Effect of Physician Gender and Race on Simulated Patients’ Ratings and Confidence in Their Physicians: A Randomized Trial | Emergency Medicine | JAMA Network Open | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 35.170.64.36. Please contact the publisher to request reinstatement.
1.
Association of American Medical Colleges. Table 1: medical students, selected years, 1965-2015. https://www.aamc.org/system/files/reports/1/2015table1.pdf. Published 2016. Accessed February 11, 2019.
2.
Association of American Medical Colleges. Table A-14.1: race/ethnicity responses (alone and in combination) of applicants to US medical schools, 2015-2016 through 2019-2020. https://www.aamc.org/system/files/2019-11/2019_FACTS_Table_A-14.1.pdf. Accessed January 2, 2020.
3.
Jagsi  R, Griffith  KA, Jones  R, Perumalswami  CR, Ubel  P, Stewart  A.  Sexual harassment and discrimination experiences of academic medical faculty.  JAMA. 2016;315(19):2120-2121. doi:10.1001/jama.2016.2188PubMedGoogle ScholarCrossref
4.
Jagsi  R, Griffith  KA, Stewart  A, Sambuco  D, DeCastro  R, Ubel  PA.  Gender differences in the salaries of physician researchers.  JAMA. 2012;307(22):2410-2417. doi:10.1001/jama.2012.6183PubMedGoogle ScholarCrossref
5.
Madsen  TE, Linden  JA, Rounds  K,  et al.  Current status of gender and racial/ethnic disparities among academic emergency medicine physicians.  Acad Emerg Med. 2017;24(10):1182-1192. doi:10.1111/acem.13269PubMedGoogle ScholarCrossref
6.
Fang  D, Moy  E, Colburn  L, Hurley  J.  Racial and ethnic disparities in faculty promotion in academic medicine.  JAMA. 2000;284(9):1085-1092. doi:10.1001/jama.284.9.1085PubMedGoogle ScholarCrossref
7.
Pololi  LH, Civian  JT, Brennan  RT, Dottolo  AL, Krupat  E.  Experiencing the culture of academic medicine: gender matters, a national study.  J Gen Intern Med. 2013;28(2):201-207. doi:10.1007/s11606-012-2207-1PubMedGoogle ScholarCrossref
8.
Jenner  S, Djermester  P, Prügl  J, Kurmeyer  C, Oertelt-Prigione  S.  Prevalence of sexual harassment in academic medicine.  JAMA Intern Med. 2019;179(1):108-111. doi:10.1001/jamainternmed.2018.4859PubMedGoogle ScholarCrossref
9.
National Academies of Sciences, Engineering, and Medicine.  Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2018.
10.
Osseo-Asare  A, Balasuriya  L, Huot  SJ,  et al.  Minority resident physicians’ views on the role of race/ethnicity in their training experiences in the workplace.  JAMA Netw Open. 2018;1(5):e182723. doi:10.1001/jamanetworkopen.2018.2723PubMedGoogle Scholar
11.
Nunez-Smith  M, Curry  LA, Bigby  J, Berg  D, Krumholz  HM, Bradley  EH.  Impact of race on the professional lives of physicians of African descent.  Ann Intern Med. 2007;146(1):45-51. doi:10.7326/0003-4819-146-1-200701020-00008PubMedGoogle ScholarCrossref
12.
Wheeler  M, de Bourmont  S, Paul-Emile  K,  et al.  Physician and trainee experiences with patient bias  [published online October 28, 2019].  JAMA Intern Med. 2019. doi:10.1001/jamainternmed.2019.4122PubMedGoogle Scholar
13.
Choo  EK, van Dis  J, Kass  D.  Time’s up for medicine? only time will tell.  N Engl J Med. 2018;379(17):1592-1593. doi:10.1056/NEJMp1809351PubMedGoogle ScholarCrossref
14.
Nunez-Smith  M, Pilgrim  N, Wynia  M,  et al.  Health care workplace discrimination and physician turnover.  J Natl Med Assoc. 2009;101(12):1274-1282. doi:10.1016/S0027-9684(15)31139-1PubMedGoogle ScholarCrossref
