Gender differences in the application of communication skills, emotional labor, stress-coping and well-being among physicians.
The increase of female physicians in medical practice is a result of the rising percentage of women that have enrolled in medical schools in Canada and the U.S. During the 1990's, 43.7% of medical school enrollees in Canada were women, with comparable numbers in the U.S. (1) These factors have implications for health care delivery in that differences in communication styles between females and males have been documented in the medical and non-medical literature. (1-4) The purpose of our study is to compare whether male and female physicians differ in their use of communication skills, emotion work, burnout, strain, and use of stress-coping strategies. Our findings from each of these variables will be discussed as well as the relevant literature on gender differences.
Female physicians have been found to be more sensitive to the doctor-patient relationship, more accepting of patients' feelings, and more open to the social and humanistic aspects of patient care. (1) Male physicians favor a biomedical pattern, whereas female physicians favour a bio-psychosocial or psychosocial pattern. (2) Females attach greater emphasis on conversations to establish and maintain relationships, to show support, understand feelings, whereas males attach greater emphasis on conversation to serve instrumental purposes, obtain information, and problem solve, minimizing feelings and emotion. (3) Females have been found to express more emotions, and to favour emotionally supportive talk more than men. (2,56) Females also spend more time building rapport, and ask more open-ended questions. (7) Female physicians offer more options and spend more time to negotiate treatment possibilities with both female and male patients. (2,6) They also are more likely to use paraphrasing techniques when patients did not understand questions, and to provide more information about diagnosis and treatment. (6) The increased important of communications for females is also reflected in the amount of time spent with each patient. Female physicians on average spend more time with their patients. (6,8)
The medical interview is the channel that enables patients to disclose and discuss health problems that impede their ability to maintain their routine or daily functioning at the level to which they have become accustomed, and are explored throughout the five stages of the medical interview; initiating the session, gathering information, building the relationship, explanation and planning, and closing the session. (9) Specific skills required in each of the stages are content (what is communicated), process (how it is communicated), and perceptual (thinking and feeling). (9)
During the initiating stage a variety of process skills and positive emotions expressed verbally and non-verbally are utilized to facilitate rapport and connection with the patient. In the information gathering stage, the patients' perspective of illness, biomedical symptoms and background information are elicited through open and closed questioning, including the use of non-verbal cues and the interpretation of patient nonverbal cues during discourse. (9) In the building stage consideration of the patients' point of view through expressions of concern and support are achieved through the use of empathic concern, which places cognitive and affective demands on physicians. (9) This approach embraces the imagined participation cognitively in the subjective experience of the patient, as well as resonating with it emotionally. (10) The pain experienced by the patient cannot be felt physiologically, but will be shared, and is communicated back to the patient through deep acting. (10,11) Deep acting involves aligning inner feelings and associated emotions, permitting the expression of self, leading to a sense of professional authenticity." Deep acting has been found to be associated with self-authenticity and personal accomplishment. (13)
Non-verbal forms of communication help patients convey information regarding their illness, level of distress, and aid in the diagnostic and treatment process. A Dutch study of psychiatric patients indicated that information imparted from non-verbal communication is beneficial in the diagnostic process, in evaluating change, and as a predictor of the prospects of depressed patients. (14) Similarly, patients with coronary disease display distinctive vocal and facial expressions. (15)
Studies have indicated that females are more proficient than males in encoding and decoding nonverbal language (use and interpretation of non-verbal communications). (4,8) The nonverbal cues of responsiveness (using a wide range of emotions) and immediacy (showing positive emotions to indicate liking) are more pronounced in females than males. (3, 4-5, 8)
Patients' health beliefs and values have a significant impact on clinical care, requiring sensitivity and responsiveness. Building the relationship through related forms of empathic concern involves exploring these beliefs and values and acting upon them in appropriate ways through verbal and non-verbal means. Studies have indicated that female physicians have practice styles that are sensitive to patient's psychosocial problems, and are better able to detect patient's feelings, including undisclosed agendas and conflict. (2,6) Females were also found to be more empathic and focused on emotions. (6,8) Females are more likely to engage in the type of exchange that explores issues of personal meaning and values within a broader social and cultural context. (5,16) In a follow-up study of medical graduates female physicians were found to place greater value to social factors in health and disease, psychological factors in health and disease, and cultural factors in health and disease. (17)
