There is lots of evidence that there is gender bias in healthcare. This Medical News Today article summarises some examples and consequences. It seems plausible that at least some of the gender bias in healthcare arises when male doctors examine or treat female patients. A useful question to ask, then, is what would happen to bias if patients were examined by same-gender doctors?
That is essentially the research question underlying this recent article by Marika Cabral (University of Texas at Austin) and Marcus Dillender (Vanderbilt University), published in the journal American Economic Review (ungated earlier version here). Cabral and Dillender first outline the problem, being that:
...female patients, relative to male patients, receive less health care for similar medical conditions and are more likely to be told by providers that their symptoms are emotionally driven rather than arising from a physical impairment... Differences in doctors’ evaluations of medical issues for male and female patients may be a key factor contributing to observed differences in treatment. Beyond influencing the treatments patients receive, medical evaluations also impact benefit eligibility in social insurance programs. Recent evidence suggests there are large gender disparities in social insurance programs that rely on medical evaluations...
Cabral and Dillender make use of:
...comprehensive administrative data and random assignment of doctors to patients within the Texas workers’ compensation insurance system. Random assignment of doctors to patients occurs in this setting through the dispute resolution process. Insurers and injured workers may request independent medical evaluations to settle disputes over an injured worker’s impairment level... The random assignment of doctors to patients means that differences in assessments between male and female doctors stem from the doctors themselves rather than from differences in the types of patients assigned to doctors.
That last point is important. It is the random assignment of patients to doctors that means that the results from this study can be interpreted as causal evidence of the effect of doctor gender on patients' outcomes, and evaluate the difference in those outcomes between male and female patients. Essentially, this is a form of difference-in-differences analysis, looking at the difference in outcomes between male and female patients with a male doctor, and comparing that with the difference in outcomes between male and female patients with a female doctor.
The outcomes that Cabral and Dillender look at are whether the patient is evaluated as having a disability, and the amount of cash disability benefits they receive after the evaluation. Having controlled for patient characteristics such as the type of injury and the industry that the patient worked in, there should be no differences between male and female patients in either disability assessment or disability benefits, depending on whether they have a male or female doctor. Instead, Cabral and Dillender find that:
...patient-doctor gender match increases evaluated disability and subsequent cash disability benefits for female patients but has little impact on outcomes of male patients... Compared to differences among their male patient counterparts, female patients randomly assigned a female doctor rather than a male doctor are 3.1 percentage points more likely to be evaluated as having an ongoing disability and receive 8.6 percent more cash benefits on average, or $483 evaluated at the mean of $5,622. There is no analogous gender-match effect for male patients. We note the magnitude of these effects is sizable. The estimated 3.1 percentage point increase in the likelihood of being evaluated as disabled is nearly large enough to offset the entire observed gender gap in this outcome when male doctors evaluate claimants.
Cabral and Dillender then turn to explaining why this gender bias exists, and find that:
Controlling for available baseline patient information, the estimates indicate that female doctors evaluate female and male patients as similarly disabled while male doctors evaluate female patients as less disabled than male patients. While only suggestive, this evidence is consistent with male doctors evaluating female patients against a stricter standard than male patients and female doctors applying similar standards to male and female patients.
On that last point though, as Cabral and Dillender note in one of the footnotes in the paper, these results alone can't distinguish between whether it is male doctors who evaluate female patients to a higher standard, or female doctors who evaluate male patients to a lower standard. However, Cabral and Dillender report a range of survey evidence from a sample of over 1500 people that is consistent with the former, including:
...that women—relative to men—more often report having a negative experience where a doctor didn’t understand their concerns, had assumed something without asking, talked down to them, made them feel uncomfortable, or didn’t believe them. When asked about how a doctor’s gender influences the likelihood of having a positive interaction, women were much more likely than men to report an own-gender doctor would be more likely to treat them with respect, understand their concerns, believe them, provide needed testing and treatments, make them feel comfortable, and ask appropriate questions instead of making assumptions.
Cabral and Dillender also report on the intensity of preferences over doctor gender, showing that:
...48.5 percent of women are willing to pay an additional $5 copay to see an own-gender provider compared to only 29.3 percent of men—a 19.2 percentage point difference.
It would have been interesting if they had extended that analysis to an estimate of the female patients' average willingness-to-pay for having a female (rather than a male) doctor, but they didn't. Finally, Cabral and Dillender looked at the policy implications, noting that based on their results:
...increasing the share of independent medical evaluations performed by female doctors from 17 percent to 50 percent would cause a 0.88 percentage point increase in the share of female patients evaluated as disabled, closing approximately 41 percent of the gender gap conditional on observables among disputed claims.
Given that still less than half of medical school graduates in the US are female, there is a long way to go before we get to that point. For comparison, in New Zealand in 2019, over 58 percent of medical school graduates were female. I guess that is good news for New Zealand, in terms of reducing the gender bias in medical evaluations here.
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