Gender Bias Through a Patient's Lens

Think back to the last time you went to the doctor. How would you rate the quality of care you received? Did the doctor show concern toward your health? And how would you describe their bedside manner? Did they seem compassionate, intelligent, funny or rude?

According to Stanford Professor of Radiology and Clayman Institute Faculty Fellow Dr. Nishita Kothary, you might answer differently depending on your doctor’s gender.

At a Clayman Institute Faculty Research Fellow presentation titled “Seeing Through a Patient’s Lens,” Kothary revealed how gender shapes patients’ evaluations of primary care physicians. Patients are 25 percent more likely to use communal language – words like “warm,” “compassionate,” and “nurturing” – when describing women physicians than men.

Dr. Nishita Kothary

With the rise of social technology, we live in an era where consumers rate just about everything. People rate restaurants on Yelp, household items on Amazon, and rideshare drivers on Lyft. And if you are a patient at one of Stanford’s outpatient clinics, you may receive an email asking you to evaluate the quality of your health provider.

Like Yelp, Stanford’s health clinic survey asks patients to rate their physicians between 1 – 5 stars. Patients also have the option of writing comments about the quality of their care.

Working with an interdisciplinary team of linguists, computer scientists, social scientists, and physicians including Magali Fassiotto, Emma Pierson, Dan Jurafsky, Heidi Chen, Bonnie Maldonado, and Jonathan Altamirano, Kothary’s team analyzed 40,000 reviews from patients who visited a Stanford outpatient clinic in 2016-17. Patients rated physicians in more than 50 medical departments, including fields like neurology, oncology and orthopedics.

Using a list of keywords generated from previous studies of gender bias in medicine, Kothary’s team examined how patients’ ratings varied based on their doctor’s gender. During her talk, Kothary discussed the team’s preliminary results, which were based on a subset of 12,000 reviews of physicians in the fields of primary care and internal medicine.

“Typically, when you look at recommendations, communal language is associated with a worse score for women. What was interesting was that the use of communal language did not decrease women’s quantitative scores.”

Kothary’s team found the inclusion of communicative language in patients’ reviews increased primary care providers’ quantitative scores. They also found that patients were more likely to use communal language when writing reviews for women physicians. And yet, Kothary’s team did not find that women averaged higher quantitative scores than men overall. Instead, their preliminary results showed that a physician’s gender did not have a statistically significant impact on the ratings they received.

Understanding how gender shapes patients’ evaluations of their physicians is integral to furthering women’s advancement in academic medicine. At Stanford, the medical school takes patients’ evaluations into consideration during physicians’ annual performance reviews, which can affect physicians’ opportunities for promotions, raises and bonuses.

For Kothary, the fact that patients included more communal language in their reviews of women physicians is both a blessing and a curse. On the one hand, her team’s preliminary findings are indicative of the high quality of care women physicians are providing their patients. Within the field of primary care, women physicians might be spending more time listening to and addressing patients’ concerns. They also might be more inclined to solicit their patients’ input when making decisions about their health. Patients may feel more comfortable speaking with women physicians about different treatment options, which can translate into better health outcomes.

“Women physicians live in a really dichotomous world. In the academic field of medicine, we are supposed to be really tough and strong. But if you look at patients, they want physicians who use communal language."

Yet, on the other hand, Kothary cautioned against interpreting her team’s preliminary results in a wholly positive light. To receive a positive review, women might need to spend more time talking to patients than men, which could place women at risk of seeing fewer clients per day. Hospital administrators might perceive women who spend more time with their patients as less “productive” than their colleagues, thus jeopardizing women’s chances of receiving raises, bonuses or promotions. 

During her talk, Kothary explained how these dueling expectations can place women in a double bind.

“Women physicians live in a really dichotomous world. In the academic field of medicine, we are supposed to be really tough and strong. But if you look at patients, they want physicians who use communal language. They want physicians who are warm and fuzzy. If I were a patient, I don’t think I’d want to be with a hard-nosed person who doesn’t have enough time of day to see me.”

Next, Kothary’s team plans to broaden their analysis to examine patients’ evaluations of physicians in medical specialty fields, including orthopedics, oncology and neurology. They are also planning to examine why women physicians did not receive an overall rating boost in comparison to men, despite the fact that the inclusion of communal language – which patients more often included in reviews of women physicians – increased physicians’ quantitative scores.

Kothary’s interest in gender research developed several years ago, after noticing how gender biases were negatively shaping women physicians’ opportunities for advancement at Stanford’s School of Medicine. “I was sitting at a luncheon. It was all female physicians, and five out of the 20 female physicians’ promotions had been held up because their trainees – fellows, residents and medical students – didn’t think they were nice people.” 

For Kothary, this moment served as a wake-up call. “When I looked at those numbers, I thought, it can’t be that Stanford has so many bad female faculty. Five out of 20, that’s a quarter of us. It couldn’t be that a quarter of us were just bad human beings.”

Kothary designed a research study to get to the root of the problem. “I’m a huge data person. If you try to speak up about a problem, people are often inclined to just roll their eyes. But if you show them numbers, it begins to make sense to them.”

Working in collaboration with colleagues in Stanford’s School of Medicine and Office of Faculty Development and Diversity, Kothary analyzed five years of graduate medical education teaching evaluation data.

The results, published in 2018 in the Journal of Surgical Education, confirmed Kothary’s hunch. Her team found that students in male-dominated surgical fields perceived women physicians as less competent teachers than men.

Kothary, however, didn’t stop there. She brought her results to the Stanford School of Medicine, which began to recognize how gender biases were built in for women in male-dominated surgical fields.

In Kothary’s field of expertise, radiology, nearly 90 percent of doctors are men. Despite working in one of the discipline’s most sex-segregated fields, Kothary has published more than 50 articles in top medical journals. Before joining Stanford School of Medicine in 2006, she was the chief resident in radiology at George Washington University and an assistant professor of radiology at Columbia University. Currently, Kothary is the lead faculty for the Department of Radiology’s Cancer Clinical Trials Office, where she received Stanford Cancer Institute’s award for Outstanding Performance in Clinical Research in 2013.

(Photo by Arvin Chingcuangco on Unsplash)