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Tuesday Jan 10, 2017

Why Do Women Docs Get Better Results (and Lower Payment)?

Studies have shown that female doctors are more evidence-based(onlinelibrary.wiley.com) than their male peers and are more likely to follow clinical recommendations(www.ncbi.nlm.nih.gov). So it was only a matter of time before someone asked the question: Do female physicians achieve better outcomes than male physicians(blogs.sph.harvard.edu)?

The answer, according to Harvard researchers who studied 1.5 million hospitalized Medicare patients, is yes. A study published last month in JAMA Internal Medicine(jamanetwork.com) found that if male doctors achieved the same outcomes as their female counterparts, there would be 32,000 fewer deaths each year in the Medicare population. 

What does it all mean? The study's authors have suggested that in addition to taking a more evidence-based approach, women likely communicate better than men.

 Beth Oller, M.D., and Mike Oller, M.D.

They also pointed out that despite equal -- if not superior -- outcomes, female physicians make, on average, significantly less than their male peers(pmj.bmj.com).

AAFP News recently sat down with family physician Beth Oller, M.D., -- a regular contributor to the Fresh Perspectives blog -- and her husband and practice partner, Mike Oller, M.D., to discuss gender, health care, communication and payment.

AAFP News: You've both read the study and seen the media reports about it. What are your thoughts?

Beth: One thing that struck me as interesting is that medical classes are half female, but we're only a third of the work force(www.advisory.com). I think if we looked at it we would find that the same traits that might make women better physicians -- the things that they talk about in the study, like paying a lot of attention, following evidence and having more time to discuss things with patients more carefully -- are also the reasons that you see the drop from half to a third. Burnout and compassion fatigue are very real things that we don't address a lot in medicine, and I think they hit women hard. We need to work on changing the system so that the kinds of treatments provided by the women in the study -- which make patient outcomes better -- are possible.

Mike: I'm a white male, which either makes me the control group or the enemy. I'm not sure which one. It bothers me to hear these statistics, but it also troubles me from a personal point of view because A) I don't think I give bad care to patients, and B) I don't think I'm robbing the system of money. I'll tell you there are white male physicians in the counties around me that I wouldn't send people to, but it has nothing to do with race or gender; it has to do with competency. Some people are good at things and some people are not so good.

Beth: Some men are great at the communication aspect, but I think it's fewer. Maybe it's because it's not as valued, and emphasis isn't put on it as much for men in medicine. As a female in medicine, you have to prove yourself more to people, especially with the older generation. So we have a tendency to sit and talk more and make sure that what we say is heard and understood. For a male in medicine, it's expected that when you walk in the door you have that respect and you're seen as a physician. In some people's minds, female still equals nurse. That doesn't offend me because I was a nurse first. I think we have that more nurturing, caring, comforting role. Woman physician is still not the norm, but it's more accepted and this study is very interesting.

Mike: Some people don't have to be good communicators because they're so good at what they do. Like, "I'm a great surgeon, so you just need to trust me." I'll tell you this: I'm a fairly large, bearded male with a deep voice, but I find more cases of sexual assault and rape than my partners. It's because I overcome my own barriers. I have to communicate better because people look at me, and right out of the gate, they are not going to listen to me unless I use every potential talent I have to communicate.

Beth: It's true. He overcomes his gruff exterior. He'll see someone for 10 minutes at walk-in clinic with a sinus infection and they open up and tell him these things. We need to find out what the women in this study -- and doctors like Mike -- are doing better or differently and focus on teaching that.

AAFP News: The study's results raise some interesting questions about the fact that, in general, women physicians are paid far less than their male peers.

Beth: I would wager that the women in the study are likely not more valued by their institutions for their better care but seen as less cost-efficient because their care takes longer. In the business of medicine, that isn't rewarded. It is rewarded in patient satisfaction, which is why we went through 11 years of school, went into hundreds of thousands of dollars in debt, and work insane hours to take care of our patients and make them happy. But in the business of medicine, especially if you're employed, you're told you need to see more patients, do it faster, document more thoroughly, use your EMR (electronic medical record system) more effectively and get patients out of the hospital sooner. The underlying message is that your job is about money and not patient care, which will burn anyone out.

The business of medicine makes it hard to do the things that could make us better doctors. For Mike and me, the reason we work for ourselves is we can schedule our appointment times and decide how long we spend at the hospital with patients. But when we spend more time with patients, we're not reimbursed for that extra time. If anything, we're paid less. We're willing to make that trade of seeing fewer patients and making less money so we don't feel like cogs in a system or hate ourselves as people. It's dehumanizing and frustrating to have to make the choice of making so much less than your peers in other specialties just to do what's best for your patients.

Mike: As a person who doesn't subscribe to the rhetoric of gender lines and color lines -- I get that they exist because there are jerks in the world -- it would be nice to have a study that says, "competent physicians make more than incompetent physicians," but my guess is that's not true. Maybe one day my kids won't even think about color or gender. You'll just be hired because you're good, and you'll retain your job because you're good.

AAFP News: Do many of your patients have a preference for a male or female physician? Who are people more likely to come to with questions?

Mike: It seems fairly split. People have identified what we're good at. If someone has an OB problem or a kid problem, they go to Beth. If it's more of a medicine or an emergency question, they go to me.

Beth: I have a very young, OB-, female- and child-predominant practice. We have a lot of farmers and ranchers in our community who just don't go to the doctor. I have a lot of older ladies who want their husbands to see somebody. They know their husband is not going to come see me and be comfortable with me, but Mike is a male who is a real straight shooter, and I'll say, "Bring them to see Mike." That doesn't offend me.

AAFP News: Some studies have found that women are more likely to follow evidence-based guidelines and preventive recommendations. What are your thoughts about that?

Mike: I sometimes transfer patients to a hospitalist group, and they have a mixture of men and women doctors. When I talk to women about things like antibiotic regimens or blood pressure control regimens, they'll quote guidelines. When I talk to male physicians, it's more like, "Here's what has worked well in the past. We'll give it a try, and it probably will work again." It's not as rigid among male physicians. But again, the hospital had a male ICU doctor who was by the book and knew every letter of every publication made in the last 30 years.

Beth: As a woman, you're more closely scrutinized. If I have a female coming in for a well woman visit, then I expect my nurse to have when the patient's last labs were, when her last mammogram and Pap were, her colonoscopy and any vaccinations that are needed. I want, for example, every single piece of what the USPSTF (U.S. Preventive Services Task Force) says you need for a 55-year-old woman. I expect that to be in the chart before I see that person so I can go through every piece. That's just the way I practice. I don't know if it's because of gender or not, but I've seen it with other women I've rotated with through med school and residency.

AAFP News: What's the bottom line?

Beth: Maybe this helps determine what kind of people you want to let into med schools. A lot of us come into it with the desire to be good communicators and really care for our patients. The humanity can be beaten out of you with the hours and the need to be productive. You're supposed to be strong. You're not supposed to be overstressed. You're not supposed to feel overworked, and you're not supposed to look weak. All those things are big problems, which is why we have the suicide rate of physicians that we have and the rate of burnout. If we could be allowed to show these characteristics that make outcomes better, it would help alleviate that.

Beth Oller, M.D., and her husband, Michael Oller, M.D., practice full-scope family medicine in Stockton, Kan.

Posted at 04:29PM Jan 10, 2017 by Beth Oller, M.D.

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