Physicians diagnose and treat patients and are attuned to the biomedical symptoms that patients present. However, disease and illness are subject to many influences, and the quality of the patient-physician relationship may impact whether or not a successful outcome occurs. To engage in this process places cognitive, affective, and psychomotor demands on the physician in the form of emotion work. (18) Emotion work is comprised of emotional labour (the effort, planning, and control needed to express the professionally and culturally desired emotion during interpersonal transaction) and display rules (the emotions that are experienced, expressed, and how they are understood by patients). (3,18) Emotional labour includes the duration, frequency, variety and intensity of emotions displayed (18), as well as the enactment of unfelt emotions (faking), suppression of felt emotions (hiding) and deep acting (displayed emotions also genuinely felt). (18) The display rules, which operate at the socio-cultural (3) and professional levels (19), regulate physicians to suppress negative feelings and express positive ones to facilitate patient discourse. (18) Emotion work is inherently stressful. The stress comes not only from the mental effort required during emotional display and enactment, but also in reconciling the discrepancy between expressed and experienced emotions inherent in faking and hiding. Communications and emotion work are inextricably linked and when they are in accord have health benefits for both patient and physician. (20) Emotion work provides physicians with a potential to deliver higher quality of care, all stemming from enhanced interactions, greater job satisfaction, greater personal accomplishment and less malpractice claims. (15,20)
Gender differences have been found in the display of positive and negative emotions. Females were found to follow the display rule pattern of expressing positive emotions and suppressing negative ones more frequently than men. (21) This suggests that female physicians are more likely than male physicians to feel at ease when showing positive emotions. (21)
The interpersonal demands of patient care exact physical and mental strain and lead to inauthentic feelings. (22) Research examining gender differences in strain suggests additional sources of stress. Female physicians faced conflicting responsibilities between career and family, and male physicians found relationships with patients, and threats of malpractice, particularly troublesome. (17,23) Female physicians also incur greater strain when they resort to stopgap remedies, such as working through breaks and lunch or working longer hours at the end of the day. (5) Among health care professionals, gender differences in burnout have been mixed (24), with some research reporting females higher. (25,26) A recent study in the U.S. reported that female physicians experienced higher levels of burnout than male physicians, however a study in The Netherlands reported no gender differences. (26) Greater burnout in female physicians may be due to gender role expectations of attending to the emotional needs of patients. Frequent and intense patient interactions all have links to emotional exhaustion. (24,27)
Stress coping involves behavioral or cognitive responses to internal threats, where the specific strategies are either emotion or problem-focused. (28) Females are more likely to exhibit emotional responses to problems and seek social support than males, whereas males are more likely to confront a problem head-on or deny a problem exists. (29) Differences in stress coping strategies may be attributable to how females and males differ in their appraisal of the severity and nature of the stressors. In a study of attending physicians in two hospitals in the United States, women reported more symptoms of psychological distress and grief, and used more coping strategies than males. They also needed and received more social and collegial support than males. (30) Female physicians may attempt to cope with the stress of high expectations, juggling multiple roles, as well as a stressful work environment (5) by reducing their practice from full to part-time. (5,31) A reduction in patient load enables female physicians to spend more time per patient and avoid the stressors of falling behind schedule than if practicing fulltime. (31) A meta-analysis review of stress-coping found that women more so than men sought social support, used active and problem-focused coping, engaged in positive reappraisal, wishful thinking and avoidance behaviors. (29)
No study has examined how female and male physicians differ in emotional labour, well-being and stress coping strategies in conjunction with the stages of the medical interview. We test the following four hypotheses:
HI: Compared to males, females engage in greater usage of communication skills to facilitate patient interactions.
