Physician Communication Style
and Patient Satisfaction: The
Importance of Physician Gender
Prof. Dr. Marianne Schmid Mast
University of Neuchâtel, Switzerland
Overview
Physician gender
Physician communication style:
• Manipulated on emotionality
and dominance
• Nonverbal behavior measured
Patient satisfaction
Patient gender
Goal
Investigate how the communication style of
women and men doctors affect patients
(patient satisfaction)
Two Dimensions of Physician
Communication

Emotionality: Physician’s taking on the
perspective of the patient and expressing
interest, concern, and empathy

Dominance: Physician’s control over
information and services, the visit agenda,
goals, and treatment decisions
=> Patient-centered: emotionality high and
dominance low (Krupat et al., 2000)
Gender Difference in
Communication Style
Women doctors communicate more emotionally
and less dominantly than men doctors
(e.g., Roter, Hall, & Aoki, 2002)
Implications of Physician Style

Dominance in physician communication is
related to low patient satisfaction (Buller & Buller,
1987)

Patient outcome is more positive when
physicians communicate more emotionally
(BenSira, 1980; Cohen-Cole, 1991; Roter et al., 2006; Williams, Weinman, &
Dale, 1998)
=> High physician emotionality and low
dominance are both related to higher patient
satisfaction
The Paradox!

No “net” difference in patient satisfaction
with women and men doctors (Hall, Irish, &
Roter, 1994)

How to explain this paradox? Maybe the
same physician communication style
adopted by a woman or man doctor
affects patients differently
Research Question
How does gender and physician
communication style (emotionality and
dominance) affect patient satisfaction?
The Challenge

Problem: In real-world physician-patient
interactions, physician gender and physician
communication style are confounded

Solution: Vary physician gender and physician
communication style independently of each
other and measure patient satisfaction

How?
Experimental Approach

Patients see a female or male doctor who
communicates either high or low on
emotionality and high or low on dominance

Physician is a virtual person ...
Method


Participants: 167 students (87 women, 80
men), age = 26.5
Role play a patient: symptoms and reason for
visit:
Recurrent headaches, second visit, goal: discuss lab results
from last visit and decide on treatment


Interaction with virtual physician (15 min)
Questionnaires: perceived emotionality,
perceived dominance, patient satisfaction
(Schmid Mast, Hall, Klöckner, & Choi, 2008)
Man (virtual) doctor
Woman (virtual) doctor
Communication with Virtual
Doctor

16 sequences (opening, data gathering, patient
education and counseling, and decision
making)

Stack of 16 cards, each with hints, e.g., “Your
headaches have become more severe during
the past two weeks”

Virtual physician talks on key command
Manipulation of Physician
Communication Style
Four different physician communication styles
High
Low
emotionality (E+)
emotionality (E-)
Hi, nice to see
you.
Hi, please
come in.
D+ E+
D+ E-
D- E+
D- E-
High dominance (D+)
How is your
headache since
I last saw you?
Low dominance (D-)
What can I do
for you today?
Manipulation Check

Perceived physician emotionality

6 Items on emotionality, e.g. friendly, nice

Reliability: Cronbach‘s Alpha = .86

Physicians with a high emotional communication
style were perceived as more emotional than
physicians with a low emotional communication
style, t(164) = 4.65, p < .0001.
Manipulation Check

Perceived physician dominance

3 Items on dominance, e.g. dominant, assertive

Reliability: Cronbach‘s Alpha = .82

Physicians with a high dominant communication
style were perceived as more dominant than
physicians with a low dominant communication style,
t(164) = 4.87, p < .0001.
Patient Satisfaction
Questionnaire

36 items, “I am very satisfied with the way the
physician treated me”

Reliability: Cronbach‘s Alpha = .96

Control variables: age, health status,
experience with doctors, perceived realism of
medical visit, felt awkwardness in experimental
situation
Data Analysis

