AMA Journal of Ethics^®

Case

Becky's leg wouldn't stop bleeding. She had been taking some empty bottles to the recycling bin for her mother when she dropped one and it broke into many pieces after hitting the stone steps. A shard of glass bounced up and cut Becky on her thigh. After investigating the cut and attempting to stop the bleeding for several minutes, Becky's parents took the 9-year-old girl to the ED for stitches. Becky's mother felt responsible—why had she let her daughter carry three bottles at once down the back steps to the recycling bin?

An emergency department staff member led them to an exam room, and a short time later Dr. Smith appeared. She started to check Becky's leg, chatting with Becky as she was doing so. She explained that she, too, had a 9-year-old daughter. Dr. Smith said, "We'll get you stitched up and that will stop the bleeding. Then we'll put a neat bandage on it and you'll have a great story to tell your friends."

Dr. Smith explained that the suturing would be like sewing, which Becky understood from watching her mom embroider. "Are you going to do it, Dr. Smith?" Becky asked. "I want you to do it. Will it hurt?"

"Well, I have some other patients to see," Dr. Smith replied. "And I don't want you to have to wait too long. Let me see."

When Dr. Smith stepped outside the exam room, Becky's dad followed her out. He went to the admitting clerk and asked whether the male resident they had seen could stitch Becky's cut.

"Why?" asked the clerk. "Dr. Smith and the other physician on duty are both residents and are both excellent. Plus, Dr. Smith will be available in just a few minutes, but Dr. Craig is in an exam room with another patient and he could be awhile. Don't you want to get this done as quickly as possible?"

Becky's dad knew that his wife was feeling really bad about the injury and had said that she would just be more comfortable if Dr. Craig could stitch Becky's leg. Becky's mom had whispered to her husband that she wasn't sure she liked all the chit-chat about sewing. This was medicine, after all. And an emergency at that.

Commentary

A study published in Pediatric Emergency Care in 2005 entitled "'Doctor' or 'Doctora': Do Patients Care?" highlighted several questions about patients' preferences for a man or woman physician [1]. The study consisted of a two-question survey for 200 children aged 8-13 and their parents who had come to the pediatric emergency department needing suture repair for a laceration. The two questions were:

1. If you had a choice, would you prefer to have a male doctor, a female doctor, or the doctor with the most experience?
2. If you picked one, would you be willing to wait longer to be seen by them or would you want the next available doctor?

Among the children, 80 percent of girls and 78 percent of boys preferred a woman doctor, and none chose the doctor with the most experience [2]. Among the parents, 60 percent preferred a man, 19 percent preferred a woman, and 21 percent preferred the doctor with the most experience [2]. Of parents who had a preference for one sex, only 28 percent said they would be willing to wait longer to see the doctor of that sex, whereas all of the parents who preferred the most experienced doctor stated they would be willing to wait longer.

This study was simple in its scope, and its limitations were rightly noted, but the strong preference among children for women doctors, which stood in stark contrast to their parents' preference for men, captures the questions from the case scenario: Why do such preferences exist? How should physicians decide whether to accommodate these preferences? How can physicians get all of their patients to be more comfortable with them?

Sex Preferences

Sex preferences have numerous foundations—e.g., culture, religion, past experiences with a man or woman—that can affect a person's comfort level when he or she must be naked in front of a doctor and can lead to judgments about a physician's caring or competence. Knowing that certain groups of patients are more likely to have strong sex preferences can make doctors aware that they may need to spend extra time discussing certain topics with those patients; however, research on the topic of human desires and fears will always have limitations. Every time a doctor walks into a room to meet a patient, he or she must do so with an open mind and avoid making too many assumptions.

When deciding whether to accommodate a patient's request for a male or female doctor, most physicians practice utilitarian ethics. In this philosophical model, an action is not inherently "right" or "wrong"; rather, the moral value of the action is determined by its contribution to achieving the greatest good. Physicians who use this technique may ask themselves, is this patient's preference strongly held, or might a few more minutes of building rapport change the patient's mind? Is another doctor readily available? How urgently does the patient need treatment? Will acquiescing put a resident at risk of not learning a skill that will be valuable in a future emergency because he or she has always deferred to patients' requests to have a doctor of the opposite sex? All of these factors should be considered before a decision to accommodate the request is made.

Religion and Preferences for Physicians

When a patient makes a request based on religious beliefs, doctors often employ what is called "deontological" or duty-based ethics, feeling a sense of duty or obligation to accommodate the patient's wishes, regardless of the utilitarian balance of greatest good.

Meta-ethicists might then be compelled to ask, "If doctors feel a sense of duty to comply with a patient's religion-related request, then why not also indulge a person's culture-based appeal, or mild preference?" In the given case scenario, we might ask, "Why should a child's wish for a woman physician be less important than her parents' desire?"

Answering these questions can be complex and personal, stirring strong emotions; but just by contemplating these questions each time he or she meets a new patient, a doctor demonstrates an awareness and sensitivity that can help guide a decision-making process with which all parties are comfortable.

The challenge in answering these questions further highlights the value of learning good bedside manner. Good bedside manner can help a patient feel more comfortable with the assessment and treatment, can dissuade some patients from asking for a different doctor, and can inspire some to rescind their request for a doctor of the opposite sex.

Several studies surveyed women about their preferences for obstetrician/gynecologists and found that most valued characteristics like interpersonal style and technical skills over the doctor's sex [3-6]. Still, a significant number of patients have a definite preference.

How can doctors improve their interpersonal and communication skills in situations like the case scenario where a parent is showing resistance? Acquiescing too quickly to a request for a different doctor can be interpreted as an acknowledgment that, indeed, doctors of a particular sex are not as well suited to provide good treatment and care. There are some approaches that can help Dr. Smith and other physicians who confront bias. First, acknowledge and show respect to the parents, the patient, and their concerns. Take the parties to the exam room—away from a common area where they might become defensive because they are in front of others—and acknowledge their frustrations; listen to and validate their concerns; and point out that everyone wants the patient to receive the best care from someone he or she feels comfortable with.

Next, empower the parents and the patient by giving them options whenever possible, for example, before drawing blood ask, "Which arm should I look at first?" This shows that you are not always trying to impose your preferences.

Lastly, if you are relaxed and do not get defensive when discussing difficult subjects like their desire for another doctor, parents and patients feel more relaxed with you.

Gaining people's trust can be difficult and sometimes impossible. When people are sick, they feel vulnerable and unsettled, and their ability to cope regresses. It is the moral imperative of the doctor to see beyond the tough circumstances, listen actively to the patient's concerns, weigh all the competing issues, and then frame the discussion in a manner that the patient can understand. When patients—sensing the doctor's sincere empathy—see that their doctor has taken that extra step to meet them where they are, they often realize they can trust the doctor and feel comfortable moving forward with care.