**3.1 Gender preferences outside the US**

4 From Preconception to Postpartum

There has always been a controversy over male physicians treating gynecologic and obstetric issues (Balayla, 2010). Even today there are considerable differences in the OB/GYN gender preference in patients within different age ranges. The shifting patient demographics, especially the increasing number of post-menopausal women, combined with the recent large influx of female OB/GYNs, has resulted in preference changes over the decades. In 1970, only 9% of medical students were female. This had increased to 45.7% by 2001 (as cited in Table 1; Johnson et al., 2005). From 1980 to 2000, the number of practicing female OB/GYNs increased from 12% to 32%. Between 1989 to 2002, the number of female OB/GYN residents rose from 44% to 74% (cf. refs. in Gerber & Lo Sasso, 2006). Projections indicate an expanding population of female OB/GYNs in the 2010s and beyond. For example, in 1980, females constituted 27.8% of the OB/GYN residents, and 12% of the physicians in practice. By 2001 those numbers increased to 71.8% and 39%, respectively (as

It is clear from the studies cited below, that good bedside manner and professionalism are extremely important to patients. Plunkett and Midland (2000) found that "well-educated" Caucasians (from Chicago, Michigan, US) placed an emphasis on communication skills when selecting an obstetrician. In contrast, patients who were to undergo surgery decided the surgical reputation of the OB/GYN was more important than bedside manner. Over 90% of either set of patients wanted the OB/GYN to be responsive to their needs, exhibit professional behavior, and to be confident and knowledgeable. Only 38% of the patients thought that OB/GYN gender was an issue, and even fewer (15%) took the age of the OB/GYN into consideration. Of the 38% of patients who considered OB/GYN gender as

important, 96% wanted a female obstetrician and 84% wanted a female gynecologist.

Plunkett et al. (2002) performed another study in Chicago, and included African-Americans, Hispanics, and individuals with varied levels of education. Less than one-half of the women (42%) considered OB/GYN gender as important. When seeing an obstetrician, bedside manner, office location, referral by another physician, and recommendations from friends and family were the four factors considered most important at 57%, 45%, 40% and 35%, respectively. When selecting a gynecologist, office location, recommendations from family and friends, bedside manner, and referrals by other physicians were the top four ranked attributes at 55%, 48%, 47% and 43%, respectively. When specifically asked if they preferred a male or female OB/GYN, 52.8% wanted a female, 9.6% wanted a male, and 37.6% had no

recommendations

There were similar findings in New York City, where 58% of patients preferred a female OB/GYN, while 7% wanted a male and 34% had no preference (Howell et al., 2002). Only 10% of patients thought the gender of their OB/GYN impacted their care. These patients thought female physicians would naturally understand more about "female issues" than would males. When asked to rank order important attributes patients desired in an OB/GYN, bedside manner, communication skills, and technical expertise were the dominant factors for selecting an OB/GYN — or leaving if they lacked any of these skills

In a large study in Michigan, Mavis et al. (2005) found that OB/GYN gender mattered most to patients who were; underrepresented minorities, unmarried, less educated, and younger

**3. What do patients prefer in their OB/GYN?** 

cited in Table 1; Johnson et al., 2005).

preference.

(Howell et al., 2002).

In Ontario, Canada, Fischer and colleagues (2002) found that 75% of patients had no gender preference, and only 21% strongly felt they desired a female OB/GYN, while 4% wanted a male OB/GYN. Various patient characteristics had no bearing on gender preference, e.g., single, pregnant, those with a history of abortion, STDs or sexual dysfunction. In Israel, Piper and colleagues (2008) found that 60.3% of patients expressed no gender preference for their OB/GYN. Women who had children had a predilection to prefer female OB/GYNs. The important factors for Israeli OB/GYN selection were; professional demeanor (98.9%), showing courtesy (96.6%), and being board certified (92%).

Studies performed in Iraq and the United Arab Emirates (UAE; Lafta, 2006; Rizk et al., 2005), showed that a high percentage of patients, 79% and 86%, respectively, preferred a female OB/GYN. Only 8% of Iraqi and 1.6% of UAE women preferred their OB/GYN to be a male. In either country, the preference for a female OB/GYN significantly increased as the educational level fell. Very few women in either country had no gender preference. It was clear that socio-cultural and religious traditions played a very significant role in preferring a female OB/GYN. In the UAE study, Muslim women did not accept a male OB/GYN, even in the presence of a female chaperone, and especially during Ramadan (Rizk et al., 2005). Another prominent barrier to accepting a male OB/GYN was feeling greatly embarrassed if they had to be examined by a male. Many patients (69%) felt that female OB/GYNs had a greater awareness of female reproductive issues, were more compassionate, and better listeners than male OB/GYNs. Younger women had a stronger preference for female OB/GYNs than older women. It seems clear that younger, less educated Muslim women view OB/GYN gender as a gateway requirement to care.

Additional data from the UAE study reveals that women look for the same positive traits in an OB/GYN of either sex, as the other aforementioned studies. They want their OB/GYN to show professionalism by being responsive to their needs, caring, empathetic, displaying a good bedside manner, and being a skilled communicator. Secondarily, they want their OB/GYN to be knowledgeable, experienced, and technically competent (Rizk et al., 2005).