2 (physician gender)
X 2 (emotionality in physician communication)
X 2 (dominance in physician communication)
X 2 (patent gender)
ANOVA

Dependent variable:
Patient satisfaction
Results
Fe m ale p hys ician - m ale p at ie n t
4 .0
3 .8
3 .8
3 .6
3 .6
Pa t i e nt s a t is fa ct ion
Pa t i e nt s a t is fa ct ion
Male p hys icia n - m ale p at ie n t
4 .0
3 .4
3 .2
3 .0
2 .8
3 .4
3 .2
3 .0
2 .8
2 .6
2 .6
lo w e mo tion a lity
2 .4
lo w e mo tion a lity
h ig h e mo tio n a lity
lo w d o m in a nc e
2 .4
h ig h d o m in an ce
Male p hys icia n - fe m ale p a tien t
h ig h d o m in an ce
Fe m ale p hys ician - fe m ale p a tie n t
4 .0
4 .0
3 .8
3 .8
3 .6
3 .6
Pa t i e nt s a t is fa ct ion
Pa t i e nt s a t is fa ct ion
h ig h e mo tio n a lity
lo w d o m in a nc e
3 .4
3 .2
3 .0
2 .8
4-way interaction:
F(1, 151) = 5.32,
p = .022
3 .4
3 .2
3 .0
2 .8
2 .6
2 .6
lo w e mo tion a lity
2 .4
h ig h e mo tio n a lity
lo w d o m in a nc e
h ig h d o m in an ce
lo w e mo tion a lity
2 .4
h ig h e mo tio n a lity
lo w d o m in a nc e
h ig h d o m in an ce
Opposite-Gender Consultations
O pp os ite - ge n de r con s ulta tions
4 .0
Interaction effect:
F(1, 83) = 10.63,
p = .002
Medium level of
patient-centeredness
3 .8
Pa t i e nt s a t is fa ct ion
3 .6
(same if control variables
are taken into account)
3 .4
3 .2
3 .0
High patientcenteredness
2 .8
Low patientcenteredness
2 .6
lo w e mo tion a lity
2 .4
h ig h e mo tio n a lity
lo w d o m in a nc e
h ig h d o m in an ce
Summary of Opposite-Gender
Consultations




Low (D+E-) patient-centeredness entails low
patient satisfaction
High (D-E+) patient-centeredness entails low
patient satisfaction
Medium level of patent-centeredness (D+E+
and D-E-) entails high patient satisfaction
Why? Headaches is a common, everyday
symptom, which does not necessitate a
particularly patient-centered interaction style
Same-Gender Consultations
Fe m ale p hys ician - m ale p at ie n t
4 .0
3 .8
3 .8
3 .6
3 .6
Pa t i e nt s a t is fa ct ion
Pa t i e nt s a t is fa ct ion
Male p hys icia n - m ale p at ie n t
4 .0
3 .4
3 .2
3 .0
2 .8
3 .4
3 .2
3 .0
2 .8
2 .6
2 .6
lo w e mo tion a lity
2 .4
lo w e mo tion a lity
h ig h e mo tio n a lity
lo w d o m in a nc e
2 .4
h ig h d o m in an ce
Male p hys icia n - fe m ale p a tien t
h ig h d o m in an ce
Fe m ale p hys ician - fe m ale p a tie n t
4 .0
4 .0
3 .8
3 .8
3 .6
3 .6
Pa t i e nt s a t is fa ct ion
Pa t i e nt s a t is fa ct ion
h ig h e mo tio n a lity
lo w d o m in a nc e
3 .4
3 .2
3 .0
2 .8
3 .4
3 .2
3 .0
2 .8
2 .6
2 .6
lo w e mo tion a lity
2 .4
h ig h e mo tio n a lity
lo w d o m in a nc e
h ig h d o m in an ce
lo w e mo tion a lity
2 .4
h ig h e mo tio n a lity
lo w d o m in a nc e
h ig h d o m in an ce
Male Same-Gender
Consultations
Male p hys icia n - m ale p at ie n t
4 .0
3 .8
Pa t i e nt s a t is fa ct ion
3 .6
3 .4
3 .2
3 .0
2 .8
2 .6
lo w e mo tion a lity
2 .4
h ig h e mo tio n a lity
lo w d o m in a nc e
All F‘s < 1.15
h ig h d o m in an ce
Emotionality and
dominance in
physician
communication
style do not
affect patient
satisfaction
Female Same-Gender
Consultations
Fe m ale p hys ician - fe m ale p a tie n t
4 .0
Emotionality in
physician
communication
style affects
patient
satisfaction
3 .8
Pa t i e nt s a t is fa ct ion
3 .6
3 .4
3 .2
3 .0
2 .8
2 .6
lo w e mo tion a lity
2 .4
h ig h e mo tio n a lity
lo w d o m in a nc e
h ig h d o m in an ce
Main effect for emotionality: F(1, 38) = 22.43,
p = .0001
Summary and Interpretation of
Same-Gender Results