H2: Compared to males, females engage in greater use of emotion work.
H3: Compared to males, females experience higher levels of burnout and strain.
H4: Compared to males, females use more stress-coping strategies.
Research took place in the fall of 2006 in a province of Canada. Surveys were distributed by the provincial medical association's bi-monthly newsletter to its members, and a direct mail-out by the researchers to the work addresses obtained from the College of Physicians and Surgeons public access website. The survey's cover letter states that, "We are conducting a study on how physicians interact and communicate with their patients, and cope with some of the major factors that lead to job stress. As caring and dedicated members of the medical profession, we wish to invite you to participate in this study by filling out the enclosed survey questionnaire. Your responses are invaluable to us for better understanding how physicians manage the challenges of their profession, and may offer insight into developing ways to improve how physicians relate to their patients and better manage their careers."
Completed questionnaires were sent to the first author's university mailing address. We received 278 surveys of 14% of the population, 53% were from members of the provincial medical association, and 47% from members of the College of Physicians and Surgeons. The low response rate is partially attributable to the university health research ethics board not granting permission to send follow-up reminders.
We compared the sample and population on the proportional representation of gender, location, and specialty. The sample was 40% female compared to 30% of the population; 80% urban compared to 75% of the population, and 40% family medicine compared to 51% of the population. For the remaining specialties of internal medicine, pediatric disciplines, surgical disciplines, residents, psychiatry, public health, and lab medicine, differences ranged from 2% to 8%.
For this sample, mean years in practice were 16.49 (SD = 11.05); mean percentage of time in patient care was 67.80 (SD = 24.11); mean minutes per patient were 19.04 (SD = 14.76). Percentage of physicians who were Caucasian was 84.6%. Mean percentage of female patients was 57.85% (SD = 14.62), male patients 43.56% (SD = 11.82); mean percentage of Caucasian patients was 62.61% (SD = 23.83); aboriginal 23.57% (SD = 21.35); other 13.12% (SD = 9.16%).
Part A of the Cross-Cultural Doctor-Patient Communication Needs Assessment' asked how competent respondents felt in handling socio-cultural issues during patient interactions. Two factors were derived: (1) use and interpretation of non-verbal communications (e.g., interpreting different cultural expressions of pain, distress, and suffering; five items, [alpha] = .81) and (2) handling culturally sensitive beliefs (e.g., addressing patients in culturally appropriate ways that result in a therapeutic alliance; three items, [alpha] = .78). Part B asked respondents: (1) how often 21 different behaviors were used to facilitate communications with patients of differing backgrounds, and (2) how useful the behaviors were for improving communications. Two process skill factors were derived from the frequency ratings: (1) initiating the session (e.g., making the patient feel welcome; six items, [alpha] = .78), and (2) explanation (e.g., eliciting the patient's agenda; six items, [alpha] =.76). Two reasoning and perceptual skill factors were derived from the usefulness ratings: (1) building the relationship and information gathering (e.g., allowing time for the patient to ask questions; 10 items, [alpha] = .86), and (2) explanation (e.g., eliciting the patient's self-diagnosis; five items, [alpha] = .82).
The emotional labour scale (33) assessed seven dimensions, the first six with three items each. Respondents used the stem: " On a typical day, how frequently do you perform such behavior?" to indicate showing (1) frequent emotions ([alpha] = .69), (2) intense emotions ([alpha] = .95), (3) variety of emotions (a= .95), and enacting (4) faking (e.g., show emotions that I don't feel, [alpha] = .77), (5) hiding (e.g., resist expressing my true feelings; [alpha] = .71), and (6) deep acting (e.g., try to actually experience the emotions that I must show; [alpha] = .87); the seventh asked the mean minutes spent per patient. The two display rules scales (34) assessed showing positive emotions (e.g., reassuring people who are distressed or upset; four items, [alpha] = .77), and suppressing negative emotions (e.g., hiding disgust over something someone has done; three items, [alpha] = .82), where respondents rated the statements using the stem: "In a typical day, indicate how often each of the following behaviors are required for your work."
