Getting Behind the Mask: Improving Quality of Care for Male Patients
Steve Rissman, ND
Over the past few years, there has been a renewed focus on the health and wellness of men. After many years of simple resignation to the fact that men die 5-7 years earlier than women, and that men and boys suffer from nearly all 15 leading causes of death at higher rates than women and girls, the medical community is responding.1 There is increasing awareness of men’s health issues such as prostate cancer, testicular cancer self-exam education, and testosterone supplementation. There is also new interest in men’s issues regarding addiction, post-traumatic stress disorder, fathering, and, most recently, anger.
When one looks at the key determinants of men’s health, often the conclusion is quickly drawn that the disparities between male and female health outcomes are due to men not taking care of themselves as “they should,” but this demonstrates a narrow understanding of men. One important consideration in men’s healthcare is the efficacy of communication between physicians and male patients. How well do physicians get behind the masculine façade to elicit information important to the case? And, perhaps more importantly, how comfortable are male physicians at confronting their own masks that may be inhibiting better communication with male patients?
In December 2016, the Journal of the American Medical Association published an important study showing that hospitalized Medicare patients of female physicians had lower mortality rates and fewer readmissions than those with male physicians, suggesting a difference in practice style between male and female physicians.2 With this in mind, both male and female NDs have a unique opportunity to become a model for a more whole perspective of patient care for men, including doctor-patient communication.
It is well known that men generally communicate differently than women. Men’s communication is often influenced by the construct of masculinity and the associated traits. Traditional masculine norms call for men to be competitive rather than cooperative, and for men to mask their vulnerability, particularly where other men are concerned. Men have been socially guided to remain guarded and not reveal weaknesses, especially with other men. Terry Real, the author of I Don’t Want to Talk About It, says that when men confront each other, there is a hierarchical tendency to their relationship such that one man goes “one up,” thereby creating a power differential forcing the other man into a “one down” position. This construct has a direct influence on communication between the two men. “Therefore, most heterosexual men are not emotionally connected with men and have difficulty self-disclosing because they are often locked into competitive relations with each other.” 5
Concealing vulnerability is in direct conflict with the nature of a physician visit, where the patient is encouraged to discuss areas of health deficiency in great detail. Yet such a disclosure of vulnerability is uncomfortable for most men and boys, and an unwillingness to unmask becomes a roadblock to complete and open communication. Asking for help, admitting weakness, and being fearful are all common patient experiences, but can also dislocate dominant ideals of masculinity, especially when visible to other men, including male physicians. For example, consider prostate cancer, which brings up issues around mortality and treatments, as well as treatment-related side effects such as impotence and urinary incontinence. These conversations can be highly emotional, which can be difficult and uncomfortable for some men. Other conditions that may be difficult for a man to discuss include premature ejaculation, erectile dysfunction, and social anxiety, so he may choose not to bring up these issues, leaving the physician challenged to solve a medical puzzle with missing pieces. Worse yet, he may be too intimidated to even go a doctor. Men are more than twice as likely as women never to have met with a physician, and 3 times more likely not to have had contact with a health care provider for 5 or more years.6 According to Dr Jennifer Hirsch, co-director of the Gender, Sexuality, Health and HIV Research Group at Columbia University’s Mailman School of Public Health, “Showing off your masculinity includes the things you don’t do, notably (not) going to the doctor.” She adds that there are pretty steep consequences. “One example is concurrent diagnosis for HIV. Because men don’t go to the doctor, they are much more likely to have developed AIDS by the time they are diagnosed as HIV-positive.”7
Other hegemonic masculinity ideals include stoicism, anti-femininity, and independence. These ideals are antithetical to the doctor-patient relationship. Stoicism creates a lack of expressiveness, while independence fosters a reluctance to work with the physician in a partnership. For example, men may say, at least to themselves, “I’ll consider going getting it checked out, but I think I know what’s best for myself,” or, “I don’t want any doctor prying into my business.” Men may also view certain medical procedures as conflicting with their sense of masculinity. It has been shown that some men associate a colonoscopy with homosexual penetration, and therefore avoid colon cancer screening. In addition, a 2009 study published in American Journal of Men’s Health found that men associate a digital rectal exam with homosexual activity, and are less proactive in getting prostate screenings.8 It might be interesting to investigate whether such concerns have contributed to the popularity of the prostate-specific antigen (PSA) test as a screening tool despite the American Urological Association’s wavering and controversial general recommendation against it.