Among men: Emotionality and dominance in
physician communication style do not affect
patient satisfaction. Maybe another aspect would,
e.g. competence
Male patient: “I don’t care how emotional or dominant he is, I care
about whether he knows what he is doing!”

Among women: High emotionality in physician
communication style entails more patient
satisfaction than low emotionality: gender-role
congruent communication
Female patient: “Despite her (male) profession, I still want her to
be a woman!”
Implications for Practice



Physician education in communication skills is
important because it affects patient satisfaction
Especially for women physicians it might be
advisable to communicate in a gendercongruent manner (high emotionality)
For a physician, it is advantageous to adopt
different communication styles and to flexibly
use them according to patient gender (and
other patient characteristics…)
Overview
Physician gender
Physician communication style:
• Manipulated on emotionality
and dominance
• Nonverbal behavior measured
Patient satisfaction
Patient gender
Effects of Physician Nonverbal
Behavior on Patient Satisfaction
Physician nonverbal
behavior
Patient perception of
physician (e.g.,
satisfaction)
Effects of Physician Nonverbal
Behavior

Effects on patients

Increase patient satisfaction (DiMatteo, Hays, &
Prince, 1986)
Increase adherence (DiMatteo, Hays, & Prince, 1986)
 Improve health outcome (Ambady, Koo, Rosenthal, &

Winograd, 2002)

Effects on physicians

Reduce malpractice litigations (Ambady, Laplante,
Nguyen, et al., 2002)

Improve diagnosis (Bensing, Kerssens, & van der Pasch,
1995)
Patient Satisfaction and Physician
Nonverbal Behavior

Patient satisfaction related to physician
expressiveness

Less time reading medical chart, more
forward lean, more nodding, more
gestures, closer interpersonal distance,
more gazing (Hall, Harrigan, & Rosenthal, 1995)

Smiling, eye contact, forward body lean,
expressive tone of voice, expressive face,
gestures, etc. (Griffith, Wilson, Langer, & Haist, 2003)
Moderators of Physician Nonverbal
Behavior and Patient Satisfaction

Gender


M – M: physician interruptions negatively related to
satisfaction, F – F: physician interruptions
positively related to satisfaction (Hall, Irish, Roter,et al., 1994)
Severity or type of illness

Patient satisfaction related to physician’s emotional
expressiveness regardless of the type of problem (medical,
psychosocial, or counseling problem) (Griffith, Wilson, Langer, & Haist,
2003)



Age
Economic status
Personality
The Study
What are the effects of gender
on physicians’
nonverbal behavior correlates
of patient satisfaction?
(Schmid Mast, Hall, Klöckner, & Choi, 2008)
The Method
Analogue patients (163: 60 M, 103 F)
 11 different 2-min physician-patient
interactions on videotape
 Indicate satisfaction after each of the 11
interactions (1 = „not satisfied at all“ to 9
= „very satisfied“)

