Special Article
Preventive Care for Women -- Does the Sex of the Physician Matter?
N Engl J Med 1993; 329:478-482August 12, 1993
- Abstract
Background
Emphasis on ensuring women's access to preventive health services has increased over the past decade. Relatively little attention has been paid to whether the sex of the physician affects the rates of cancer screening among women. We examined differences between male and female physicians in the frequency of screening mammograms and Pap smears among women patients enrolled in a large Midwestern health plan.
Methods
We identified claims for mammography and Pap tests submitted by primary care physicians for 97,962 women, 18 to 75 years of age, who were enrolled in the health plan in 1990. The sex of the physician was manually coded, and the physician's age was obtained from the state licensing board. After identifying a principal physician for each woman, we calculated the frequency of mammography and Pap smears for each physician, using the number of women in his or her practice during 1990 as the denominator. Using unconditional logistic regression, we also calculated the odds ratio of having a Pap smear or mammogram for women patients with female physicians as compared with those with male physicians, controlling for the physician's and the patient's age.
Results
Crude rates for Pap smears and mammography were higher for the patients of female than male physicians in most age groups of physicians. The largest differences between female and male physicians were in the rates of Pap smears among the youngest physicians. For the subgroup of women enrolled in the health plan for a year who saw only one physician, after adjustment for the patient's age and the physician's age and specialty, the odds ratio for having a Pap smear was 1.99 (95 percent confidence interval, 1.72 to 2.30) for the patients of female physicians as compared with those of male physicians. For women 40 years old and older, the odds ratio for having a mammogram was 1.41 (95 percent confidence interval, 1.22 to 1.63). For both Pap smears and mammography, the differences between female and male physicians in screening rates were much more pronounced in internal medicine and family practice than in obstetrics and gynecology.
Conclusions
Women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner.
Media in This Article
Figure 1
Rates of Cancer Screening among the Patients of Male and Female Physicians, According to Five-Year Age Groups, in a Patient Population of 97,962 Women.Table 1
Sex of Physicians and Number of Patients, According to the Physician's Specialty and Age.Article Activity
- Article
The growing consensus among the public and the scientific community that women's health issues have been neglected has kindled unprecedented interest in the quality and quantity of health care that women receive1. In response, Congress and others have increased their emphasis on ensuring women's access to appropriate medical care, including preventive services. Rates of screening for breast and cervical cancer are considered important markers of access to and quality of health care by both government and private-sector agencies.
Many factors affect women's cancer-screening rates, among them the sociodemographic characteristics of the target population2; knowledge, attitudes, and beliefs about disease, screening, and the efficacy of treatment3; patients' compliance with recommendations4; and structural factors, such as health insurance coverage5. The most common reason women give for not undergoing screening for breast and cervical cancer, however, is that it was not offered or recommended by their physicians6. In order to improve screening rates, it is critical to understand further what characteristics of physicians may be associated with low rates of preventive services offered to and accepted by women.
There is reason to suspect that the sex of the physician may be an important factor. Although Link and Zabar7 found no difference in the rates of breast, rectal, and genitourinary examinations performed by male and female residents in a teaching setting, three other studies have found that the sex of the physician influences the provision of preventive care8-10. Hall et al.10 studied practices in teaching hospitals and affiliated neighborhood clinics and concluded that female staff physicians were more likely to meet a standard of appropriateness for breast examinations and Pap smears than were male staff physicians, whereas female residents were less likely than male residents to treat and follow up urinary tract infections in children appropriately.
Although the sex of the physician is easy to determine, studying its correlation with the provision of health services is complicated by a variety of possible confounding relations. For example, female physicians are generally younger than their male counterparts, and thus there may have been more emphasis on preventive care in their training. Older physicians are more likely to care for older women, who may have different attitudes about cancer screening than younger women. Because previous studies have not controlled for the age of the patient and the physician, they have not adjusted for the potential effects of these factors. In this study, we examined differences in the use of screening mammograms and Pap smears between female and male physicians caring for women enrolled in a large Midwestern health plan.
Methods
The physician and patient samples were selected from Medica, a large open-choice health plan of the independent-practice-association type in the Twin Cities area of Minnesota. In accordance with Minnesota law, the Medica benefit package covers preventive services, including mammography and Pap smears. Both samples were restricted to residents of the Twin Cities (Minneapolis and St. Paul) metropolitan area because the representation of female physicians in nonmetropolitan areas is limited.
