Gendered Innovations in Orthopaedic Science: Can We Talk?

Every new patient potentially offers a new adventure that challenges us intellectually. But on a busy day, having a patient virtually hand you the completed surgery-scheduling form becomes a joy. “Hey doc, after my ankle sprain, I never felt normal. I can’t play soccer and I don’t trust my ankle on uneven ground. Can you help me?” Yes, I can stabilize that ankle!

Such an occasion embodies one of my medical school lessons: “Listen to your patients. They will always tell you what the problem is.” Indeed, the job is easy when the story and storyteller follow a straight line, but that’s not always the case. On the two-way street of communication, the gender of both the speaker and the listener can impact the interaction, and ultimately, patient satisfaction.

Finding the Tree in the Narrative Forest

Generally, men offer fact-based, task-oriented, directed communication, whereas as women emphasize emotion, experience, and personal narrative [3, 4, 7, 12]. Following that paradigm, it’s likely that my idealized ankle instability patient was a man. I notice that among my new patients, the women more often provide a rich, detailed history of present illness. Considering the patients with whom I have long-term relationships, I recall the personal stories of far more women than men.

To illustrate the narrative approach, consider an older woman I treated for vague ankle pain. She wasn’t exactly sure why her primary care doctor had sent her, but she knew that her ankle didn’t feel quite right. Respecting her age, I girded myself to allow even more than the requisite 2 minutes of patter before asking her directed questions. During her allotted time, she even discussed her vacation with no apparent relationship to the ankle fracture repair the year before. I recall the tale seemed to cover her entire trip before the patient mentioned her annoyance at the little bump that opened and drained during a party. “And, you know, it had done that once before. Very distressing.”

If I had tuned out or truncated her monologue, I would have missed her handing me the diagnosis of a latent infection. Such a classically “female” narrative communication style relates to a gender-based tendency to perceive communication as a process. Building this sense of relationship with the patient can be reassuring and improve compliance with treatment for both men and women [11, 14].

Considering communication in the exam room as merely transactional, or a mechanism for extracting the history of present illness and issuing treatment edicts, can doom a meaningful patient-doctor relationship. A conversation that goes beyond simply sharing information – from banalities about the weather to finding commonalities through experiences, interests, or hobbies – offers a chance for our patients to assess us as both physicians and human beings. This aspect of communication seems to be more valued by women than men [7].

Patient-centered Communication: Let’s Talk

But physician gender may be associated with characteristic patterns of communication as well. A study of primary-care physicians found that women physicians averaged longer appointments and demonstrated more partnership behavior and emotionally-focused talk than colleagues who are men [11]. Women physicians also exhibited empathy, question-asking, and information-giving more consistently than physicians who are men [5]. These findings were from studies of primary care and pediatric physicians, potentially limiting attribution to orthopaedic surgeons. Further, these behaviors do not universally predict overall patient satisfaction with physicians [11]. However, empathy and information-sharing should be fundamental even in a surgical practice.

As an extension, there may be inherent differences in the patient-doctor relationship predicated on the genders of each party. Based on primary care experience, gender-concordant dyad (same gender of patient and physician) visits produced higher satisfaction scores than discordant appointments in one study [2] but not another [5]. That I perceive that far more of my long-term women patients shared their personal stories may reveal as much about me as a woman, and about how I develop patient-doctor relationships. Independent of the dyad type, these studies demonstrated that the highest levels of patient satisfaction emerged in the course of exploration of patient concerns and expressions of empathy. Thus, despite the gender of either party, patients seek the same fundamental components in the relationship. Women physicians may be more predisposed to provide this patient-centered communication.

Why Does It Matter and What Can We Do?

Patients consistently cite communication as a critical component of satisfaction [6, 13], and patient satisfaction influences everything from referrals to reimbursement. Communication failures frequently are found as a root cause for medical errors or malpractice suits [6, 14]. Unfortunately, orthopaedic surgeons may not provide the best communication. A survey on how well the physician communicated demonstrated discordant perceptions between orthopaedic surgeons and their patients [6, 14]. Although being listened to was very important to most patients, they felt it was not as highly prioritized by the surgeons. Lack of empathy emerges as the salient factor [14]. Luckily, communication skills can be effectively learned by physicians [11, 13, 14]. Indeed, orthopaedics as a profession has embraced ways to improve communication through more publications and inclusion of formal training programs. For example, Team STEPPS®, a curriculum developed with the Agency for Healthcare Research and Quality, approaches communication as a patient safety issue educating medical teams and patients on critical communication concerns [1, 10].

As medicine increasingly encourages collaborative, evidence-based choices for patients, gender may impact the shared decision-making process. Fundamental to shared decision-making is understanding and answering the issues of greatest concern from the patient’s perspective. In the orthopaedic realm, dismissing the intensity of symptoms hidden in a narrative could delay access to appropriate, effective treatment such as joint replacement [3, 8, 9]. Since surgical outcomes correlated with patient expectations, providing communication that works for both men and women can impact surgical success [13].

Yes, we can talk, and more importantly, we should talk. That starts with the physician carefully listening to the patient and avoiding prejudice based on communication style or word choice as we make assessments and treatment recommendations. Further, conversation should be considered more than a directed means to obtain a diagnosis. Perhaps especially for the women we treat, it affords the foundation to a trusting patient-doctor relationship which promotes treatment adherence. When it is our turn as physicians to talk, recognize that “female” traits of partnership and empathy may better engage patients of both genders, and guide patient-centered treatment and ultimate satisfaction.