He Said, She Said

In his self-help bestseller, Men Are from Mars, Women Are from Venus, psychotherapist John Gray proposed that, by improving the way they communicate with the opposite sex, men and women can "get what they want" in their relationships with one another. Does the same hold true for the physician-patient relationship? Does gender affect the quality of communication between doctors and their patients? The answer is yes.

While a fair amount of attention has been paid to the fact that female doctors tend to spend more time with patients, asking more questions and providing more information, many physicians may not be attuned -- or know how to respond -- to the different ways men and women communicate as patients.

"Patients will have behaviors associated with [their] genders. It would be helpful if we physicians had more information so that we could make appropriate adaptations," says Cindy Barter, MD, a family practitioner from Pittstown, N.J., and a faculty member of the Bayer Institute on Health Care Communication, which has been offering physicians educational programs in communication skills since 1987.

As we examine some broad differences in the way male and female patients communicate and offer some suggestions for adjusting your interviewing skills accordingly, keep in mind that not every patient will display these tendencies. Also, as veteran researcher Debra Roter, PhD, of the John Hopkins Bloomberg School of Public Health suggests, all patients, regardless of gender, tend to be anxious or concerned to some degree during a medical visit, and they expect to have their concerns addressed. Other factors impact the interview too, including the physician's gender, as well as the patient's age, ethnicity, and severity and type of health issue, according to Judith Hall, PhD, of the Department of Psychiatry at Northeastern University.

He's the silent type

One chapter of John Gray's book, titled "Men Go to Their Caves and Women Talk," offers an apt description of the way the genders act during a visit to the doctor. "Men are just more reluctant to give many details and women are much more forthcoming," says Barter. "More than once I've had a patient's wife ask, 'Did he tell you about the pain in his right arm? He complains about that all the time at home.' And her husband has said nothing about it. Even in a supporting role, women are just more inclined to offer information than are men." 

Barter suggests male patients can be encouraged to be more participative. "I coach my male patients in how to become active partners in their healthcare," she says. "I tell them, 'It's your health we are talking about here. Look at your numbers [blood pressure, weight, etc.]. Know what they mean.' I encourage them to ask questions and reinforce this by giving them the information they seek."

How? Think about the way you ask questions and how you might subtly get more information out of these patients. Closed-ended questions -- those that require just a yes or no response -- often lead to a dead end with patients. Consider the following:

Physician: You told the nurse that you've been having headaches, is that right?
Male patient: Yep.

Next time, consider a focused open-ended question that directs the patient's response but requires him to provide information about his problem in his own words. 

Physician: Why don't you describe for me the headaches you've been having? 

Follow up with questions that will move the story forward in time, such as "What happened next?" or "What else occurred?"

No big deal?

Male patients are also more likely to downplay their reason for the visit, or, as Barter says, even disassociate themselves. "It is not uncommon for my male patients to say something like, 'My wife told me to come in.' They're protecting themselves from showing any weakness that may be revealed by a visit to the doctor," she says.

Likewise, men tend to just "go along" and not make waves or challenge the physician. "I've had [male patients] say, 'Sure, doc,' and I know good and well they aren't going to do what I've said," says Sheldon Greenfield, MD, of the Harvard School of Public Health and an internist for more than 30 years.

If you sense problems with compliance, get patients to play a more active role rather than just listening to what you want them to do. "I ask my male patients to go beyond simply agreeing to follow the treatment plan," says Barter. "I ask them to explain it back to me in detail to be sure that I've been clear. Then I can discover any areas of confusion." This tactic is, in fact, helpful with all patients, regardless of gender. 

Male patients may also tend to make light of the situation in an attempt to cover concerns about health problems. According to social psychologist Sherrie Kaplan, PhD, of the Harvard School of Public Health, "Rather than [talking about] his fears, a male patient will likely make a joke." When you hear these types of comments, offer reassurance and give information that will address the patient's concerns. For example:

Male Patient: "How's the old ticker doing, doc?"
Physician: "Sounds like you had some concerns about that. Let me tell you what's going on."

Tune into your male patient's nonverbal messages as well, such as the sound of his voice, facial expression, and body language. Although these messages are much more subtle with most male patients than with females, you can find them if you pay attention.

Let her talk

Greenfield suggests physicians should appreciate the tendency of their female patients to talk more during the medical visit. "We have to remember that male patients' behavior, while quicker and easier, does not [result in] as productive an encounter nor as good an outcome as the more active interaction with females," he says.   
Why the difference in their approaches? "Girls start seeing the doctor at an earlier age," Kaplan suggests, "and as they mature, their reproductive needs bring them back more often. Women are usually the ones to bring children to the doctor as well, so they have a lot more practice at being a patient."

Because women often find it easier to talk about intimate topics than do men, an open-ended question such as, "How have things been going?" can be sufficient to encourage most female patients to provide needed information. But as your time to see patients becomes compressed, you may feel you have to control the amount of time you let patients talk.

If allowed to, most patients complete their stories within two minutes, according to a landmark 1984 study (Beckman and Frankel). In a 1999 study, Marvel et al found that physicians interrupt, or "redirect" patients within 23 seconds, on average. The message? Let your patients talk. You'll likely get more complete and useful information than if you place your own expectations into the course of the conversation right away. It can be helpful to follow up with a brief repetition, known in linguistic parlance as a "recompleter," of what the patient has told you. 

Physician: Just so I've got a handle on everything now -- you've been having headaches and trouble sleeping, and you're experiencing a lot of stress on the job.

If the conversation starts going off-track, you can help the patient to focus on the visit at hand, and suggest another appointment if it seems appropriate. For instance:

Physician: It seems like you've got quite a few items you want to discuss today. Tell me which one is the most pressing so we can concentrate on that. Then we can set up another time to talk about the other things you're concerned about.

Dig for information

Hall describes female communication as "more emotionally charged," raising the question of whether some physicians dismiss what some female patients say as "hysteria." Greenfield acknowledges that "there is the perspective that women have more psychosomatic illnesses than do men, and I just wonder how much of that impression is caused by the way we interpret how they communicate." 

But even emotional words can hold some very real concerns and information that you should not dismiss. First give value to what the patient has said, and then pull out any factual details that might be helpful.

Physician: It sounds as though the chest pains you had were pretty frightening. When did you first notice them?

Female patients may also "mask their dissatisfaction with politeness," says Hall. She reports a study in which physicians were asked to rate how satisfied they thought patients were with their visits; they tended to rate women's satisfaction higher than it actually was. Listen closely for indications of dissatisfaction in the verbal messages of your female patients:

Physician: How are things going today?
Patient: (smiling/speaking in a calm voice) Well, fine. Of course, I did have to wait quite a while out front.

Be aware, too, of the "little things" female patients place value on. For instance, they are more inclined to want the physician to sit directly opposite them (rather than behind a desk) and to make eye contact during the interview.

While it may seem that men and women come from different places when it comes to communication, there is no need for that to result in missed opportunities and unproductive medical visits. Recognize the differences that can exist -- and your own way of responding -- and you'll be able to better understand and meet their healthcare needs.

Vicky Bradford can be reached via
editor@physicianspractice.com.

This article originally appeared in the September 2003 issue of Physicians Practice.