AMA Journal of Ethics^®

Abstract

There are many reasons why gender-concordant care benefits patients and is requested by them. For training hospitals, however, such requests present challenges as well as opportunities in providing patient-centered care. Responding to a case in which a female patient who is having a routine exam refuses care from a male medical student, we discuss ethical principles involved in gender-concordant care requests, when it is appropriate to question such requests, and a team-based approach to responding to them.

Case

A male medical student on his obstetrics-gynecology clerkship is assigned a 35-year-old female patient in the outpatient clinic who comes in for a routine well-woman exam, including a pelvic examination and Pap test, clinical breast examination, and discussion about contraception management. The student enters the examination room and introduces himself, but the patient straightforwardly tells him that she would prefer a woman student. The student feels conflicted and confused. He is committed to patient-centered care and wants to be respectful of the patient’s wishes, but he also feels some frustration at not being able to conduct clinical activities that are a routine part of education in the rotation. He is unclear about what is appropriate to discuss with patients, or even with the attending physician, about his involvement in the care of this particular patient. When he emerges from the room and lets the attending physician know that the patient refused his exam, she simply instructs him to wait for the next patient.

Commentary

There are many reasons why gender-concordant clinical care may benefit patients’ health and well-being. Shared gender-specific life experiences may engender trust and help patients to communicate symptoms and concerns to gender-concordant clinicians [1-4]. Patients with gender-concordant clinicians are more likely to undergo cancer screening and utilize other preventive care services [5-8]. By contrast, patients who receive gender-discordant care may have worse clinical outcomes [9], particularly if they delay care or unwillingly consent to gender-discordant care and subsequently withhold information that is important to the diagnosis and treatment of their medical condition [10-12]. Gender-concordant care may also lessen the embarrassment, discomfort, or sociocultural taboo that may occur during physical examination of “private” areas, such as genitals. For example, there are religious norms that prohibit some patients (e.g., some Muslims, Orthodox Jewish persons) from being touched by gender-discordant physicians [13-15]. Among some men seeking care for issues related to sexual health, there may be a sense that being examined by women is “impolite” and that discussing issues such as sexual behaviors or erectile dysfunction is improper with female students [16-18].

This paper discusses the ethical principles related to gender-concordant clinician requests and suggests a team-based approach for addressing such requests within academic medical centers.

Ethical Principles in Gender-Concordant Care Requests

This case highlights important issues that arise when patients request gender-concordant clinician care, particularly from medical student trainees. In this complicated situation, several ethical principles need to be balanced.

Beneficence. First, the patient’s well-being should be the attending physician’s primary concern. Putting the interests of the patient in this case first may mean subordinating both the student’s personal interest in having diverse clinical experiences and society’s interests in producing well-trained young physicians. While certainly not all women prefer female gynecologists, a substantial number do [19]. The strength of the preference, however, may vary significantly from patient to patient or even for the same patient, depending on clinical circumstances.

Respect. Second, the patient should be respected as a person. Competent patients have the right to refuse unwanted care, even if recommended by the physician [20]. This includes the right to refuse care from an unwanted clinician. Respecting such refusal may be particularly important in clinical cases such as this, which routinely involve sensitive, potentially embarrassing examinations (e.g., of genitals and breasts) and conversations (e.g., about sexuality, substance abuse, or intimate partner violence). Furthermore, patients should be treated in a compassionate and respectful manner, even if the student or physician feels hurt or unfairly stereotyped by the patient’s request.

Fairness. Third, students and physicians should act fairly. The student in this case may perceive that it is unfair that he is unable to be involved in a case that might advance his education. However, patients who request a gender-concordant physician may feel that they have been treated unfairly by the health care system and society at large. For women, there often exists a lived experience of vulnerability that has implications for the clinical encounter. For example, the prevalence of sexual assault in adult US women is estimated to be 20 percent [21], and a slightly higher rate (29 percent) was reported in one study of adult US women in primary care [22]. Because many women have had less power to make decisions about their lives and their bodies (in comparison to men), they may feel more strongly about having gender-concordant clinical care [23] and yet simultaneously feel less able to refuse gender-discordant medical care, even by trainees. As such, women’s expressed preferences for gender-concordant care may rise to even higher standards of respect for personhood than what is routinely seen in clinical practice. In addition, the power imbalance in the gender-discordant care of female patients can be exacerbated by race or ethnicity, class, and other social identities that are marginalized in the US. As a result, women with multiple marginalized social identities (e.g., African-American women, women immigrants with language barriers) may be particularly at risk for not having their preferences for gender-concordance respected within clinical encounters [24-26]. Yet, even requests that reflect a patient’s sense of entitlement and privilege rather than a position of individual or social vulnerability should still be considered as potentially falling within patients’ right to be treated fairly in clinical encounters.