The self-authenticity scale' had respondents rate how often the five items were true (e.g., I experience the professional aspect of myself as an authentic part of who I am; [alpha] = .78). The physiological symptoms of strain scale (36): headaches, upset stomach, gas or bloated feeling, trouble getting to sleep, had respondents rate how often the four symptoms were experienced during a typical week. ([alpha] = .59). Three burnout dimensions" were assessed: emotional exhaustion (e.g., I feel like I'm at the end of my rope; nine items, [alpha] = .91), depersonalization (e.g., I feel I treat some patients as if they were impersonal objects; five items, [alpha] = .71), and personal accomplishment (e.g., I can deal very effectively with the problems of my patients; eight items, [alpha] = .72), where respondents rated how often the behaviors occurred during a typical week.
Two measures were used. The Ways of Coping Checklist (38) assessed two behavioral strategies: seeking social support (e.g., talking to someone about how I was feeling; six items, [alpha] = .77), and escape avoidance (e.g., hoping a miracle would happen; eight items, [alpha] = .78), where respondents rated how often they engaged in specific behaviors, using the question stem, " Last week, I dealt with a highly stressful situation by ... " The Cybernetic Coping Scale (38) assessed the behavioral strategy of changing the situation (e.g., I focused my efforts on changing the situation; four items, [alpha] = .83), and the cognitive strategies of accommodation (e.g., I made an effort to change my expectations; two items, [alpha] = 65), devaluation (e.g., I told myself the problem was unimportant; four items, [alpha] = .80), avoidance (e.g., I tried to avoid thinking about the problem; four items, [alpha] = .78), and symptoms of stress relief (e.g., I just tried to relax; four items, [alpha] = .76).
The hypotheses were tested with independent one-tailed t-tests. Table 1 shows the means and standard deviations of genders, the t-test results, and the effect size of the difference (Cohen's d).
For H1, which posited that females engaged in greater communication skills than males, females were higher than males on use and interpretation of non-verbal communication, handling culturally sensitive beliefs, both process skills, and on the reasoning and perceptual skills of building the relationship and information gathering. No difference was found for reasoning and perceptual skills of explanation. HI was supported for five of the six communication skills.
For H2, which posited that females engaged in greater use of emotion work than males, females spent more minutes per patient, showed a greater variety of emotions, more often engaged in deep acting, and followed the display rule of showing positive emotions. No difference was found for either intensity of emotions shown, faking, hiding, or following the display rule of suppressing negative emotions. H2 was supported for five of the nine emotion work variables.
For H3, which posited that females experienced higher levels of burnout and strain than males, females more than often than males experienced greater strain. No difference was found for any of the burnout dimensions. H3 was supported for two of the five subjective well-being variables.
For H4, which posited that females used a greater range of stress-coping strategies than males, females more often then males sought social support, changed the situation, accommodated one's expectations and relieved the symptoms of stress. No difference was found for escaping the problem, devaluing the problem's severity or avoiding thinking about the problem. H4 was supported for four of the seven stress-coping strategy variables.
