Autonomy, gender, and preference for paternalistic or informative physicians: A study of the doctor-patient relation

In the past few decades, medical ethicists1,2,3 have departed from the Hippocratic model in encouraging patients to take a .more active role in their healthcare.4,5,6 Emanuel and Emanuel4 contrast informative versus paternalistic styles as endpoints in a continuum of doctor-patient relationships. In the paternalistic model the physician acts as the patient's guardian and articulates what is best for the patient.

In this model, the physician-patient interaction ensures that patients receive interventions that best promote their health and well-being. To this end, physicians use their skill to determine the patient's medical condition and his or her stage in the disease process and to identify the medical tests and treatments most likely to restore the patient's health or ameliorate pain. Then the physician presents the patient with selected information that will encourage the patient to consent to the intervention the physician considers best. At the extreme, the physician authoritatively informs the patient when the intervention will be initiated. (p. 2221)

The paternalistic model assumes that there are shared objective criteria for determining what is best for the patient. Hence, the clinician can discern with limited patient participation what is best for the patient.

In the informative model, the physician treats the patient as a consumer.

The objective of the physician-patient interaction is for the physician to provide the patient with all relevant information, for the patient to select the medical interventions he or she wants and for the physician to execute the selected interventions. To this end, the physician informs the patient of his or her disease state, the nature of possible diagnostic and therapeutic interventions, the nature and probability of risks and benefits associated with the interventions and any uncertainties of knowledge. It is the physician's obligation to provide all of the facts, and the patient's values then determine what treatments are to be given. (p. 2221)

In the informative model, the physician provides the patient the means to exercise control and to make an informed decision as to the course of treatment.

The present study explores the relationship of physician communication style to patient characteristics. Do some patients prefer one type of physician style and other patients another? Do some patients need the freedom implicit with an informative physician style while other patients need the protection implicit in the paternalistic physician style?

Some studies7,8,9 report that younger and higher educated individuals are more likely to take an active role in medical decisions while men, married individuals, and patients with a more severe prognosis tend to prefer a more passive role and allow the physician to make medical decisions.10 However, another study11 reported that patient gender accounts for only a small proportion of the variance of decision-making style.

Several recent studies have specifically examined the decision-making style and preferences of patients diagnosed with cancer. One study12 reports that an index group of 150 patients newly diagnosed with breast cancer were more likely to want to play a passive role in decision-making as compared to 200 women with benign breast disease. In both the index and control groups, older women and women of lower social class preferred a more passive role. A second larger study13 examined 1,012 women with breast cancer. Women younger than 50, married, with English as a first language, having greater than a high school education, at earlier stages of the disease, and having undergone a lumpectomy were more likely to prefer active or collaborative roles in decision-making. The third study in this series studied examined men diagnosed with prostate cancer.14 This study reports that among 60 men newly diagnosed with prostate cancer, rehearsal in self-efficacy tended to increase active participation in treatment decisions.

Unfortunately, none of these three studies take into account physician style4 per se nor did they measure relevant patient personality characteristics such as locus of control or autonomy. Finally, each of these studies was nested within gender making it impossible to compare differences in gender in this regard. This is especially unfortunate because of the literature on gender differences in help-- seeking behavior. A considerable amount of work, for example, indicates that women are more open than men to receive and utilize social supports15-19 though one study20 reports that gender differences are a function of sex role characteristics rather than sex per se.

The present study attempts to link this body of literature with the Emanuel and Emanuel model.4 We hypothesize that non-autonomous individuals prefer paternalistic physician styles and autonomous patients, informative physician styles. However, this pattern may be affected by patient gender. The present study examines patient preference in clinician styles as a function of general patient autonomy level, knowledge of the specific disease, and patient gender.

Method

Sample:

One hundred thirty-one ambulatory care patients at Michael Reese Hospital and the University of Illinois at Chicago Medical Center were surveyed. The study was approved by the Institutional Review Boards of Michael Reese Hospital and the University of Illinois Medical Center. Of the 131 patients, 91 were women and 40 were men. The patients were of the following ethnic backgrounds: 18 Caucasian, 54 African American, 21 Asian American, 3 Hispanic, 32 other, and three unknown. The average age of the men was 37.6 years and the women was 45.6 years. Thirty-eight percent completed high school and 61 % completed college. Thirty percent were professional, 20% were clerical, and 46% were unemployed.

Survey overview:

The survey was comprised of three major parts. The survey took approximately 15 - 20 minutes to complete. The written survey was administered in the clinic waiting room by a research associate. The research associate was available to answer any questions pertaining to the study and to read the survey to the subject, if necessary, in a private location to ensure confidentiality. The first part was presented to all subjects and asked general demographic information about the subject. The second and third parts contained scenarios and questions specific to gender. In the second part, male subjects were asked to imagine that they were recently diagnosed with prostate cancer and were about to see a specialist to determine the treatment plan. Likewise, female subjects were asked to imagine that they had been recently diagnosed with breast cancer. Both male and female subjects were then presented with two potential physician response styles adjusted for the gender-specific disease: Dr. P (paternalistic style) and Dr. I (informative style). The third part measured the subjects' autonomy level on the Individuation-Attachment Questionnaire (IAQ). Finally, subjects were asked questions about their degree of knowledge of the specific imagined disease state (prostate cancer for men and breast cancer for women).

Independent variables:

The major independent variables in this study consisted of the following: a) the degree of subject autonomy (high versus low), b) subject knowledge of the disease, c) subject gender, and d) the physician response style (paternalistic or informative).

Subject autonomy level. Subject autonomy level was conceptualized as an overall personality style and was measured on the (IAQ)21,22,23 which has been used in the past in connection with NIMH psychological autopsy study on adolescent suicide24 and consists of twenty five-point Likert scales asking subjects to agree or disagree with a series of statements dealing with attachment and individuation themes. It is designed to yield four separate attachment and individuation scores: Need for Individuation (NI) (the need to make one's own decisions: e.g., "I believe everyone must find his or her own way in life."), Fear of Individuation (FI) (the fear of making one's own decisions: e.g., "It is important for me to do what other people think I should do."), Need for Attachment (NA) (the need to form close relationships: e.g., "I need to share my feelings with others."), and Fear of Attachment (FA) (the fear of forming close relationships: e.g., "A close relationship makes it hard to be yourself."). It has been employed in a number of studies involving over 2,000 respondents at various ages across the life-span, both clinical and non-clinical, both male and female. Reliabilities on the four sub-scales ranged from .75 (FI) to .84 (NA) and inter-correlations between the four sub-scales are quite low (.22 to -.19). Validity coefficients of the four scales with independent clinical assessments of these same characteristics ranged from .58 (FI) to .71 (NI).