15.
McMurray  JE, Linzer  M, Konrad  TR, Douglas  J, Shugerman  R, Nelson  K; The SGIM Career Satisfaction Study Group.  The work lives of women physicians: results from the physician work life study.  J Gen Intern Med. 2000;15(6):372-380. doi:10.1046/j.1525-1497.2000.9908009.xPubMedGoogle Scholar
16.
Hall  JA, Blanch-Hartigan  D, Roter  DL.  Patients’ satisfaction with male versus female physicians: a meta-analysis.  Med Care. 2011;49(7):611-617. doi:10.1097/MLR.0b013e318213c03fPubMedGoogle ScholarCrossref
17.
Schindelheim  GL, Jerrard  DA, Witting  M.  Patient preference for emergency physician age and gender.  Am J Emerg Med. 2004;22(6):503. doi:10.1016/j.ajem.2004.07.011PubMedGoogle ScholarCrossref
18.
Cousin  G, Schmid Mast  M, Jaunin-Stalder  N.  When physician-expressed uncertainty leads to patient dissatisfaction: a gender study.  Med Educ. 2013;47(9):923-931. doi:10.1111/medu.12237PubMedGoogle ScholarCrossref
19.
Rogo-Gupta  LJ, Haunschild  C, Altamirano  J, Maldonado  YA, Fassiotto  M.  Physician gender is associated with Press Ganey patient satisfaction scores in outpatient gynecology.  Womens Health Issues. 2018;28(3):281-285. doi:10.1016/j.whi.2018.01.001PubMedGoogle ScholarCrossref
20.
Bertakis  KD, Franks  P, Azari  R. Effects of physician gender on patient satisfaction. J Am Med Womens Assoc (1972). 2003;58(2):69-75.
21.
Gerbert  B, Berg-Smith  S, Mancuso  M,  et al.  Video study of physician selection: preferences in the face of diversity.  J Fam Pract. 2003;52(7):552-559.PubMedGoogle Scholar
22.
Nolen  HA, Moore  JX, Rodgers  JB, Wang  HE, Walter  LA.  Patient preference for physician gender in the emergency department.  Yale J Biol Med. 2016;89(2):131-142.PubMedGoogle Scholar
23.
Laveist  TA, Nuru-Jeter  A.  Is doctor-patient race concordance associated with greater satisfaction with care?  J Health Soc Behav. 2002;43(3):296-306. doi:10.2307/3090205PubMedGoogle ScholarCrossref
24.
Cooper-Patrick  L, Gallo  JJ, Gonzales  JJ,  et al.  Race, gender, and partnership in the patient-physician relationship.  JAMA. 1999;282(6):583-589. doi:10.1001/jama.282.6.583PubMedGoogle ScholarCrossref
25.
Roter  DL, Hall  JA, Aoki  Y.  Physician gender effects in medical communication: a meta-analytic review.  JAMA. 2002;288(6):756-764. doi:10.1001/jama.288.6.756PubMedGoogle ScholarCrossref
26.
Schmid Mast  M, Hall  JA, Roter  DL.  Disentangling physician sex and physician communication style: their effects on patient satisfaction in a virtual medical visit.  Patient Educ Couns. 2007;68(1):16-22. doi:10.1016/j.pec.2007.03.020PubMedGoogle ScholarCrossref
27.
Hall  JA, Roter  DL, Blanch-Hartigan  D, Mast  MS, Pitegoff  CA.  How patient-centered do female physicians need to be? analogue patients’ satisfaction with male and female physicians’ identical behaviors.  Health Commun. 2015;30(9):894-900. doi:10.1080/10410236.2014.900892PubMedGoogle Scholar
28.
Hall  JA, Gulbrandsen  P, Dahl  FA.  Physician gender, physician patient-centered behavior, and patient satisfaction: a study in three practice settings within a hospital.  Patient Educ Couns. 2014;95(3):313-318. doi:10.1016/j.pec.2014.03.015PubMedGoogle Scholar
29.
Moher  D, Hopewell  S, Schulz  KF,  et al; Consolidated Standards of Reporting Trials Group.  CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials.  J Clin Epidemiol. 2010;63(8):e1-e37. doi:10.1016/j.jclinepi.2010.03.004PubMedGoogle Scholar