Our communication findings are consistent with the literature, which indicates that females attach greater importance to the psychosocial aspects of patient care, are more sensitive to alternative beliefs, and engage in greater use of process skills to facilitate this engagement. No significant difference was found for reasoning and perceptual skills during explanation, which suggests that females and males are equally proficient in content skills. Studies indicate that positive and conducive physician-patient communication has a beneficial impact on quality of care. Patients report better symptom resolution, emotional health, physiologic measures, pain control', satisfaction, improved functioning, health services utilization" medication taken in the right dosages. (20)
External time constraints, though, are inhibiting the disclosure of concerns by patients, socio-emotional discussions are abandoned and the biomedical takes precedence. (5) This is a greater issue for the females, as their communication style is more suited to socio-emotional encounters and is reflected in their desire to reduce their work hours rather than eliminate psycho-social tasks. (5) Physicians feel that communication difficulties are attributed to a lack of resources, high patient volumes, and patient's inability to understand physician difficulties. (6)
Emotion Work and Well-Being
Our findings indicated that females more often than males spent more time with patients and expressed a greater variety of positive emotions, which is consistent with other research. (8)
Females appear more comfortable with and adept at emotion work, as is reflected in their greater usage of a variety of emotions. Believing that building the relationship with patients was important may have resulted in empathic concern towards patients, enacted through deep acting. (10) Use of deep acting allows for genuine self-expression (11) and feelings of authenticity (13), and partly accounts for why females felt more self-authentic than males. Our findings contrast with Erikson and Ritter's study (22), which found that emotional labour led to burnout and inauthentic feelings. No gender differences were found for either surface acting or burnout, but differences existed for deep acting and strain. Enacting heart felt emotions were mentally and physically draining, especially in monitoring and controlling one's internal state and displaying empathic concern, thus the greater strain experienced by females. In contrast, surface acting, as an undesirable form of emotional expression, was used with equal infrequency across genders, whereas, hiding as a more acceptable way to manage negative feelings, was used with equal frequency as well.
The strain experienced by females may account for the greater variety of behavioral and cognitive stress-coping strategies that were utilized in contrast to the males. Females, having more strain than males, would be motivated to find various means to reduce the stressors or their impact. The choice of coping strategies is influenced by gender based norms, where, for example, seeking social support from relatives, colleagues and friends may be more socially acceptable for women than men. (31)
Females in our study were more willing to change the situation, such as spending more time with patients, reducing the numbers of patients, as female physicians in other studies have done. (5) Reduction in patient loads allowed them to spend more time in non-work activities, but may have required accommodation in their professional and personal expectations. (31)
Our findings should be interpreted with caution, given the low response rate, however the sample is representative relative to the population of physicians in the province and was within 10% or less on gender distribution, practice location, and specialty. This demographic representation, along with findings that are consistent with previous studies on physicians in other settings, does suggest that our findings are not idiosyncratic or unique to this sample.,
The core of medical practice is the relationship between patient and physician. Satisfaction with this relationship is directly related to the quality of communications that occur. Of particular interest are our findings regarding the interpersonal aspects of care, and their link to the use of emotions as an inherent component of the bio-psychosocial model of health care. (40) Few studies to date have analyzed how physician gender impacts upon communications, stress, and stress coping. Our study has implications for medical practice, and professional development.
