A 2017 study concluded that elderly hospitalized patients treated by female internists have lower mortality and fewer readmissions compared with those cared for by male internists. But does this study really reflect the most important factors that should be considered when choosing a primary care provider?
Stories in the media about this study have been making the rounds online. It is the latest way that we oversimplify the complicated process of selecting a primary caregiver.
It ignores the fact that the study focused on elderly patients admitted to a hospital. Instead, its conclusions have been generalized to doctors at large.
Googling Dr. Google
Every year, more and more people turn to the Internet as their primary source of health information and advice. Already nearly half have adopted this habit, leaving just 14% of all patients looking to actually talk to a doctor before Googling symptoms or lurking through health-related forums.
Now, according to the pop science, Cliff Notes addendum to the clinical study, the informed consumer can confidently eschew male physicians in favor of female doctors.
How the story drove consumer choice
Popular reporting on the JAMA story fed right into the notion that patients are (or should be) consumers of healthcare. The message is that you should:
- Shop around for providers and services
- Do your own market research before making any purchasing decisions
- Have skin in the financial game by paying higher deductibles and leveraging HSAs.
It may be tongue-in-cheek, but the catchphrase has already emerged: Ask if there’s a female doctor available, and you (or an elderly family member) might live longer.
If we are going to fully commit to this “informed shopper” approach to pairing people with primary care providers, it may be worthwhile to suggest that selecting the right flat-screen TV isn’t a more nuanced decision than connecting with the right provider.
Making “mid-levels” great again
Suppose we accept the premise that gender is a reliable predictor of quality of care—among physicians. How about a Medical Assistant (MA), Physician’s Assistant (PA), or a Nurse Practitioner (NP) compared to any physician?
In the “patients are consumers” model, these mid-level providers are taking on more primary care roles and responsibilities to meet the rising caregiver demand as well as to save costs.
Compared with physicians, “mid-levels” all require less total time in school (reducing input costs) and are reimbursed at lower average levels (reducing payer expenses), making it easier for more people to receive basic care (reducing collective waste in the healthcare system).
But can patients trust the quality of care they receive?
We already know that having nurses of any designation in greater numbers provides superior outcomes in hospitals and clinics.
If we limit the assessment of nurses to those working in a primary care environment, the scales even out. Nurse Practitioners (some of whom, it should be noted, have earned their Doctor of Nursing Practice, confounding the provider naming game) provide equal care to patients as physicians.
If we’re going to continue to play the gender card in assessing providers, it should be acknowledged here that the nursing profession is about 90% female.
Whether that supports the premise of seeking out female caregivers or just reflects some other variable is open for debate.
Gendered care and women’s health
Gendered care adds another wrinkle. Women’s health presents a unique need even at the primary care level.
Meeting demand further strains the already stretched supply of primary care physicians. It adds the need for OB-GYN physicians into the equation.
Even with the added specialization in women’s care, a Certified Nurse Midwife acting in a primary care role can generally match General Practitioner physicians in quality of care while beating them on costs.
In fact, seeing a Nurse Midwife for primary care saves female patients especially, as they can feasibly eliminate the need to pay for a GP and an OB-GYN specialist; one doctor is always cheaper than two.
Narrowing the funnel
Given the influx of digital technology in the healthcare space, it may be worth controlling for provider age as well as gender and specialty.
On the one hand, age might come with experience—that’s generally how we assume wisdom gets packaged.
But in medicine, with its constant stream of innovation and development and technology and science in constant flux, you might just as well see age as a hindrance to keeping up, rather than an indication of accrued wisdom.
By some measures, younger providers do look like the safer, smarter bet.
Doctors and nurses alike stand to benefit from modern advances in simulation during their schooling today. It allows them to come face-to-face with real-world challenges. They can experience specific patient encounters, diseases, and varying patient profiles before they even begin their clinical internships.
They also have the benefit of learning to work with on-the-job technology like EHRs right from the start rather than having to shift workflows and break habits to accommodate new standards.
The advantages of a young female nurse
Taken together, all the evidence so far points to a young, female nurse as the best possible option for patients shopping around to find a primary care provider.
As is typical of such assessments of care quality and outcome statistics, all this accounting treats patients like objects, rather than partners in their own care.
Back to basics
Following the breadcrumb trail of provider gender and credential to the cheapest, highest-quality option available does nothing to prepare patient/consumers to be present and engaged with their primary caregiver.
But I would like to suggest that the real variable for patients to consider in primary care is communication.
Being heard and being understood
A patient’s ability to speak and be heard, to listen and understand, will ultimately determine his or her outcomes in primary care.
As noted before, gender and credentials can play into this. Female patients may feel more comfortable receiving primary care from a Nurse Midwife—even for non-reproductive health issues. Evidence suggests that NPs spend more time on average with each patient, listening and speaking.
Communication skills extend beyond the bedside. Along with annual physicals and recording encounters, part of the responsibility of anyone in a primary care role today is providing context to patients on the uses and limitations of Google and the Internet generally as a health information resource.
This isn’t just a question of tech-savvy or familiarity with the web, but a matter of instilling confidence and providing a human context behind the 1s and 0s.
As much as we talk about using data to inform decisions, most patients will still have a biased perception of both their experience and their care outcomes. What patients want may not be precisely what the data leads them to.
Whether their search is online or in person, they need to feel connected to the people giving them answers. That can be achieved through traditional appointments as well as teleconsultations or even question and answer sessions conducted through a patient portal.
The bottom line
The better the relationship between provider and patient, the better the chances that patients will be able to balance the impulse to seek medical advice online with the professional insight of his or her primary care professional.
Technology doesn’t just keep providers on the cutting-edge of care, it keeps them in contact with patients navigating an intimidating ecosystem.
If communication can foster a stronger relationship, make patients feel more comfortable seeing a doctor, and yield results that patients are satisfied with, does it really matter whether the provider is male or female, doctor or nurse?
That, I think, is the most important question posed by the results of the study.