Psychosomatics 44:359-366, October 2003
© 2003 The Academy of Psychosomatic Medicine
Gender and Symptoms in Primary Care Practices
Jeffrey L. Jackson, M.D., M.P.H.,
Judith Chamberlin, Dr.P.H., and
Kurt Kroenke, M.D.
Received Nov. 16, 2002; accepted Feb. 25, 2003. From Walter Reed Army Medical Center, Washington, D.C. Address reprint requests to Dr. Jackson, Medicine-EDP, 4301 Jones Bridge Rd., Bethesda, MD 20814; jejackson{at}usuhs.mil (e-mail).
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ABSTRACT
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The authors sought to explore gender differences among patients with physical symptoms who came to see internists. The women were younger, more likely to report stress, endorsed more "other, currently bothersome" symptoms, were more likely to have a mental disorder, and were less likely to be satisfied with their care. The men were slower to improve, but there was no difference between the sexes after 3 months. There were no differences in the number, type, duration, or severity of symptoms or in the expectation of care, costs of visits, intervention received, use of health care services, or likelihood of being considered difficult by their physician. The gender of the clinician had no effect on any outcome.
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INTRODUCTION
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Women's health issues have received increasing attention in the United States. The curricula at most medical schools and residency programs commonly incorporate material on health needs specific to women. From a physiological perspective, comprehensive health care for women must address issues that are unique to women, such as the reproductive system (pregnancy, menses, and menopause), as well as distinct screening requirements for disease and malignancy. Several classes of malignancies (ovarian cancer and breast cancer) and disease processes (thyroid disease, osteoporosis, and rheumatological diseases) are more common among women than men. Women are more likely to be the victims of violence and sexual assault or abuse1 and are more likely to experience depressive, anxiety, and eating disorders.2 Women have also been consistently shown to report symptoms more frequently than men.3,4 Theories that may account for this gender difference include those involving physiological, sociocultural, and psychological processes.5,6
Our study was designed to explore differences between men and women with physical complaints who were seen at a walk-in clinic. Our specific questions included the following: 1) How do men and women differ when they are seen for evaluation of a physical symptom; and 2) Do they experience similar outcomes, including satisfaction, improvement in functional status, and symptom resolution?
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METHOD
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Adults examined at a general medical walk-in clinic at Walter Reed Army Medical Center with a chief complaint of physical symptoms were eligible for participation. We obtained written informed consent from the participants. Immediately before seeing a physician, all patients completed a survey regarding symptom characteristics, worry about serious illness, and symptom-related expectations (e.g., causal explanation, expected duration of treatment, prescription, diagnostic test, referral, other). Additionally, the patients completed the Medical Outcomes Short Form—6 (SF-6),7 a six-item measure of functional status, and were evaluated for DSM-IV depressive and anxiety disorders with the Primary Care Evaluation of Mental Disorders (PRIME-MD).8,9 The PRIME-MD is a validated instrument, comprising two parts, a patient questionnaire and a semistructured interview for patients endorsing certain symptoms. The first part of the PRIME-MD asks whether the individual has been bothered by 15 common physical symptoms. Immediately after the visit, the patients completed the RAND 9-item visit-specific satisfaction survey10 and a questionnaire that assesses worries about possible residual symptoms of serious illness and unmet expectations. With an automated clinical database we determined the total number of patient visits with a physician within the Walter Reed system, which includes a number of outlying clinics, 3 months before and after the index visit.
Two weeks and 3 months after the visits, the patients were mailed a questionnaire regarding symptom outcome, worry about possible residual symptoms of serious illness, unmet expectations, functional status, and satisfaction. Telephone contact of nonrespondents was attempted.
All eligible patients who came to the clinic on selected half-days were invited to participate. This clinic primarily provides continuity of care but has walk-in appointments available for patients desiring to be seen that day. Such walk-in patients are assigned to physicians on a queue system: first come, first assigned to the next available clinician. Clinicians are assigned patients from a roster of available appointments, with clinicians listed alphabetically within each time slot. Nearly all study patients were seen by physicians examining them for the first time. The demographics and case mix of patients seen in a military outpatient clinic are comparable to those in civilian settings.11–13 The study protocol was approved by our institution's human subjects committee.
After each patient visit, the physicians completed the 10-item Difficult Doctor Patient Relationship Questionnaire14 to assess clinician-perceived difficulty of the encounter and indicated what they did for the patient (provided an explanation of symptom cause and likely duration, prescription, referral, or diagnostic test). The Difficult Doctor Patient Relationship Questionnaire has been previously shown to be a reliable instrument with an internal consistency of 0.88–0.96.