30.
Burgess  DJ.  Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? how features of the healthcare setting may lead to biases in medical decision making.  Med Decis Making. 2010;30(2):246-257. doi:10.1177/0272989X09341751PubMedGoogle Scholar
31.
Rui  P. Kang K. National hospital ambulatory medical care survey: 2015 emergency department summary tables. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2015_ed_web_tables.pdf. Published 2015. Accessed February 11, 2018.
32.
Coppock  A.  Generalizing from survey experiments conducted on Mechanical Turk: a replication approach.  Polit Sci Res and Methods.2019;7(3):613-628. doi:10.1017/psrm.2018.10Google Scholar
33.
Behrend  TS, Sharek  DJ, Meade  AW, Wiebe  EN.  The viability of crowdsourcing for survey research.  Behav Res Methods. 2011;43(3):800-813. doi:10.3758/s13428-011-0081-0PubMedGoogle Scholar
34.
Berinsky  AJ, Huber  GA, Lenz  GS.  Evaluating online labor markets for experimental research: Amazon.com’s Mechanical Turk.  Polit Anal. 2012;20(3):351-368. doi:10.1093/pan/mpr057Google Scholar
35.
Horton  JJ, Rand  DG, Zeckhauser  RJ.  The online laboratory: conducting experiments in a real labor market.  Exp Econ. 2011;14(3):399-425. doi:10.1007/s10683-011-9273-9Google Scholar
36.
Coppock  A, McClellan  OA.  Validating the demographic, political, psychological, and experimental results obtained from a new source of online survey respondents.  Res Polit. 2019;6(1):1-14. doi:10.1177/2053168018822174Google Scholar
37.
Hang  BS, Bork  S, Ditkoff  J, Long B, Koyfman A. Nausea and vomiting. In: Tintinalli  JE, Stapczynski  JS, Ma  OJ,  et al, eds.  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Companies; 2011.
38.
US Department of Health and Human Services, National Institutes of Health, Office of Extramural Research. NIH policy on reporting race and ethnicity data: subjects in clinical research. 2001. https://grants.nih.gov/grants/guide/notice-files/not-od-01-053.html. Accessed January 3, 2020.
39.
Oppenheimer  DM, Meyvis  T, Davidenko  N.  Instructional manipulation checks: detecting satisficing to increase statistical power.  J Exp Soc Psychol. 2009;45(4):867-872. doi:10.1016/j.jesp.2009.03.009Google Scholar
40.
Meade  AW, Craig  SB.  Identifying careless responses in survey data.  Psychol Methods. 2012;17(3):437-455. doi:10.1037/a0028085PubMedGoogle Scholar
41.
Ma  DS, Correll  J, Wittenbrink  B.  The Chicago face database: A free stimulus set of faces and norming data.  Behav Res Methods. 2015;47(4):1122-1135. doi:10.3758/s13428-014-0532-5PubMedGoogle Scholar
42.
Glick  P, Fiske  ST.  Hostile and benevolent sexism: measuring ambivalent sexist attitudes toward women.  Psychol Women Q. 1997;21(1):119-135. doi:10.1111/j.1471-6402.1997.tb00104.xGoogle Scholar
43.
Kunst  JR, Fischer  R, Sidanius  J, Thomsen  L.  Preferences for group dominance track and mediate the effects of macro-level social inequality and violence across societies.  Proc Natl Acad Sci U S A. 2017;114(21):5407-5412. doi:10.1073/pnas.1616572114PubMedGoogle Scholar
44.
Huddy  L, Feldman  S.  On assessing the political effects of racial prejudice.  Annu Rev Polit Sci. 2009;12(1):423-447. doi:10.1146/annurev.polisci.11.062906.070752Google Scholar
45.