Questioning Gender-Concordant Care Requests

While there are ethical reasons to support patient requests for gender-concordant care, there are, nonetheless, circumstances in which it is appropriate to question such requests. For example, if a male patient requests gender-concordant care because “no woman can be a competent doctor,” the attending physician might ask the patient why he feels that way and then explain that women students and physicians are as qualified and competent as men. The most important reason to refuse a request for gender-concordant care is when a patient’s health is potentially compromised (e.g., urgently needed medical attention is delayed) [27].

While questioning patient requests for gender-concordant care can have a negative impact on the patient-clinician relationship, it is important to note that questioning such requests can also have a positive impact. It can open an important dialogue with patients about their preferences for care that may actually enhance the patient-physician relationship, signal to patients all clinicians’ commitment and competence to practice patient-centered care, and help to foster an organizational culture that validates all students (regardless of their gender).

Team-Based Approach to Gender-Concordant Care Requests

Medical students should not address these situations alone. There are important roles for all members of the health care team to play in navigating clinical encounters in which patients request gender-concordant medical student care. Because such requests may arise from concerns about students (rather than physicians) as well as concerns about gender, addressing both issues is desirable. Based on the authors’ collective experience caring for patients and examining ethical issues that arise from clinical practice, we recommend the following actions for those participating in medical training.

Clerkship directors. Clerkship directors should work in advance to alert patients to the presence of medical students—through signage, patient handouts, or other mechanisms that are integrated into routine workflow—in hopes that patients will be less likely to refuse student care, in general, once they understand the educational mission of such care. In addition, clerkship directors should identify alternative clinical experiences during the rotation for medical students who could be at risk for not meeting their clinical requirements (e.g., because of patient requests for gender-concordant care). All US medical schools require that students gain sufficient exposure and skills to key aspects of clinical examinations and medical care. Many medical schools utilize standardized patients (e.g., for pelvic and urological examinations) to provide additional opportunities that complement clinical clerkship experiences [28]. Clerkship directors should utilize and expand the options available at their medical institutions and provide visible organizational leadership that signals to students and faculty the institution’s proactive commitment to the clinical training of medical students.

Attending physicians. Attending physicians should help students and patients navigate requests for gender-concordant care. Like clerkship directors, attending physicians should be obligated to make patients aware of the presence of medical students through individual patient interactions. That is, when feasible, physicians should ask patients’ permission to have students involved in their care, using language that helps patients understand the parameters (e.g., “I’m working with well-trained students who are taking histories and doing chaperoned pelvic exams”), identifies the student’s gender in relevant clinical specialties (e.g., “The student with me today is named James Smith, and he is in his third year of medical school”), describes some of the benefits of including students (e.g., “Students have more time to spend with you during today’s visit and can answer many questions that you may have about your health condition”), and provides social norms and opportunities for patient refusal (e.g., “There is no pressure to say yes to a student, and your care here will not be affected in any way if you decline”).

For patients who decline gender-discordant care, attending physicians should explore the underlying reasons with the patient using open-ended language (e.g., “Can you tell me more about that?”) and address patient misconceptions about gender-discordant care (e.g., “All our students—men and women—meet high admission standards, receive thorough training in professionalism, and are carefully evaluated before they participate in patient care”). Attending physicians should use these opportunities as teachable moments for medical students by modeling sensitive conversations with patients and debriefing with students after the clinical encounter. In our case study, rather than simply informing the student to wait for the next patient, the attending physician could have debriefed with the medical student in real time to learn more about the student’s interaction with the patient, stepped in briefly to make sure the patient understood clinic protocols about student participation, and had a discussion at the end of clinic that described how the patient’s concerns were addressed and underscored for the student the teaching points inherent to the case.

Medical students. Medical students should understand that while their involvement in patient care is important, it is nonetheless optional at the level of individual patient encounters. This is particularly true in the ambulatory care setting where the acuity and severity of medical problems is lower and the need for student assistance is less urgent. Medical students should also know that learning to address patient requests for gender-concordant care (and other identity-based care), including identifying cases in which it makes sense to disagree with the patient’s request, is an important part of learning medical professionalism. That is, recognizing and understanding one’s own emotional responses to patients (e.g., anger, confusion, ambivalence, sadness) while recognizing the primacy of patient care and well-being is an integral part of professionalism and a skill to be honed during medical training. Finally, medical students should seek support and guidance from their attending physician, clerkship director, and physician mentors to help navigate, and learn from, clinical encounters such as this. In our case study, the student could have asked the attending physician for specific feedback and guidance on how to address the patient’s request, thus prompting discussion about gender-concordant care requests.

Conclusion

In summary, patient requests for gender-concordant student care present challenges and opportunities for medical students, physicians, and institutions to simultaneously promote patient-centered clinical care and training in medical professionalism. There are many reasons that patients may request gender-concordant care, and how institutions and clinicians address these requests requires thoughtful engagement with the ethical principles of patient well-being, respect for persons, and fairness. Medical students should acknowledge their emotional responses to the situation, promote the primacy of patient care, and seek help from their attending physicians, clerkship directors, and institutions in navigating these clinical scenarios.