From the clinical database, orders for prescriptions and diagnostic tests were obtained for each patient. These were tabulated with Health Care Financing Administration relative value units and converted to dollars by using the 1996 Medicare schedule. Prescription costs were based on rates generated by the Heath Care Financing Administration or on prices for generic drugs (when available). Rates for health care use for 3 months before and after the index visit were also measured.
Analyses were performed by using STATA (Stata 6.0, College Station, Tex.). Continuous variables were analyzed with analysis of variance or covariance or the Mann-Whitney U test, as appropriate. Repeat measures analysis of variance (ANOVA) was used to assess improvement among continuous variables between presentation and follow-up. Categorical variables were analyzed by using Mantel-Haenszel chi-square tests or logistic regression analysis. The relationship between gender and current symptoms was analyzed with Fisher's exact test for overall significance and the chi-square test by collapsing the tables into specific symptoms and all other symptoms. Functional status was assessed by adding six domain scores. Satisfaction was analyzed in each domain as "fully satisfied" versus "otherwise." An overall satisfaction score was created by adding individual domain scores and analyzed by using ANOVA. Patient difficulty was analyzed as a dichotomous variable, with a score of 30 or greater as indicative of difficulty.
The somatoform section of the PRIME-MD asks about 15 physical symptoms or clusters that account for over 90% of physical complaints (excluding upper respiratory symptoms) reported in outpatient clinics.15 Fainting, an infrequent complaint, and menstrual problems, not applicable to men, were not analyzed. Logistic regression was used to adjust each of these symptom categories by patient age, mental disorders, educational status, and functional status.
These data were collected as part of a clinical trial of providing information to clinicians before visits regarding patients' symptom-related expectations and mental disorders. Clinicians received this information regarding the second 250 of 500 patients who were enrolled. The intervention had a modest effect on patients' unmet expectations of care, 2-week satisfaction with care, and the number of encounters experienced as difficult by the physician;16 adjustment for study group was made in all analyses of outcomes affected by the intervention.
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RESULTS
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A total of 528 patients were invited to participate. The 500 participants were similar to the nonparticipants in terms of age, race, sex, and type of complaint. The patients had a mean age of 54.7 years, approximately one-half (N=258) were women, 49% were white, and 45% were African American.
The women (51.9 years) were younger, on average, than the men (57.5 years) (F=10.26, df=1, 496, p=0.001) and were more likely to be widowed (risk ratio=2.8, 95% confidence interval [CI]=1.7–4.6) but otherwise had similar ethnic and educational backgrounds. The patients were seen with a variety of symptoms that we collapsed into 15 categories (Table 1). There were no differences in the type or duration of the symptoms between the men and the women. The leading symptom category was musculoskeletal complaints, present in one-third of the subjects. More than one symptom was present in 19% of the patients (N=95), with pain reported 65% of the time (N=325). The women were no more likely than the men to report more than one physical symptom as their reason for seeking medical care, after adjustment for the presence of mental disorders (F=20.48, df=1, 494, p=0.17). Slightly more than one-half of all patients (55%, N=275) had experienced their symptom less than 2 weeks and 68% (N=340) less than a month. Both the men and the women had experienced their symptom a median of 2 weeks (z=5.49, df=430, p=0.55). Both sexes reported similar symptom severity and were equally worried that their symptoms could represent a serious underlying disease (Table 1). Nearly all (98%, N=490) had at least one expectation before their visit, including a desire for a causal explanation (80%, N=400), an estimated duration for improvement (62%), a medication prescription (66%), a diagnostic test (56%), or a referral to a subspecialist (47%). The men were slightly more likely to desire a diagnostic test (X-ray or laboratory) (Table 1).
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TABLE 1. Demographic and Clinical Characteristics and Outcomes of Patients Seen at a Walk-In General Medical Clinic, by Gender
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The women were more likely to have a mood or anxiety disorder (risk ratio=1.6, 95% CI=1.2–2.2). Overall, a depressive or anxiety disorder was present 29% (N=145) of the time, with 75% of the patients with mood disorders (N=109) and 63% with anxiety disorders (N=36). The presence of a mental disorder had a profound effect on a number of variables, including being more likely to report more than one physical complaint as a reason for seeking medical care (odds ratio=2.4, 95% CI=1.5–3.8), worse functional status (F=92.8, df=1, 466, p<0.0001), greater stress ( 2=62.6, df=1, p<0.0001), a greater number of other bothersome physical symptoms (F=161.3, df=1, 495, p<0.0001), reporting their symptom to be more severe (p<0.0001), and having more unmet expectations after the visit (F=18.8, df=1, 497, p<0.0001).