The 11 Target Physicians on Video
11 general practioners in their private
practice
 Patients were between 36 and 67 years
old
 Second minute and the third last minute
of the consultation

Nonverbal Behavior Correlates of
Patient Satisfaction

22 nonverbal behaviors




Speaking time, self-touch, gazing, interpersonal
distance, loudness of voice, smiling, gesturing...
including appearance such as formal clothing,
medical atmosphere, attractiveness
Coding reliability (mean r) .71 to .98
For each analogue patient: Correlation of
satisfaction with each of the behaviors across
11 targets (also separately across the female
and across the male physician targets)
Correlation Coefficients
1
2
3
4
5
6
7
8
9
10
11
Speaking
time
26
13
30
9
44
24
20
51
35
19 18
Satisfaction
3.5 4.6
2.5
7.1 6.9
4.4
3.8
1.2
3.1
6.8 8.2
For each analogue patient: Correlation coefficient
between satisfaction and speaking time
r = -.52
Analyses

2 (physician gender) X 2 (patient
gender) ANOVA for each of the
behavioral satisfaction correlates
Results
No significant participant gender main
effects
 No significant participant gender by
physician gender interaction effect (2
exceptions)
 Many significant physician gender main
effects

Female Physicians versus
Male Physicians
Physician behavior
Female
Male
p
physician physician
Speaking time
-.29
-.10
.05
Talking w/doing something else
-.23
.04
.001
(Patient speaking time)
.31
.09
.01
Gazing
.29
-.06
.001
Looking at medical chart
-.26
.15
.001
Distance
-.15
.13
.001
Forward lean
.27
-.24
.001
Body orientation toward patient
.14
-.13
.001
Female Physicians versus
Male Physicians
Physician behavior
Female
Male
p
physician physician
Self-touch
.23
-.12
.001
Expansiveness
-.15
.25
.001
Loudness of voice
-.33
.20
.001
Brow lowering
.31
-.01
.001
Medical atmosphere
.13
-.28
.001
Formal clothing
.30
.11
.02
Gesturing
-.15
.33
.001
Frowning
-.06
-.30
.01
Overview Female Physicians












Less speaking time
(More patient speaking time)
Less talking while doing something else
More gazing
Less looking at medical chart
Less interpersonal distance
Less expansiveness
Softer voice
More self-touch
More lowered eyebrows
More formal clothing
More medical atmosphere
Overview Female Physicians












Less speaking time
(More patient speaking time)
Less talking while doing something else
More gazing
Less looking at medical chart
Less interpersonal distance
Less expansiveness
Softer voice
More self-touch
More lowered eyebrows (concern)
More formal clothing
More medical atmosphere
Overview Male Physicians









More interpersonal distance
Less orientation toward patient
More looking at medical chart
More expansiveness
Less self-touch
Louder voice
More gesturing
Less medical atmosphere
Less frowning
Overview Male Physicians









More interpersonal distance
Less orientation toward patient
More looking at medical chart
More expansiveness
Less self-touch
Louder voice
More gesturing
Less medical atmosphere
Less frowning
Interpretation of Results

Female physicians



gender-role congruent nonverbal behavior is
related to more satisfaction
Environment is expected to convey competence
Male physicians

gender-role congruent nonverbal behavior
especially in the realm of interpersonal distance
(less oriented toward, more distant, more looking at chart,
is related to more satisfaction
Environment is expected not to be „medical“
expansive)

Conclusion

Physician communication training should take
physician characteristics (e.g., gender) into
account



Not one training fits all
Authenticity
Tailored communication

Personality: Affiliative patients adhere more to
phyiscians who show affiliative than non-affiliative
nonverbal behavior (Cousin & Schmid Mast, in prep.)
David Sipress, published in The New Yorker, September 4, 2000