Anti-femininity compounds the communication difficulties by producing hindrances to self-awareness, self-care, and self-nurturance—key components of naturopathic medical care. Additionally, fear of the feminine can cause men to keep relationships with male practitioners distant, and to lack respect for female health care practitioners. Anti-feminine behaviors may also manifest as reluctance to talk about risky behaviors, such as using performance-enhancing drugs, or not using condoms, sports helmets, or safety belts.1
The male physician has his own issues around intimate conversations with men. If a male physician is unwilling to be reasonably open and vulnerable with his patients, which is not encouraged in most medical settings, his reticence may influence the patient, diminishing or preventing effective communication with male patients. Thus the quality of the interview—both the quality of the questioning and receiving of information by the physician, as well as the quality of the information and answers provided by the patient—can potentially affect a man’s health outcomes.
There are several recently published studies looking at the effectiveness of improving physician communication in achieving such goals as increased rates of cancer screenings, improved management of chronic conditions, and improved outcomes for hospitalized patients.9,10,11 In a 2016 publication, a program was created to look at challenges to effective shared decision-making in racial and sexual orientation minority groups.12 While there is need for studies specifically related to doctor-patient communications behind the mask of masculinity, these studies point to the relevance of enhanced communication to health outcomes.
While it isn’t news that shared decision-making and patient collaboration are now encouraged over simply following the doctor’s orders, male physicians still typically engage more authoritatively with patients, in a style that is more regimented and less interactive.13,14 Meta-analyses of the effects of physician gender on medical communication generally show that male primary care physicians engage in less-active partnership behaviors, ask fewer psychosocial questions, and engage in far less emotionally-focused talk. Research has also shown that male physicians have shorter consultation times than their female colleagues.15,16 One meta-analysis concluded that “female patients received significantly more information and more total communication from their physicians than male patients.”17 Male patients seldom receive emotional acknowledgment such as concern and reassurance, and infrequent partnering statements from physicians.18 There is generally more discussion of social agendas in male-male consultations than in other gender combinations. This may reflect avoidance of emotional issues, but because male patients visit their doctors less frequently, it may simply indicate that doctors utilize the opportunity to discuss such issues with their male patients during these infrequent visits.
Rather than developing partnering relationships with their male patients, male physicians generally have a scripted communication style, which may or may not align with a patient’s needs, depending in part on the cultural background of the patient. In an analysis of videotaped clinic visits and transcripts from colorectal cancer screening visits, cultural backgrounds were found to influence patient preference for physician communication style.20 For example, in the US, the extent to which patients accepted unequal power relations was low, as opposed to China and Mexico, where patients expected physicians to take control of the visit and to be less direct and more implicit in their communication. Latinos tended to defer authority to the doctor, as did people in Hong Kong, where doctor-centered interactions were appreciated but caring and listening were not. European physicians tended to adopt a type of communication that was direct and explicit. A 2016 study of Austrian physicians found that one third of male physicians in the study had a very paternalistic style and about a third of the male physicians felt “power over” their patients.21 Physicians who are less culturally broad-minded may tend to stereotype black men as hyper-masculine and more threatening than white men, black women as aggressive and domineering, and Asian men and women as passive and submissive, all of which can negatively influence doctor-patient communication.22
The goal is not for physicians to adapt to each culture, but to be aware of his or her own style, which may be favored or disliked by certain patients. Since male physicians consistently rank lower in communicating respect, positivity, empathy, listening, and a humanistic nature, educating male physicians on cultural competence, including masculinity across cultures, could improve their overall communication with patients.
Unfortunately, society still holds male and female physicians to different standards, such that the same style of communication may be perceived differently, depending on the gender of the physician. According to one study, verbal aggressiveness among male physicians does not affect patient compliance, yet the more verbally aggressive female physicians are, the less satisfied and the less compliant their patients become.19 Male patients speak more assertively, make more negative statements, and interrupt more when their physician is female. Patients tend to talk more to female providers than to male providers.23 Female doctors are rated as having more warmth, sensitivity, relational skills, and interpersonal responsiveness, while male physicians are rated as having more competence, authority, expertise, independence, and self-confidence. Because both kinds of qualities are important, any physician exhibiting a more complete set of these qualities would likely be more highly valued as she or he would be more equipped to match the patient’s desired communication style. Male physicians also talk differently to their patients depending on gender, speaking more assertively toward their female patients.