Who Selects Obstetrics and Gynecology as a Career and Why, and What Traits Do They Possess? 7

Carmel and Glick did a study in 1996 where physicians were asked to rank six attributes of a "good" doctor. The physicians placed the following descriptions in rank order from highest to lowest; humane to patients, has good medical knowledge and skills, is devoted to helping their patients, has a good working relationship with the staff, can research and publish, and are good at management and administration. Carmel & Glick (1996) concluded that the rank order of these attributes was in contrast to the duties needed to get promoted in academia, i.e., research, publications, administrative duties and spending less time with each patient. Therefore, the current academic "system" does not reward being a "good" doctor. Medical students, after starting their clinical rotations, have slightly different priorities as compared to practicing physicians. Students felt that knowledge and skills were the most important factors, followed by being humane, intellectually competent, honest, and reliable (Notzer et al., 1988). It is understandable for students to place knowledge and skills as the most

In light of the above, and despite the pressured academic environment in which physicians work, the ability to teach and mentor is viewed as extremely important by medical students. Therefore, faculty and residents must maintain a high degree of professionalism/humanism while still being technically competent. The same is true for residents being taught by faculty. Although patient care must take first priority, 62% of OB/GYN residents say finding time to look for "teachable moments" on the collection and interpretation of critical information in emergent situations is vital to the education of students and residents. Over 90% say you must find time to teach procedures (Gil et al., 2009). Faculty agree to a greater degree than residents that they need to be an appropriate role model, to be enthusiastic about patient care, and teach evidence-based medicine. Although residents still feel these are important skills, they are more pressured for time than faculty and are less likely to

Regardless of time constraints under which faculty and residents are placed, students appreciate constructive criticism given in a timely manner. Students have some ability to self-assess their progress, but specific, descriptive, written feedback is best for increasing student learning (Stalmeijer et al., 2010). In this regard, medical students say the ideal attending physician should spend more than 25% of their time teaching, with at least 25 hours of teaching per week occurring during rounds. Residents and faculty need to stress the importance of the doctor/patient relationship and emphasize the social aspects of medicine so that the patient is seen as an individual rather than an illness. Finally, students feel the faculty need to have served as chief resident in order to be a successful teacher

Numerous studies have shown empathic physicians are better at maintaining a good doctor/patient relationship. This makes the patients more relaxed, confident in their physician, compliant, and less likely to sue for malpractice (cf. refs. cited in Newton et al., 2008). Accordingly, the American Association of Medical Colleges and the Accreditation Committee for Graduate Medical Education have emphasized the importance of promoting empathy and professionalism in the curriculum. Displaying empathy is counter to the

**4. What is the ideal obstetrics/gynecologist physician and mentor?** 

important qualities since they were in the initial stage of their career.

express these traits because of time constraints (Johnson & Chen, 2006).

**5. Empathy in the doctor/patient relationship** 

(Wright et al., 1998).

Racz et al. (2008) examined the acceptability of involving Ontario-based medical students in OB/GYN care in two different patient groups: ages 17-85 and secondary school students with an average age of sixteen. Twenty-two percent of the older patients preferred a female student, increasing to 55% in the younger patients. Overall, the greater number of intimate examinations a patient had experienced, the less of a preference she had for OB/GYN gender. When the patients were asked about the presence of medical students in the examination room, there were significant differences expressed by the two age groups. The older patients were more accepting of having medical students of either sex participate in their care (73%) than the younger patients (32%). Over 36% of the younger patients said it would be "very embarrassing" or "unbearable" for a male medical student to perform an intimate examination. Because male medical students were rejected by younger patients to a much higher degree than by the older patients, it is advisable for clerkship directors to forewarn male medical students that younger patients may not want them in the examination room.

In conclusion, although many women may prefer a female physician, it has been demonstrated that physician gender is often not the most important attribute under consideration when patients select an OB/GYN. Clearly, good bedside manner and communication skills are essential in establishing an effective doctor/patient rapport. This is often followed by technical expertise and a good medical reputation. Before the 1970s, most patients had little say in the gender of their OB/GYN, but with the rapidly increasing number of practicing female OB/GYNs, patients now have a greater freedom to make gender a selection preference. Therefore, to maintain an adequate patient population, it will become even more important for male OB/GYNs to practice good bedside manners and empathic communication skills, as well as having technical expertise.

#### **3.2 The influence of media on gender bias**

A unique study by Kincheloe (2004) clearly found a physician gender bias when he examined six popular women's magazines over an 18 month period; *Cosmopolitan, Fitness, Glamour, Good Housekeeping, Ladies Home Journal* and *Redbook*. Kincheloe found that female physicians were 20 times more likely to have an identifying photograph as compared to males. Women OB/GYNs were interviewed 47-80% of the time, and female physicians from all other specialties accounted for 31-57% of the articles. When pronouns were used to describe an OB/GYN, a negative connotation was used 92% of the time for male OB/GYNs vs. 17% for females.

In five of the six magazines reviewed, physicians had their quoted gender changed from neutral to reflect female-specific pronouns. The exception was if the physician was portrayed negatively, and then the physician was significantly more likely to be identified as male (Kincheleo, 2004). Since attitudes are shaped by what we see, hear and read, women who buy these magazines seem to be influenced, whether purposefully or subliminally, to acquire a negative bias toward male physicians, in general, and male OB/GYNs specifically. Patients, and the physicians who refer patients, must be reminded to tell their patients that OB/GYN choice should be based on professionalism and clinical skills vs. using gender as a main deciding factor.
