Female physicians may order more diagnostic tests and admit a larger share of patients than male physicians, according to a recent study. However, the differences may be small and without statistically significant variations in 30-day mortality or short inpatient stays.
Investigators analyzed 1.6 million visits to 105 Veterans Affairs (VA) emergency departments from 2011 through 2019. They included adult patients aged 20 years or older who presented with chest pain, shortness of breath, or abdominal pain and were treated by 1,078 male physicians and 448 female physicians. The patients had a mean age of 62.6 years, and 90% of them were male.
The investigators adjusted for time and location of the visits; patient age, sex, race and ethnicity, illness severity, and comorbidity burden; and physician age and specialty.
Across all three presenting concerns, female physicians ordered more radiology and laboratory tests and admitted a higher proportion of the patients, although the absolute differences were modest.
For chest pain, female physicians ordered an adjusted mean of 1.14 radiology tests and 8.64 laboratory tests compared with 1.10 and 8.35, respectively, among male physicians. Admission rates were 45.7% and 44.0%.
The largest admission difference appeared among patients with shortness of breath. Female physicians admitted 50.0% vs. 47.8% of these patients compared with male physicians. They also ordered an average of 1.12 radiology tests and 8.02 laboratory tests vs. 1.08 and 7.69, respectively.
For abdominal pain, admission rates were 30.8% among female physicians and 29.8% among male physicians. Female physicians ordered slightly more radiology (1.08 vs. 1.03) and laboratory (8.03 vs. 7.81) tests, respectively.
Across the chest pain, shortness-of-breath, and abdominal-pain groups, female physicians ordered 0.04 to 0.05 more radiology tests and 0.21 to 0.33 more laboratory tests per visit compared with male physicians. Their admission rates were also 1.0 to 2.2 percentage points higher across the groups.
No statistically significant differences emerged in 30-day mortality for any of the three presenting concerns. Short inpatient stays of less than 24 hours also did not differ significantly. Although female physicians admitted more patients, those additional admissions were not disproportionately followed by discharge within 1 day, suggesting that the patients required inpatient care.
The investigators found that female physicians were slightly more likely to order potentially low-value testing, defined as ordering chest computed tomography (CT) with contrast as the initial test for patients with chest pain or shortness of breath who did not have a high pretest probability of pulmonary embolism, compared with male physicians. Among patients with shortness of breath, 5.2% of those treated by female physicians received the scan vs. 4.8% of those treated by male physicians.
Female physicians ordered more tests in selected laboratory-testing scenarios, including D-dimer testing for chest pain and shortness of breath and B-type natriuretic peptide testing for chest pain. For example, 12.1% of the patients with shortness of breath treated by female physicians received a D-dimer test vs. 11.0% of those treated by male physicians.
The proportion of tests with positive results was similar for female and male physicians. The investigators stated that because the additional tests ordered by female physicians were no less likely to be positive, the extra testing may have been clinically appropriate.
"Female physicians may give greater consideration to other biopsychosocial factors, including symptom management, functional status, and social support," wrote lead study author Dan P. Ly, MD, PhD, MPP, of the VA Greater Los Angeles Healthcare System, and colleagues.
In an accompanying editorial, authors described the differences in testing and admission decisions as intriguing but small. They noted that the investigators suggested greater aversion to risk and concern about judgment from peers among female physicians as possible explanations. The editorialists noted other factors could include case mix, responses from nurses and other health professionals, gendered expectations of physician behavior, and patient-clinician interactions.
The editorial authors wrote that the study relied on physician sex recorded in the data and could not examine the broader influence of gender, including social expectations and perceptions of physician behavior. They called for additional research into how these factors may shape practice patterns.
The study was limited to the VA health system and relied on data collected through 2019. The investigators could not determine whether more or fewer tests and admissions reflected higher-quality care, nor could they assess whether the additional CT scans yielded clinically significant findings.
Full disclosures of the study authors can be found in the study. The editorial authors reported no conflicts of interest.
Source: JAMA Internal Medicine, Editorial