The shifting power structure within society, that is also seen in the medical profession, may be affecting male physicians’ behaviors. Medical consumerism and evidence-based medicine, which standardizes clinical decision-making and reduces reliance on physician expertise,24,25 may contribute to a shift in power away from physicians. Additionally, many physicians feel a loss of power to pharmaceutical and insurance companies.26 These changes may impact the behavior of some male physicians, as they work to reclaim a sense of power. It may also be important to consider the influence of technology on communication. For example, electronic medical records and online remote visits may create distance and alter the relationship between the doctor and physician.
A Potential Role for Naturopathic Medicine
According to a page on the website of the American Association of Naturopathic Physicians, men represent only approximately 27% of naturopathic patients. In addition, almost three-fourths of naturopathic physicians are female, and currently only 23% of naturopathic medical students are male.3,4 This may truly be a missed opportunity for men and for the naturopathic community, especially given that at least one study demonstrated that patients may be in better hands with female physicians. Naturopathic students are taught to look at the whole individual, including the physical, emotional, and social aspects of their patients, and thus may be better prepared to understand communication nuances with men. However, the effects of traditional masculinity ideals on the male physician-male patient dyad are likely still contributing to health detriments, especially if these issues are not being discussed in naturopathic curricula and integrated into the discourse of practicing NDs.
Researchers have found that during the third year of medical school, typically as students start seeing more patients, levels of empathy decline and cynicism increase, despite efforts to teach empathy.27,28,29 Such tendencies can be amended, particularly if male physicians reflect on their own comfort with masculinity, including their vulnerabilities, biases, and communication style; yet most male physicians have not been trained or supported to do this, since even this level of self-reflection or introspection has been seen as more of a feminine quality, which conflicts with the dominant masculine norm.
Strategies for NDs
For male physicians who are comfortable “sinking into the abyss” with their male patients, there are some approaches that may be helpful. If the cause of the communication gap is centered on the discomfort of being open and vulnerable with other men, then the physician must treat the discomfort. Possible solutions include:
- Educating the patient on barriers to male-male communication
- Using “like to cure like” by encouraging physicians to express their own vulnerabilities around masculinity
- Creating a “men’s clinic” at a specific day and time, so male patients see other men in the office
- Offering to work online via video camera, which provides a more comfortable level of intimacy for some men
Shared medical appointments (SMAs) have been used to optimize physician efficiency and reduce cost, but the elements of belonging to a group, being accountable, and witnessing communication between men may prove beneficial as well. A 2012 study of veterans (94% male), who participated in SMAs to focus on obesity, physical activity, and smoking cessation showed that participants expressed confidence in their providers as experts in their field and that providers were supportive and inclusive in the decision-making process.30 Additionally, “participants reported improvement in their overall health and well-being, improved self-management skills, and satisfaction with the SMA format. Veterans reported feeling empowered to improve their health and described a deep connection with their peers and group leaders. The connection they experienced with other veterans in the SMAs was similar to the close-knit relationships held with other members of their military unit.” A more recent study in Australian Family Physician found that aboriginal men, who tend to avoid going to the doctor, reported that men felt less afraid in SMAs than in the “unnatural nature of one-on-one consultations” with physicians.31
Many men express intimacy, especially with other men, through the use of humor, reciprocal assistance, shared activity, and problem solving on a project. Awareness of this could allow NDs to change their approach to a traditional visit, perhaps allowing for more joking or more active interactions. Collaborative methods for creating a treatment plan would be an example of such interaction. Men also tend to be more action- and competition-oriented, so perhaps NDs could include small challenges in a patient visit. An interactive video might be another solution. In this way, the ND helps preserve some of the traditional masculine identity without threat of emasculation.
It is interesting to wonder whether male NDs who go against the norm feel marginalized, and whether this influences their choice to go into specific specialty areas of practice, as it does for allopathic doctors. Furthermore, could introspection and retraining on masculinity issues and male communication help NDs—male and female— provide more effective healthcare for their male patients, leading to improved health outcomes? These are questions researchers have not yet answered. Perhaps there is a medical student or budding physician who would like to develop a research project…
“We cannot just change what men think, we have to change what we think about men.” – Dan Griffin
- Courtenay WH. Dying to be Men: Psychosocial, Environmental, and Biobehavioral Directions in Promoting the Health of Men and Boys, Vol 10. New York, NY: Routledge; 2011.
- Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206–213.
- Naturopathic Physicians. American Association of Naturopathic Physicians. http://www.naturopathic.org/files/Events/Nat%20Med%20Week/AANP%20Press%20Kit.pdf. Accessed November 21, 2016.
- The Typical ND Student. American Association of Naturopathic Medical Colleges. https://aanmc.org/advisors/facts/. Accessed November 21, 2016.