Peyton  K, Huber  GA.  Do survey measures of racial prejudice predict racial discrimination? experimental evidence on anti-black discrimination.  SocArXiv. Published online April 18, 2018.Google Scholar
46.
Ma  DS, Correll  J, Wittenbrink  B.  The Chicago Face Database: a free stimulus set of faces and norming data.  Behav Res Methods. 2015;47(4):1122-1135. doi:10.3758/s13428-014-0532-5PubMedGoogle Scholar
47.
Hall  JA, Irish  JT, Roter  DL, Ehrlich  CM, Miller  LH.  Satisfaction, gender, and communication in medical visits.  Med Care. 1994;32(12):1216-1231. doi:10.1097/00005650-199412000-00005PubMedGoogle Scholar
48.
Hargraves  JL, Hays  RD, Cleary  PD.  Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS) 2.0 adult core survey.  Health Serv Res. 2003;38(6, pt 1):1509-1527. doi:10.1111/j.1475-6773.2003.00190.xPubMedGoogle Scholar
49.
Centers for Medicare & Medicaid Services. HCAHPS: patients' perspectives of care survey. Page last modified, October 15, 2019. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/hospitalqualityinits/hospitalHCAHPS.html. Accessed February 15, 2019.
50.
Presson  AP, Zhang  C, Abtahi  AM, Kean  J, Hung  M, Tyser  AR.  Psychometric properties of the Press Ganey outpatient medical practice survey.  Health Qual Life Outcomes. 2017;15(1):32. doi:10.1186/s12955-017-0610-3PubMedGoogle Scholar
51.
Kraft-Todd  GT, Reinero  DA, Kelley  JM, Heberlein  AS, Baer  L, Riess  H.  Empathic nonverbal behavior increases ratings of both warmth and competence in a medical context.  PLoS One. 2017;12(5):e0177758. doi:10.1371/journal.pone.0177758PubMedGoogle Scholar
52.
Fiske  ST, Cuddy  AJ, Glick  P, Xu  J.  A model of (often mixed) stereotype content: competence and warmth respectively follow from perceived status and competition.  J Pers Soc Psychol. 2002;82(6):878-902. doi:10.1037/0022-3514.82.6.878PubMedGoogle Scholar
53.
Cardarelli  R, Licciardone  JC, Ramirez  G.  Predicting risk for disciplinary action by a state medical board.  Tex Med. 2004;100(1):84-90.PubMedGoogle Scholar
54.
Rogers  P.Demographics of Disciplinary Action by the Medical Board of California (2003-2013). Sacramento: California Research Bureau; January 2017.
55.
Lin W.  Agnostic notes on regression adjustments to experimental data: reexamining Freedman’s critique.  Ann Appl Stat. 2013;7(1):295-318. doi:10.1214/12-AOAS583Google Scholar
56.
Lakens  D, Scheel  AM, Isager  PM.  Equivalence testing for psychological research: a tutorial.  Adv Methods Pract Psychol Sci. 2018;1(2):259-269. doi:10.1177/2515245918770963Google Scholar
57.
Green  DP, Kern  HL.  Modeling heterogeneous treatment effects in survey experiments with bayesian additive regression trees.  Public Opin Q. 2012;76(3):491-511. doi:10.1093/poq/nfs036Google Scholar
58.
Chipman  HA, George  EI, McCulloch  RE.  BART: bayesian additive regression trees.  Ann Appl Stat. 2010;4(1):266-298. doi:10.1214/09-AOAS285Google Scholar
59.
Milano  A, Dalawari  P, McGregor  AJ,  et al.  Emergency department evaluation of patient satisfaction: does physician gender impact Press Ganey scores? a multicenter study.  Am J Emerg Med. 2018;36(9):1708-1709. doi:10.1016/j.ajem.2018.01.067PubMedGoogle Scholar
60.
Street  RL  Jr, O’Malley  KJ, Cooper  LA, Haidet  P.  Understanding concordance in patient-physician relationships: personal and ethnic dimensions of shared identity.  Ann Fam Med. 2008;6(3):198-205. doi:10.1370/afm.821PubMedGoogle Scholar
61.