Conflict of interest: None declared.
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Brenda Lovell , Raymond T. Lee , Celeste M. Brotheridge 
 University of Manitoba, 490 Drake Centre, Winnipeg, Manitoba, Canada
 Universite du Quebec a Montreal, Montreal, QC, Canada
Corresponding author: Brenda Lovell, University of Manitoba
490 Drake Centre
Winnipeg, Manitoba, Canada
R3T 5V4 Ph: 204-474-6745
Table 1. Difference between male and female physicians. Variable Males M SD Communication Skills 1. Use & interpretation of nonverbal comm. 3.38 .63 2. Handling culturally sensitive beliefs 3.05 .86 3. Process skills: Initiating the session 4.43 .48 4. Process skills: Explanation 3.87 .69 5. Reasoning & perceptual skills: Building 4.39 .52 the relationship and information gathering 6. Reasoning & perceptual skills: Explanation 4.05 .70 Emotion Work and Well -Being 7. Mean minutes per patient 16.52 12.71 8. Frequency of emotions shown 3.44 .71 9. Variety of emotions shown 2.78 .98 10. Intensity of emotions shown 2.37 .88 11. Surface acting: Faking 1.91 .87 12. Surface acting: Hiding 2.87 .72 13. Deep acting 2.30 .96 14. Showing positive emotions 3.67 .66 15. Suppressing negative emotions 2.44 .89 16. Self-authenticity 3.99 .71 17. Personal accomplishment 3.71 .42 18. Physiological symptoms of strain 1.55 .58 19. Emotional exhaustion 2.41 .72 20. Depersonalization 1.85 .60 Stress-Coping Strategies 21. Seek social support 2.59 .86 22. Escape the problem 1.50 .57 23. Change the situation 3.00 .79 24. Accommodate one's expectations 3.20 .73 25. Devalue the severity of the problem 2.34 .75 26. Avoid thinking about the problem 2.04 .70 27. Relieve the symptoms of stress 2.70 .76 Variable Females M SD Communication Skills 1. Use & interpretation of nonverbal comm. 3.51 .59 2. Handling culturally sensitive beliefs 3.30 .76 3. Process skills: Initiating the session 4.61 .37 4. Process skills: Explanation 4.06 .59 5. Reasoning & perceptual skills: Building 4.53 .42 the relationship and information gathering 6. Reasoning & perceptual skills: Explanation 4.15 .64 Emotion Work and Well -Being 7. Mean minutes per patient 22.35 16.57 8. Frequency of emotions shown 3.61 .79 9. Variety of emotions shown 3.14 1.04 10. Intensity of emotions shown 2.29 .85 11. Surface acting: Faking 1.90 .76 12. Surface acting: Hiding 2.85 .75 13. Deep acting 2.76 1.10 14. Showing positive emotions 4.01 .57 15. Suppressing negative emotions 2.34 .90 16. Self-authenticity 4.20 .57 17. Personal accomplishment 3.77 .36 18. Physiological symptoms of strain 1.72 .64 19. Emotional exhaustion 2.49 .72 20. Depersonalization 1.77 .56 Stress-Coping Strategies 21. Seek social support 2.99 .77 22. Escape the problem 1.61 .59 23. Change the situation 3.24 .76 24. Accommodate one's expectations 3.44 .72 25. Devalue the severity of the problem 2.33 .79 26. Avoid thinking about the problem 2.03 .70 27. Relieve the symptoms of stress 3.10 .82 Variable Cohen's t-ratio d Communication Skills 1. Use & interpretation of nonverbal comm. 1.67 * .20 2. Handling culturally sensitive beliefs 2.46 ** .30 3. Process skills: Initiating the session 3.20 ** .39 4. Process skills: Explanation 2.32 * .33 5. Reasoning & perceptual skills: Building 2.17 * .28 the relationship and information gathering 6. Reasoning & perceptual skills: Explanation 1.14 .14 Emotion Work and Well -Being 7. Mean minutes per patient 3.01 ** .40 8. Frequency of emotions shown 1.78 * .22 9. Variety of emotions shown 2.85 ** .35 10. Intensity of emotions shown .74 .09 11. Surface acting: Faking .05 .01 12. Surface acting: Hiding .19 .02 13. Deep acting 3.47 ** .44 14. Showing positive emotions 4.49 ** .55 15. Suppressing negative emotions .96 .12 16. Self-authenticity 2.47 ** .30 17. Personal accomplishment 1.19 .15 18. Physiological symptoms of strain 2.34 ** .29 19. Emotional exhaustion .87 .11 20. Depersonalization 1.02 .12 Stress-Coping Strategies 21. Seek social support 3.78 ** .47 22. Escape the problem 1.50 .19 23. Change the situation 2.50 ** .31 24. Accommodate one's expectations 2.64 ** .32 25. Devalue the severity of the problem .10 .01 26. Avoid thinking about the problem .14 .02 27. Relieve the symptoms of stress 3.94 ** .49 Note. Males n = 166; females n = 112. All variables, except mean minutes per patient, range from 1-5. * p < .05, 1-tailed test; ** p < .01, 1-tailed test.
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Lovell, Brenda; Lee, Raymond T.; Brotheridge, Celeste M.|
|Publication:||Archives: The International Journal of Medicine|
|Date:||Jul 1, 2009|
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