow-up question asking if they would like to have a choice (item 20). Of the 73 participants responding to this follow-up question, 38 (52.1%) answered Yes and 35 (47.9%) answered No. Interestingly, 38.5% of patients who are not given a choice in selecting their obstetrician-gynecologists (item 19) state that the ability to choose their own providers (item 20) is of minor importance to them.
Patients who were able to select their obstetrician-gynecologists, however, were significantly more satisfied (item 22) than those who were not able to choose (item 19) (F(1,215)=4.54, P<.05). Despite these results, patients who received care from a female provider during their last visit (item 21) were not significantly more satisfied (item 22) with their care than those who saw a male provider (item 21) (F(2,241) =1.05).
When further questioned about their preferences (or lack thereof) regarding physician gender (eg, personal embarrassment [item 30a], comfort [item 30b], provider sympathy [item 30c], knowledge [item 30f], and bedside manner [item 30i]), the majority of patients indicated that the physician's gender did not matter to them.
In a subgroup analysis of patient age and race as well as income and education levels, there was no significant effect on patient gender bias (item 30g). Patient age (item 1), however, was significantly associated with patients' perceived levels of comfort during pelvic examinations (item 30b) (F(2,242)=9.02, P<.001). More specifically, patients who reported a greater level of comfort during pelvic examinations provided by male obstetrician-gynecologists were significantly older (mean age, 42.8 years) than patients who reported greater levels of comfort while women were providing pelvic examinations (mean age, 33.7 years) (t(96)=2.16, P<.05). Respondents who specified no gender preference for their obstetrician-gynecologists while they were undergoing pelvic examinations (item 26) (mean age, 42.4 years) were significantly older than respondents preferring female physicians (t(230)=4.19, P<.001).
Patient race was also significantly related to perceived comfort levels during pelvic examinations (item 30b) (2(8)=15.45, P<.05), with white respondents being more likely to have no gender preference in comparison with black and Hispanic women. Regardless of the subgroup analyzed, however, at least half of the patients were willing to see male obstetrician-gynecologists.
Comment
It has been proposed that the number of men applying to obstetrics and gynecology residency programs is decreasing because of a fear of being unable to secure employment after graduation and residency training. Although a few recent studies9–11 have suggested that patients seeking obstetric and gynecologic care prefer to have women as their caregivers in this role, the impact of these studies is limited by small sample sizes, biased populations, and a failure within the study design to analyze the importance of physician gender in patients' selection of physicians and in their satisfaction levels. Chandler et al9 found that 52% of patients preferred women, 44% had no preference, and 4% preferred men. Nevertheless, in their discussion, they point out that 93% of survey respondents believed that physician reputation and personal experience were the most important factors in choosing on obstetrician-gynecologist. However, Chandler's study had two considerable limitations: (1) it was distributed only to military employees, making the results difficult to generalize; and (2) researchers did not seek to determine whether patients' stated gender preferences for physicians providing their care influenced their physician selection.
A recent study by Howell et al12 demonstrated that a majority of patients did not prefer a female obstetrician. Despite the study's small sample size and their unique subject enrollment techniques (ie, selecting only from obstetrics patients who had recent positive experiences with their physicians), their findings concurred with those of Chandler et al9 in that both studies found that physician gender was less important to patients than other physician characteristics.
In 2001, men still composed the majority of the obstetric physician and gynecologist workforce at 61% (Table 1).13,14 Because of this majority, it is logical that there will continue to be a demand for female providers, as a more even balance between men and women continues to develop. Therefore, the pertinent question becomes: What is the appropriate balance of men and women in obstetrics and gynecology And does the development of gender balance correlate with a lack of demand for male providers
Much has been written about gender differences in obstetrician-gynecologists,2–4,8,9,15–20 the projected supply of men and women in this specialty practice field,2,21 and the potential implications of a shift in gender distribution among providers.22 A literature review, however, found no studies to date addressing whether one isolated factor—namely, physician gender—bears any correlation with their selection by patients.
Although the practice of obstetrics and gynecology still has more male than female providers, the number of women in this field has been growing steadily for many years.1,2 If current trends continue, it is estimated that women will soon outnumber men in the field of obstetrics and gynecology, and a paucity of men will be in such training programs.2 Given the popular belief that most women prefer same-gender obstetrician-gynecologists,8 the common conclusion conveyed to many medical students is that it may be difficult for male obstetrician-gynecologists to secure employment in the future.8 If a majority of patients prefer to seek care from women, then the current trend should be encouraged; if it is not true, however, we may experience an unnecessary demographic "shortage" of men in obstetrics and gynecology.