The women were more likely to report recent stress at all three time points measured (baseline, 2 weeks, and 3 months), even after adjustment for the presence of mental disorders. Both sexes reported similar health-related functional impairment, although the women were more likely to report emotional health problems than the men, even after adjustment for the presence of mental disorders and recent stress. The women endorsed a greater number of currently bothersome somatic symptoms from the PRIME-MD than the men (F=32.6, df=1, 496, p<0.0001). Of 15 common physical symptoms on the somatoform portion of the PRIME-MD, the women endorsed all of the symptoms except problems or pain during intercourse as currently bothersome more often than the men. After adjustment for age, mental disorders, functional status, and educational status, the women were still significantly more likely to endorse seven categories of symptoms than the men (Table 2).
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TABLE 2. Frequency of Physical Symptoms From the Symptom Checklist of the Primary Care Evaluation of Mental Disorders for Two Groups of Primary Care Patients, by Gender
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Immediately after their visit, both sexes had a dramatic decline in worry about serious illness, to approximately 30%, and both had a similarly low number of unmet expectations, with 11% (N=55) reporting at least one. Seventy-six patient encounters (15%) were rated as difficult by the provider, with no differences noted by gender. There were also no differences in direct cost of the visit (F=0.78, df=1, 497, p=0.94) or in 3-month use of health care services.
The women were slightly more likely than the men to report symptom improvement 2 weeks after the visit (odds ratio=1.2, 95% CI=1.1–1.4), but by 3 months, both sexes experienced equal improvement (women: 80%, N=206, versus men: 70%, N=169) (2=0.30, df=1, p=0.53). The men were more worried than the women 2 weeks and 3 months after the visit that their symptom could potentially represent a serious illness, although during the 3-month follow-up period, there were no differences in the use of health care services or in the rates of hospitalization between the sexes.
The women were less satisfied with the care that they received. With univariate analysis of each domain of satisfaction, the women were less satisfied with their overall care (risk ratio=0.82, 95% CI=0.70–0.97), with physician competence (risk ratio=0.82, 95% CI=0.69–0.97), bedside manner (risk ratio=0.82, 95% CI=0.74–0.91), explanation of what was done for them (risk ratio=0.83, 95% CI=0.71–0.97), and the amount of time spent with their doctor (risk ratio=0.79, 95% CI=0.69–0.92). When we adjusted for other well-described confounders of satisfaction, such as patient age, functional status, and the presence of unmet expectations, the women continued to have lower summed satisfaction scores and to be more critical of three specific domains: bedside manner, technical competence, and the amount of time spent with their clinician (Table 3). This combination of variables explained 24% of the variance in satisfaction between the sexes.
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DISCUSSION
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Our study suggests that among adults seen at a walk-in clinic with a physical complaint, women and men have many similarities and some differences. The distribution of symptom type and the number, duration, and severity of symptoms are similar, and both sexes are initially equally worried that the symptom could represent a serious illness. Both sexes have similar health-related functional impairment, similar visit expectations before the visit, and similar unmet expectations after the visit, and are equally unlikely to be considered difficult by their clinicians. The majority of patients of both sexes experience symptom improvement during follow-up, although women appear to improve slightly more quickly. There were no differences in the use of health care services, the direct cost of visits, or the likelihood of referral or hospitalization.
Interesting differences emerged, however. The women in our study had lower satisfaction scores and were particularly critical of their physicians' bedside manner and the time spent with their clinician. The women were also more likely to have a mood or anxiety disorder, to endorse a greater number of somatic symptoms as currently bothersome, were more likely to report ongoing stress in their lives, and to report impairment in emotional functioning, even after adjustment for the higher rates of mood and anxiety disorders. Although both sexes had equally dramatic immediate declines after the visit in their worries about the possibility of serious illness, by 2 weeks and through 3 months afterward, the men experienced a rebound and were significantly more worried about their symptoms than the women at both follow-up time points.
Physical symptoms are common, with three-fourths of all adults experiencing at least one in any given week.17–22 Although only 25% of symptomatic adults seek medical care,8,11 physical symptoms still account for over one-half of all outpatient visits, an estimated 400 million U.S. clinical encounters each year.23,24 Previous research has suggested that women are more likely to seek care for their symptoms than men, that women seek care earlier than men, and that their health problems are less likely to be life threatening,25,26 although most of this work was performed before 1980. Although we studied a select group of patients—those who were seen with physical complaints—our data suggest that these findings may no longer be true. We found that men and women both came in for visits at the same time after symptom onset and with similar types of symptoms that were equally severe. They were also equally likely to have been previously seen by a physician for their problems and were equally likely to report symptomatic improvement by 3 months after the visit.