The physician sample consisted of all primary care physicians in obstetrics-gynecology, family practice, or internal medicine (1064 male and 259 female physicians). The health plan provided names and state license numbers for all its physicians. These were matched to a list from the Minnesota Board of Medical Practice to obtain information on age. The age of 208 physicians could not be determined. Sex was coded on the basis of the physician's first name. When the name was ambiguous (for example, Pat or Robin), the physician's office was called. We ascertained the sex of all but seven physicians. In 1990, 117,501 women 18 to 75 years old were enrolled in Medica and visited a physician at least once. For 13,496 women, the identity of the physician could not be ascertained, and for 297 women the sex of the physician was unknown, leaving 103,708 women for further analysis. For analyses of Pap-smear rates, we included women 18 to 75 years old; analyses of mammography rates included women 40 and over.
The claims submitted by family practitioners, internists, and obstetrician-gynecologists for the treatment of women in the study population were identified. Because of the way claims were coded, we could not determine whether the physician's specialty was family practice or internal medicine; therefore, these specialties are pooled in all analyses. Claims submitted by obstetrician-gynecologists indicated the specialty of the physician. The numbers of mammograms and Pap smears ordered by each physician were identified on the basis of paid claims for those tests.
In order to arrive at a denominator for use in calculating the screening rate for each physician, we first determined the number of women in his or her practice in 1990. Each woman in the sample was “assigned” to the physician who had the clearest responsibility for ordering and performing screening tests, according to the following algorithm. To select a principal physician for each woman, we identified the internist or family practitioner and the obstetrician-gynecologist whom the woman visited most frequently during the study year. When a woman saw only an obstetrician-gynecologist (as was the case for 34,377 women), the principal obstetrician-gynecologist was considered responsible for ordering the mammogram or Pap smear. When a woman did not visit an obstetrician-gynecologist during 1990 (n = 57,933), we assumed that the principal internist or family practitioner was responsible for screening. When the patient visited both an internist or family practitioner and an obstetrician-gynecologist (n = 11,398), we assumed that the principal internist or family practitioner was responsible for the cancer-screening tests when the ratio of visits to the principal internist or family practitioner to visits to the obstetrician-gynecologist was at least 3:1. When this was not the case (n = 5746), we did not attempt to attribute the cancer screening to a particular physician, and those cases were dropped from analysis (103,708 - 5746). The resultant sample comprised 97,962 patients.
To eliminate questions about the attribution of a mammogram or Pap smear to a given physician, we also studied a subgroup of 29,005 women who were enrolled in the health plan for the entire year and visited only one physician. We did not include patients whose physician's age was unknown (n = 2967) or whose physician saw five or fewer patients in the sample (n = 1325). The remaining 24,713 patients saw a total of 680 physicians, of whom 130 were obstetrician-gynecologists. Within this subgroup, the analysis of rates of mammography was restricted to the 13,454 women 40 years of age or older, since guidelines for preventive care do not recommend routine mammography before the age of 40.
The mean rates of screening by Pap smear and mammography were computed for physicians according to sex, age, and specialty. The odds ratio for undergoing screening by mammography or Pap smear for the patient of a female physician as compared with the patient of a male physician was calculated with unconditional logistic-regression methods, with adjustment for the patient's age and for the physician's age and specialty11. We used the same methods to analyze separately the subgroup of women who were enrolled in the health plan for the entire 12-month period and saw only one physician during that year.
In the unadjusted analyses, physicians were grouped according to five-year age groups, with female physicians older than 52 grouped together. In the logistic-regression analyses, because of the small number of older female physicians, physicians were divided into three age groups: <38 years, 38 to 42 years, and ≥ 43 years. These categories were chosen to maximize the number of physicians in the smallest cells that resulted from dividing the physician sample into 12 sex-age-specialty groups. Patients were divided into four age groups for the logistic-regression analyses: <40 years of age, 40 to 49 years of age, 50 to 69 years of age, and ≥ 70 years of age.