With male obstetrician-gynecologists still outnumbering females by 3 to 2 in 2001,14 the demand for female physicians is readily apparent. However, the gradual influx of women into the field (Table 1) has lead to a common misinterpretation, namely that there is no longer a need for qualified male physicians in this medical specialty. In fact, a small pilot survey conducted simultaneously indicated that most obstetrics and gynecology department chairpersons believe that the majority of patients prefer to see women for care (P.F. Schnatz, DO, unpublished data, 2001). The results of the present study demonstrate that the majority of women surveyed (72.5%) are satisfied with obstetrician-gynecologists of either gender or prefer to see a male provider. Only 14.7% of respondents believe that women are better obstetrician-gynecologists.
As noted, the majority of patients indicate no gender preference in their obstetrician-gynecologists. Moreover, this finding remained unchanged throughout all the subgroups analyzed. Only 33.5% of patients surveyed revealed gender bias when queried regarding specific medical procedures, physician attributes, and their personal opinions. Among these women, four out of five had biases in favor of female providers. However, the gender bias of these patients did not dictate their final selection of physicians for their own care. More women with a stated gender preference had, in fact, seen a male obstetrician-gynecologist for their most recent physician encounter.
Of respondents who chose their own healthcare providers, 56.5% selected men, whereas 46.2% selected women. This finding, combined with responses regarding patients' perceptions of important physician qualities, strongly supports the hypothesis of this study, that physician gender is a minor factor to patients selecting obstetrician-gynecologists. Although one might suggest that patients who prefer women as their obstetrician-gynecologists might seek the care of men merely for purposes of expedience and convenience, the fact that patient satisfaction levels vis-à-vis physician gender was unchanged argues against this hypothesis.
If gender bias (or lack thereof) were the most important factor in physician selection for patients seeking obstetric and gynecologic care, approximately 6% of patients would seek care only from men, 27%, only from women, and the remainder, who indicate no gender preference, would be divided randomly between providers of both sexes. This theoretical demand would result in a 60% to 40% demand in favor of women as providers of obstetric and gynecologic care. The results of the present study, however, demonstrate that many patients who prefer that their obstetrician-gynecologists are women actually receive their obstetric and gynecologic care from male providers.
Because the qualities important to patients can be found in both men and women in the practice of obstetrics and gynecology, patient demand for obstetrician-gynecologists can easily be satisfied with an equal distribution between the sexes. According to the results of this survey, patients desire that the specialty be composed of well-qualified physicians, whether male or female.
Instead of asking if there will be a role for men in this specialty practice in the future, perhaps physicians of both sexes should ask, "What qualities do our patients most appreciate" and "What skills can I acquire to become the best physician I can for my future patients"
It is important for people entering this medical subspecialty to realize there will always be some patients with a definite gender bias. The findings of the present study are extremely important for men in medical school who might otherwise be discouraged from entering obstetrics and gynecology for fear of a lack of employment opportunities.
Conclusion
Based on the data reported in this study, an equal distribution of male and female obstetrics and gynecologic providers is clearly well justified. Obstetrician-gynecologists who are qualified, reputable, compassionate, and are viewed by their patients as being knowledgeable, experienced, and personable are in demand. The sex of the physician is of minor importance to his or her patients when compared to these other characteristics.
Instead of promoting a specific gender as more qualified (or unqualified) for certain medical specialties, colleges and schools of medicine should fully support any candidates who exhibit the personal and professional qualities that are most important to patients.
The continued encouragement and active recruitment of interested, motivated, and qualified men who are called to enter the practice of obstetrics and gynecology will result in an optimal balance—and an equal distribution of men and women in this specialty field.
Acknowledgment
This study was conducted through the Department of Obstetrics and Gynecology at Hartford Hospital and the University of Connecticut with the support and approval of the University of Connecticut General Clinical Research Center (GCRC) and a research grant from the National Institutes of Health (#M01RR06192).
The authors thank the physicians and staff at all 13 survey study sites for their help with study recruitment and data gathering. The authors also thank Theresa George for her assistance with data entry, and Carlos Holden for his assistance with translation. Finally, the authors gratefully acknowledge the following individuals for their assistance in the preparation of this manuscript: Stephen Curry, MD; John F. Greene, MD; David M. O'Sullivan; J. David Schnatz, MD; and Susan R. Schnatz, RN.
the Johns Hopkins University School of Medicine (Johnson) in Baltimore, Md; the University of Connecticut School of Medicine (Schnatz, Kelsey, Ohannessian) in Farmington, Conn; and Hartford Hospital (Schnatz) and Saint Francis Hospital (Kelsey), both in Hartford, Conn. Dr Ohannessian is now in the Department of Individual Family Studies at the University of Delaware in Newark.
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