Since it is well demonstrated that patients who come in with symptoms represent only the tip of the iceberg, it is impossible to tell from this data whether both sexes are equally likely to experience troublesome symptoms for which they did not seek care, a finding seen in previous studies.27 We found that women were more likely to report 13 of 15 common physical symptoms as currently bothersome; these gender differences persisted even after we controlled for the higher comorbidity of depressive and anxiety disorders in women. This is similar to findings in an earlier study of 1,000 primary care patients (Table 2).28 These findings did not translate to greater number or type of physical symptoms for which women were seeking medical help in our study. Because symptoms endorsed on a checklist may overestimate clinically relevant symptoms,29 our current study provides a better assessment of gender differences for encounters in which a symptom was the principal reason for the clinical visit. This may explain why population-based studies have consistently found higher rates of somatization among women. Women may be more willing to endorse symptoms from a checklist. Whether this represents a greater symptom burden is unclear, since women reported a similar number of symptoms as the reason for seeking medical care.
We found no differences in duration of symptoms, in self-reported symptom severity, functional status, likelihood of having seen a physician for this symptom before, or in worry about serious illness before the visit. Over 3 months of follow-up, there were also no differences in use of health care services or in rates of hospitalization, and there were no deaths. The men in our study were slightly less likely to have improved by 2 weeks after their visit, a difference that disappeared 3 months. Previous work has suggested that women are more likely to see a doctor for symptoms than men and that when men come in for a visit, they are likely to be more ill. Cultural scientists have posited that this may be a result of differing roles for the sexes, that women may be more willing to assume the sick role or that men may be too busy in the provider role to seek care.30 However, much of the data supporting those conclusions were based on population studies from before the 1980s, and much of it dates back to before the 1960s. Society has seen significant cultural changes in the last few decades. Our data suggest that men are no longer more reluctant to seek medical care than women and that they are no more ill than women when they do seek care. The higher rates of mood and anxiety disorders that we saw among women and the greater functional impairment among the patients with mental disorders have been previously reported.31–33 The persistence of higher emotional impairment among women, even after adjustment for a higher prevalence of mental disorders, may suggest that even in the 21st century, women may be more open to discussion regarding emotional health than men.
Women had lower satisfaction scores and were particularly critical of their clinician's bedside manner and the amount of time spent with them. Despite a growing literature on satisfaction, aspects of health care delivery used by patients to determine personal satisfaction remain largely unknown, with most studies explaining less than 20% of the variance.34–36 Previous work has consistently found that physicians' interpersonal attributes, in particular their communication skills, correlate with satisfaction and specific communication barriers, including lack of warmth and friendliness on the part of the doctor, failure to take into account the patient's concerns and expectations, lack of a clear-cut explanation concerning diagnosis and causation of illness, and excessive use of medical jargon all decrease satisfaction.37 Older patients consistently report greater satisfaction. Health status is also important since patients who report their health as poor are less satisfied than those who describe themselves as healthy.38–42 Higher levels of psychological distress43 or higher scores on the Zung Self-Rating Depression Scale44 have been associated with lower levels of satisfaction. Fulfillment of patient expectations also appears to be important, since many studies have found that the presence of an unmet expectation after the visit is an important marker for dissatisfaction.45,46 Even after adjustment for these well-described confounders of satisfaction, the women remained less satisfied than the men, although we were able to explain only a small amount of the variance; the bulk of what constitutes satisfaction remains unknown. A study of patients in health maintenance organizations found that the women were more likely to have chosen the sex of their physician, that women were less satisfied than the men with the physicians, and that the women who chose female clinicians were the least satisfied of all. In this setting, in which patients were haphazardly assigned to clinicians, there was no relationship between patient sex and clinician sex and satisfaction. The female patients were less satisfied with both their male and female clinicians.47 Further work regarding the components of satisfaction, particularly in walk-in settings with patients new to the physician, is warranted. Our findings suggest that among such patients, women may be generally less satisfied with their encounters than men.
In general, our findings suggest that physicians seeing patients with physical symptoms in walk-in settings can take solace in the fact that men and women are more similar than different. However, they should be aware that men are more likely to have persistent concerns about serious illness, women are more likely to have underlying mental disorders, and women are more likely to report ongoing stress and are less likely to be satisfied with the encounter.
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ACKNOWLEDGMENTS
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Funded by intramural grant number 32001 from the Uniformed Services University of the Health Sciences.
The views expressed in this article are those of the authors and should not be construed to represent in any way those of the Department of Defense or the Department of the Army.
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ABSTRACT
INTRODUCTION