There was significant variability among individual physicians in rates of both Pap smears (P<0.001) and mammography (P<0.001) in the subgroup of patients, after adjustment for the patient's age and the physician's sex, age, and specialty. We estimated the “design effect” due to this variability among physicians and adjusted all results of statistical tests and confidence levels reported here to account for this effect12.
Results
For the entire data set, unadjusted for the patient's age and the physician's specialty, rates of Pap smears and mammography were consistently higher for female physicians than for male physicians, with the exception of physicians around 50 years of age (Figure 1Figure 1
Rates of Cancer Screening among the Patients of Male and Female Physicians, According to Five-Year Age Groups, in a Patient Population of 97,962 Women.). The largest difference in rates between male and female physicians was found for screening with Pap smears in the youngest group of physicians -- an age group in which the male physicians had extremely low screening rates. The findings for mammography were similar, although the sex differences in all the physicians' age groups were smaller than for Pap smears.Table 1Table 1
Sex of Physicians and Number of Patients, According to the Physician's Specialty and Age. shows the distribution of physicians according to age and specialty for the subgroup of 24,713 women who were enrolled in the health plan for the entire year and visited only one physician. Because the results for this subgroup differed little from the results for the entire sample, we have reported results from the subgroup to eliminate concern about the attribution of tests. Twenty percent of the physicians were women, and the overwhelming majority of the female physicians were less than 50 years of age. Twenty-six percent of the female physicians were obstetrician-gynecologists, as compared with 17 percent of the male physicians. The average age of the patients of the female physicians was 39.9 years, as compared with 46.0 years for the patients of male physicians (P<0.001).In the subgroup of 24,713 women, unconditional logistic-regression analysis revealed that, after adjustment for the patient's age and the physician's age and specialty, the overall odds ratio for having a Pap smear was 1.99 (95 percent confidence interval, 1.72 to 2.30) for the patients of female physicians, as compared with those of male physicians. After adjustment for the patient's age and the physician's age and sex, obstetrician-gynecologists were much more likely to screen patients with these two tests than internists and family practitioners (odds ratio = 8.44; 95 percent confidence interval, 7.24 to 9.84). After adjustment for the patient's age, the rates of Pap smears were uniformly higher for female physicians than for their male counterparts in all age-specialty groups of physicians, with odds ratios ranging from 1.05 to 2.35 (Table 2Table 2
Rates of Screening with Pap Smears for Female and Male Physicians, According to the Physician's Age and Specialty, after Adjustment for the Patient's Age.). The odds ratios were significantly different from 1.0 in all age groups of internists and family practitioners and in the group of obstetrician-gynecologists 38 to 42 years old. There was a significant interaction between the physician's sex and the physician's specialty (chi-square = 5.49, P = 0.02); the physician's sex had a much more profound effect among internists and family practitioners (odds ratio = 2.14; 95 percent confidence interval, 1.83 to 2.51) than among obstetrician-gynecologists (odds ratio = 1.40; 95 percent confidence interval, 1.02 to 1.92). No other interactions were significant (P>0.25).The pattern of rates of screening with mammography was similar to that for Pap smears. Overall, the odds of having a mammogram were higher for the patients of female physicians than for those of male physicians (odds ratio = 1.41; 95 percent confidence interval, 1.22 to 1.63). Although mammography rates were lower than Pap-smear rates, obstetrician-gynecologists still had higher rates than internists and family practitioners (odds ratio = 2.51; 95 percent confidence interval, 2.18 to 2.90). Differences in mammography rates between female and male physicians in different age-specialty groups, adjusted for the patient's age, revealed a broadly similar picture (Table 3Table 3
Rates of Mammography for Female and Male Physicians, According to the Physician's Age and Specialty, after Adjustment for the Patient's Age.), with odds ratios significantly different from 1.0 in all age groups of internists and family practitioners. Once again there was evidence of an interaction between the physician's sex and the physician's specialty (chi-square = 3.74, P = 0.05), with substantial differences between the sexes among internists and family practitioners (odds ratio = 1.50, 95 percent confidence interval, 1.29 to 1.76), whereas there was little or no evidence of such differences among obstetrician-gynecologists. There was also a marginally significant interaction between the sex of the physician and the physician's age group (chi-square = 5.71, 2 df; P = 0.06); larger differences in screening rates between female and male physicians occurred among physicians 38 to 42 years old.Discussion
This study documents differences between female and male physicians in the rate of cancer-screening tests among their women patients; the differences are particularly striking among physicians in internal medicine and family practice. In obstetrics and gynecology, in contrast, there were significant differences between the sexes in only one age group (those 38 to 42 years old), and these physicians had screening rates that were consistently higher than those for internists and family practitioners. We also found that the lowest rates for both Pap smears and mammograms were in the youngest group of internists and family practitioners (those less than 38 years old).