- Real T. I Don’t Want To Talk About It. New York, NY: Simon and Schuster; 1997.
- Elder K, Griffith D. Men’s Health: Beyond Masculinity. Am J Public Health 2016;106(7):1157.
- Spoer B. Why Performing Conventional Masculinity is Bad for Men. Voice Male. 2016;20(68):18-19.
- Winterich JA, Quandt SA, Grzywacz JG, et al. Masculinity and the body: How African American and White men experience cancer screening exams involving the rectum. Am J Mens Health. 2009;3(4):300–309.
- Price-Haywood EG, Harden-Barrios J, Cooper LA. Comparative effectiveness of audit-feedback versus additional physician communication training to improve cancer screening for patients with limited health literacy. J Gen Intern Med. 2014;29(8):1113–1121.
- Lari SM, Attaran D, Tohidi M. Improving communication between the physician and the COPD patient: an evaluation of the utility of the COPD Assessment Test in primary care. Patient Relat Outcome Meas. 2014;5:145–152.
- Leykum LK, Lanham HJ, Provost SM, et al. Improving outcomes of hospitalized patients: the Physician Relationships, Improvising, and Sensemaking intervention protocol. Implement Sci. 2014;9:171.
- DeMeester RH, Lopez FY, Moore JE, et al. A model of organizational context and shared decision making: Application to LGBT racial and ethnic minority patients. J Gen Intern Med. 2016;31(6):651–662.
- Hall JA, Irish JT, Roter DL, et al. Satisfaction, gender, and communication in medical visits. Med Care. 1994;32(12):1216–1231
- Ballou KA, Landreneau KJ. The authoritarian reign in American health care. Policy Polit Nurs Pract. 2010;11(1):71–79.
- Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651–661.
- Shay LA, Lafata Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making. 2015;35(1):114–131.
- Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care. 1988;26(7):657–675.
- Hall JA, Irish JT, Roter DL, et al. Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psychol. 1994;13(5):384–392.
- Burgoon M, Birk TS, Hall JR. Compliance and satisfaction with physician-patient communication: An expectancy theory interpretation of gender differences. Hum Commun Res. 1991;18:177–208
- Gao G, Burke N, Somkin CP, Pasick R. Considering culture in physician-patient communication during colorectal cancer screening. Qual Health Res. 2009;19(6):778–789.
- Löffler-Stastka H, Seitz T, Billeth S, et al. Significance of gender in the attitude towards doctor-patient communication in medical students and physicians. Wien Klin Wochenschr. 2016;128(16-17):663–668.
- Ridgeway CL, Kricheli-Katz T. Intersecting cultural beliefs in social relations: Gender, race, and class binds and freedoms. Gender Soc. 2013;27(3):294–318.
- Shin DW, Roter DL, Roh YK, et al. Physician gender and patient centered communication: the moderating effect of psychosocial and biomedical case characteristics. Patient Educ Couns. 2015;98(1):55–60.
- Timmermans S, Angell A. Evidence-based medicine, clinical uncertainty, and learning to doctor. J Health Soc Behav. 2001;42(4):342–359.
- Timmermans S, Kolker ES. Evidence-based medicine and the reconfiguration of medical knowledge. J Health Soc Behav. 2004;45(Suppl):177–193.
- Hadley J, Mitchell JM. The growth of managed care and changes in physicians’ incomes, autonomy, and satisfaction, 1991-1997. Int J Health Care Finance Econom. 2002;2(1):37-50.
- Eikeland H, Ørnes K, Finset A, Pedersen R. The physician’s role and empathy – a qualitative study of third year medical students. BMC Med Educ. 2014;14:165.
- Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182–1191.
- Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996-1009.
- Cohen S, Hartley S, Mavi J, et al. Veteran experiences related to participation in shared medical appointments. Mil Med. 2012;177(11):1287–1292.
- Stevens JA, Dixon J, Binns A, et al. Shared medical appointments for Aboriginal and Torres Strait Islander men. Aust Fam Physician. 2016:45(6):425–429.
Dr Steve Rissman is a tenured associate professor in the Integrative Health Care Program at MSU Denver, where he teaches Clinical Pathophysiology, Men’s Health, Men and Anger, and Men Across Cultures. He has studied, taught and written on men’s health topics for over twenty years. In his practice, Dr Rissman works with men and boys confounded by behaviors related to anger and rage, anxiety, and depression, using naturopathic therapies intended to help lead men through the abyss of dis-ease toward a rich, purposeful life.