Derose  KP, Hays  RD, McCaffrey  DF, Baker  DW.  Does physician gender affect satisfaction of men and women visiting the emergency department?  J Gen Intern Med. 2001;16(4):218-226. doi:10.1046/j.1525-1497.2001.016004218.xPubMedGoogle Scholar
62.
Schmittdiel  J, Grumbach  K, Selby  JV, Quesenberry  CP  Jr.  Effect of physician and patient gender concordance on patient satisfaction and preventive care practices.  J Gen Intern Med. 2000;15(11):761-769. doi:10.1046/j.1525-1497.2000.91156.xPubMedGoogle Scholar
63.
Chen  JG, Zou  B, Shuster  J.  Relationship between patient satisfaction and physician characteristics.  J Patient Exp. 2017;4(4):177-184. doi:10.1177/2374373517714453PubMedGoogle Scholar
64.
Greene  J, Hibbard  JH, Sacks  RM.  Does the race/ethnicity or gender of a physician’s name impact patient selection of the physician?  J Natl Med Assoc. 2018;110(3):206-211. doi:10.1016/j.jnma.2017.05.010PubMedGoogle Scholar
65.
Alsan  M, Garrick  O, Graziani  GC. Does diversity matter for health? experimental evidence from Oakland. Working paper 24787. Natl Bureau Econ Res. https://www.nber.org/papers/w24787?utm_campaign=ntw&utm_medium=email&utm_source=ntw. Published 2018. Accessed September, 21, 2018.
66.
Tsugawa  Y, Jena  AB, Figueroa  JF, Orav  EJ, Blumenthal  DM, Jha  AK.  Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians.  JAMA Intern Med. 2017;177(2):206-213. doi:10.1001/jamainternmed.2016.7875PubMedGoogle Scholar
67.
Shannon  G, Jansen  M, Williams  K,  et al.  Gender equality in science, medicine, and global health: where are we at and why does it matter?  Lancet. 2019;393(10171):560-569. doi:10.1016/S0140-6736(18)33135-0PubMedGoogle Scholar
68.
Greenwood  BN, Carnahan  S, Huang  L.  Patient-physician gender concordance and increased mortality among female heart attack patients.  Proc Natl Acad Sci U S A. 2018;115(34):8569-8574. doi:10.1073/pnas.1800097115PubMedGoogle Scholar
69.
Morgan Stanley. An investor’s guide to gender diversity. https://www.morganstanley.com/ideas/gender-diversity-investor-guide. Published January 17, 2017. Accessed April 25, 2019.
70.
The Lancet.  Feminism is for everybody.  Lancet. 2019;393(10171):493. doi:10.1016/S0140-6736(19)30239-9PubMedGoogle Scholar
71.
Catalyst. Men advocating real change. https://www.catalyst.org/marc/. Published 2019. Accessed April 25, 2019.
72.
van Vliet  LM, van der Wall  E, Albada  A, Spreeuwenberg  PMM, Verheul  W, Bensing  JM.  The validity of using analogue patients in practitioner-patient communication research: systematic review and meta-analysis.  J Gen Intern Med. 2012;27(11):1528-1543. doi:10.1007/s11606-012-2111-8PubMedGoogle Scholar
73.
Kirwan  JR, Chaput de Saintonge  DM, Joyce  CR, Currey  HL.  Clinical judgment in rheumatoid arthritis. I. rheumatologists’ opinions and the development of ‘paper patients’.  Ann Rheum Dis. 1983;42(6):644-647. doi:10.1136/ard.42.6.644PubMedGoogle Scholar
74.
Kreuter  F, Presser  S, Tourangeau  R.  Social desirability bias in CATI, IVR, and web surveys: the effects of mode and question sensitivity.  Public Opin Q. 2008;72(5):847-865. doi:10.1093/poq/nfn063Google Scholar
75.
de Quidt  J, Haushofer  J, Roth  C.  Measuring and bounding experimenter demand.  Am Econ Rev. 2018;108(11):3266-3302. doi:10.1257/aer.20171330Google Scholar
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Health Policy
    February 21, 2020