These low screening rates for young physicians are particularly disturbing when one considers the increased attention to preventive care in the medical school and residency curriculum over the past decade. The data suggest that improving cancer-screening rates through better education of physicians about preventive care may be difficult. Moreover, the low screening rates for all groups of internists and family practitioners, regardless of sex, suggest that administrative changes are needed to increase screening. Prototypes for such interventions13 have been described elsewhere and include reminders to patients and physicians or office-based systems that bypass the physician and rely on nurses or other medical staff to offer a targeted service14.
The fact that screening rates differ according to the sex of the physician raises some interesting issues. Many patients report a preference for a physician of the same sex; this is particularly true for female patients and in clinical situations requiring rectal and genital examinations15. This preference is reflected in the unequal sex distribution of patients between male and female physicians, with more women choosing female physicians16,17. Women patients also report greater satisfaction with female physicians than with male physicians18. Women patients who choose female physicians may also pay more attention to preventive care, or they may differ from other patients in other factors -- such as socioeconomic status or attitudes toward preventive care -- that might predispose them to seek screening. Thus, though we know that all the women in this sample were insured and had coverage for mammograms and Pap smears, we do not know whether there were systematic differences in characteristics -- other than age -- between the patients of male physicians and those of female physicians. If self-selection was partially responsible for the findings, however, these data should serve to increase awareness of the special challenge male physicians face in ensuring that their women patients obtain preventive care.
The sex of the physician may correlate with other behavior and characteristics of physicians that affect screening. Women physicians may be more likely to offer screening tests, or they may exercise greater diligence in repeatedly offering screening or may communicate the risk of cancer more effectively to their patients. Women patients may also be more likely to follow through in obtaining tests suggested by women physicians because they are more comfortable discussing issues of concern with female physicians or being examined by them.
Female physicians may be more comfortable than male physicians in discussing or performing breast examinations or Pap smears. In particular, young male physicians may be uncomfortable examining women's reproductive organs or discussing issues related to sexuality and therefore uncomfortable offering cancer-screening tests. This discomfort may lessen as physicians mature with age and gain practice experience, and it may explain why screening rates among older physicians are higher than those among younger physicians. It is also possible that male physicians may be concerned about accusations of sexual harassment and may thus be less likely to obtain Pap smears or perform the clinical breast examinations that should accompany mammograms.
We found far fewer differences between female and male physicians in obstetrics-gynecology. The relatively consistent rate of cancer screening may result from the unique focus of obstetrician-gynecologists on women's health, from fewer differences in the interpretation or use of guidelines in the field, or from the fact that obstetrician-gynecologists feel more comfortable in caring for female patients.
Finally, these data suggest that certain aspects of the care rendered by women physicians may be more effective than the care provided by male physicians, at least for women patients. If so, it will be beneficial to identify the factors responsible for the differences, particularly if they can be incorporated into the practice of all physicians, regardless of sex.
Supported in part by a grant (R01-CA-52994) from the Public Health Applications Research Branch of the National Cancer Institute.
We are indebted to Jerry Lutgen, Cindy Taylor, Sharla Rose, and Kirstin Peterson for assistance with the preparation of data, to John MacLean for assistance in the preparation of the manuscript, and to Judith Garrard, Ph.D., for reviewing the manuscript.
Source Information
From the Departments of Medicine, Hennepin County Medical Center and the University of Minnesota (N.L., K.M.); the School of Public Health, University of Minnesota (N.L., P.M., J.E.); the Cancer Control Section, Minnesota Department of Health (J.S.); and the Center for Health Care Policy and Evaluation, United HealthCare Corporation (L.Q.) -- all in Minneapolis.
Address reprint requests to Dr. Lurie at the Medicine Office (814), Hennepin County Medical Center, 701 Park Ave., Minneapolis, MN 55415.
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