Effective Consultation for Patients with Hypertension: Does the Physician'S Gender Matter for Risk-Factor Control?

'…overall impression is, therefore, that the consultation style might differ between male and female physicians in PHC facilities…'

In Western countries, the largest group of patients to regularly visit primary healthcare (PHC) facilities and family physicians for a chronic condition is the group consisting of men and women with hypertension. Elevated blood pressure is not only a well-documented risk factor for cardiovascular disease, but is also a time-consuming diagnosis for both physicians, their patients and other healthcare staff. Much research has been devoted to describing the benefits of blood pressure control in patients at risk, as documented in recent guidelines [1], but less effort has been spent on quality control and the reduction of overall risk [2]. This is of great importance as the quality of the consultation will influence compliance with both lifestyle advice and drug therapy. The result can be measured as changing and improving levels of risk factors in national or regional samples of treated hypertensive patients, for example, the ones carried out in countries such as Sweden [3], the UK [4] and the USA [5].

One aspect of the consultation for patients with hypertension that is overlooked is the implications of the gender of patients in relation to the gender of their physician. Previous research has documented that this might be of some importance for overall satisfaction with the consultation as well as other quality aspects [6].

In two recent observational studies from PHC facilities in Sweden, we and others have tried to investigate these issues [7,8]. In the first study (known as Hyper-Q), the aim was to study the association of the physicians' gender on blood pressure, lipid control and cardiovascular risk factors in treated hypertensive men and women, stratified for the gender of their physicians [7]. This was based on a cross-sectional survey of hypertensive patients from 264 primary-care physicians (PCPs; 187 men and 77 women) from across Sweden, who recruited 6537 hypertensive-treated patients (48% men) who were consecutively collected from medical records and registered on a web-based form. We found that hypertensive women more often reached target systolic/diastolic blood pressure levels below 140/90 mmHg when treated by female PCPs than when they were treated by male PCPs (32 vs 24%, respectively; p < 0.001). This difference remained when comparing female and male physicians' nondiabetic female patients. Both male and female patients had better control of total cholesterol and low-density lipoprotein-cholesterol levels when treated by female PCPs than when treated by male PCPs (total cholesterol <5 mmol/l: women 30 vs 24%; p < 0.001; men 42 vs 34%; p < 0.001; respectively). Female PCPs had a higher proportion of treated hypertensive patients with diabetes than did male PCPs. However, male PCPs had a higher prevalence of treated hypertensive men with microalbuminuria compared with female PCPs. Thus, it was concluded that female physicians appeared to more often reach the treatment goal for blood pressure in female patients and cholesterol levels in all patients than did the male physicians. The causes for these findings, however, remain obscure.

In a similar observational study, another separate cohort (known as the AUDIT) of approximately 4000 hypertensive-treated patients from PHC facilities in Sweden was investigated using much the same methods [8]. The results were also largely similar, specifically, that female patients with hypertension demonstrated a better risk-factor control when treated by a female physician as compared with treatment by a male physician.

Could these repeated findings be biased, or are female physicians, in general, more successful in reaching good compliance and risk-factor control in cardiovascular risk patients, as illustrated by these two observational studies from PHC? One bias could be related to the selection of physicians interested in participating in surveys, such as the two related. Such participating physicians are probably more interested in hypertension and risk-factor control than the average PHC physician. Together with a high level of willingness to use computer-based registration routines, this could eventually have biased the selection of physicians to a different degree in relation to gender. Second, even if the registration was based on data taken from consecutive medical records, a bias could still be found in the accuracy of the data obtained. However, there are no indications suggesting that the medical records are better or worse documented or kept in relation to the gender of the physician.

'Female PHC physicians tend, on average, to have patients in better risk-factor control, especially female patients, than male PHC physicians.'

The overall impression is, therefore, that the consultation style might differ between male and female physicians in PHC facilities responsible for the long-term management of cardiovascular risk-factor control in patients with treated hypertension. Differences in motivation, educational efforts or follow-up routines for patients with less optimal risk-factor levels could all contribute to explain the gender-associated findings [6]. Future research should combine both quantitative and qualitative methods to explore these circumstances, for example, by use of videotaped consultations and feedback to the physicians that are involved [9,10]. This could contribute to the development of better consultation styles for all physicians responsible for patients with hypertension and, especially, female patients. It should not be overlooked that some evidence exists demonstrating that a clinical consultation based on guidelines and the evidence-based approach could sometimes be less flexible and more business-like when videotaped, compared with the traditional consultation before the era of computers [10]. Therefore, it is necessary to find an appropriate balance in the consultation so that patients also feel free to voice their worries.

One part of the suboptimal consultation outcomes is the stress induced by the consultation and the related poor communication patterns. This is exemplified by the stress-induced ‘white coat’ reaction, which is more pronounced in elderly patients than in younger patients. Any white coat reactions to blood pressure measurements in stressful conditions should be minimized if possible; an alternative solution is to use 24-h ambulatory blood pressure recordings more frequently, if available, to reduce the influence of stress reactions during the consultation that, in turn, influence blood pressure levels [1].

In conclusion, it has been shown that risk-factor control differs in patients with treated hypertension in relation to the gender of their physician. Female PHC physicians tend, on average, to have patients in better risk-factor control, especially female patients, than male PHC physicians. These findings should stimulate continuous research into the gender aspects on consultation styles, education of the patient and compliance in order to reduce cardiovascular disease risk.