    Effect of Physician Gender and Race on Simulated Patients’ Ratings and Confidence in Their Physicians: A Randomized Trial

    Author Affiliations
    • 1National Clinical Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    • 2Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
    • 3Yale Law School, New Haven, Connecticut
    • 4Department of Psychology, Boston College, Chestnut Hill, Massachusetts
    • 5Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
    JAMA Netw Open. 2020;3(2):e1920511. doi:10.1001/jamanetworkopen.2019.20511
    Key Points español 中文 (chinese)

    Question  In a simulated clinical encounter, do participants evaluate physicians differently based on the physician’s gender or race?

    Findings  In this randomized trial of 3592 online respondents, simulated physician gender and race did not significantly affect participant satisfaction or confidence in physician clinical judgment compared with a white male physician control.

    Meaning  Participants reported equal satisfaction and confidence in the simulated physicians’ diagnosis and treatment plans regardless of the physician’s gender or race.

    Abstract

    Importance  Women and black physicians encounter workplace challenges because of their gender and race. It is unclear whether these individuals are assessed with lower patient satisfaction or confidence ratings compared with white male physicians.

    Objective  To examine whether physician gender and race affect participant ratings in scenarios in which physician competence is challenged.

    Design, Setting, and Participants  This randomized trial enrolled a geographically diverse sample of 3592 online respondents in the United States who were recruited from 2 crowdsourcing platforms: Amazon Mechanical Turk (n = 1741) and Lucid (n = 1851). A 2 × 2 factorial design for the gender and race of simulated physicians was conducted between March 9 and July 25, 2018. Participants were excluded before intervention if they were younger than 18 years, were pregnant, or had a history of cancer or abdominal surgical procedures.

    Interventions  A clinical vignette was presented to the participant with a picture of the emergency department physician. Participants were randomly assigned to physicians with different gender and race, with 823 assigned to black women, 791 to black men, 828 to white women, and 835 to white men. A contradictory diagnosis from an online symptom checker introduced doubt about the clinical diagnosis.

    Main Outcomes and Measures  A composite outcome (range, 0-100, with 0 representing low patient confidence and satisfaction and 100 representing the maximum on the composite scale) measured participant (1) confidence in the physician, (2) satisfaction with care, (3) likelihood to recommend the physician, (4) trust in the physician’s diagnosis, and (5) likelihood to request additional tests.

    Results  Among 3277 adult participants, complete data were available for 3215 (median age, 49 years [range, 18-89 years]; 1667 [52%] female; 2433 [76%] white). No significant differences were observed in participant satisfaction and physician confidence for the white male physician control physicians (mean composite score, 66.13 [95% CI, 64.76-67.51]) compared with white female (mean composite score, 66.50 [95% CI, 65.19-67.82]), black female (mean composite score, 67.36 [95% CI, 66.03-68.69]), and black male (mean composite score, 66.96 [95% CI, 65.55-68.36]) physicians. Machine learning with bayesian additive regression trees revealed no evidence of treatment effect heterogeneity as a function of participants’ race, gender, racial prejudice, or sexism.

    Conclusions and Relevance  No significant differences were observed for simulated patients’ evaluations of female or black physicians, suggesting that bias in favor of white male physicians is negligible in survey-based measures of patient satisfaction.

    Trial Registration  ClinicalTrials.gov Identifier: NCT04190901

    ×