Gender and Connecting with Your Health Provider: A Q&A with Dr. Christine J. Ko

With a grant from Women’s Health Research at Yale, Dr. Christine J. Ko identified the absence of a common gene mutation in a form of skin cancer (squamous cell) frequently found on women’s legs. She is continuing to explore this as a promising biological marker to predict the growth rate and recurrence of these lesions. A professor of dermatology and pathology at Yale School of Medicine, she has been pursuing this work toward a clinical application while actively seeing patients. Recently, she wrote a book, published by Routledge, titled “How to Improve Doctor-Patient Connection.” We chatted with Dr. Ko to get her insight into the roles psychology and gender play in health care interactions.

WHRY: You write in your book about how the late diagnosis of your son’s deafness inspired you to connect better as a physician and a patient. Was that a difficult process for you?

Dr. Ko: Yes and no. It was difficult to organize the book in a coherent fashion, as initially I was not writing this as a doctor. I was writing it from a place of pain, as a mother whose son was misdiagnosed for too long, thinking: Is there a way that other people do not have to be as lost as I was? Through writing the book, I realized that if I had known how to connect better as a doctor or as a patient advocate, I would have navigated the health care system better. Maybe I would have known how to get my questions answered in a way that I could understand, and maybe the doctors we saw would have had a better idea of what my son and I needed. I realized through the whole journey that it’s ultimately about personal connection. We just have to see people — doctors, patients, parents, children, friends, colleagues — literally and figuratively. And listen to them.

WHRY: You write with critical honesty about your own shortcomings as a physician in your relationships with patients. And you discuss how metacognition — the awareness and understanding of one’s own thought processes — can help improve the doctor-patient connection. Do you think this might be difficult for doctors — even those open to the concept — to accept and put into practice?

Dr. Ko: Maybe, but doctors are already trained to think about their thought processes as related to diagnosis and what can sometimes go wrong with diagnosis or treatment plans. The shift is that doctors just need to apply these same thought processes to doctor-patient connection, not just diagnosis and management. For example, as a female physician, I am looked at differently compared to male physicians. By simply being aware of that, I realized that I am expected from the beginning to be warm. If I am not perceived as warm by patients, automatically I have lost a lot of ground. How can I show a patient warmth? On a simple, easy level, I can enter the room with a warm smile. This takes no extra time. And it’s not that I’m pretending to be warm. It’s having the awareness that my neutral face (without a smile) is not generally perceived as warm, whereas my smiling face is. By smiling, I am more likely to be perceived by the patient as a caring doctor. Awareness of the implicit biases we encounter can be helpful in creating smoother interactions.

WHRY: You focus a lot on the two general types of human information processing: System 1 (fast, intuitive processing) and System 2 (slow, logical, analytical processing). And how over-reliance on System 1 can lead not only to diagnostic errors but failure to see patients as people. Can you talk about that and how it might relate to interactions involving female patients?

Dr. Ko: I think many of us do not understand how we make decisions. If I intuitively like a certain painting, that is an example of System 1 processing. If someone asks why I like it, and I analyze and give reasons, that is an example of System 2 processing. The first is like a gut feeling. We react that way to a lot of what we are taking in. I think this dynamic is often at play with female patients. Unfortunately, and I do not think doctors mean to do this, research has documented that female patients with particular symptoms of say, heart disease, are more often misdiagnosed with anxiety (rather than heart disease), particularly compared to male patients with the exact same symptoms. It is important to have an awareness that gender is a factor in how patients are perceived.

This same type of misdiagnosis or delay in diagnosis affects children and people of color as well. Especially if you are a female patient, and even more so if you are a female person of color, there is a higher chance that you will experience misdiagnosis or diagnostic delay. Both doctors and patients need to be aware of that risk and try to consciously mitigate it by checking what might be going wrong here?

WHRY: Recent news reports have discussed a phenomenon dubbed “medical gaslighting.” Studies show female patients and people of color are more likely to have their symptoms dismissed by medical providers. Women, particularly women of color, are more likely to be misdiagnosed than men in a variety of situations. What do you make of this longstanding trend? What could medical providers do to break this pattern?

Dr. Ko: I don’t love the term “gaslighting” because it implies a deliberate, purposeful attempt to mess with another person’s experience of reality. I don’t think that doctors are treating women or people of color differently in a deliberate, conscious manner. This differential treatment is, I believe, an example of System 1 processing. It happens without conscious intent. Doctors are human and have implicit biases like anyone else. With no blame on individual doctors, we have got to get better, and this includes system changes. But to start with, on the individual level, the doctor-patient relationship can be more of a partnership than it’s currently set up to be. Doctors are medical experts, but patients are experts in their own experience. We need to trust each other more and listen to each other more.

WHRY: What role must female patients take to improve relationships with medical providers that can lead to better health outcomes?

Dr. Ko: Trust yourself. Be aware of yourself. Why are you going to the doctor? Have that very clear in your mind. Make sure that your needs are addressed. And tell the doctor if your needs are not addressed. As an expert in your own experience, you are deserving of respect. Ask when things do not feel right or sit right with you. A good doctor will be willing to listen.

Dr. Margaret Pisani, professor of internal medicine at Yale School of Medicine, edited a book published by Elsevier in September highlighting the latest research on “Gender and Respiratory Disease.” The book features more than a dozen articles on topics such as sex differences in obstructive sleep apnea, women and lung cancer, unique aspects of asthma in women, and challenges faced by women with cystic fibrosis.

In October, a chapter by WHRY Director Carolyn M. Mazure, PhD, will appear in a new book, “Taking Care of You: The Empowered Woman's Guide to Better Health,” edited by orthopedic surgeon Dr. Mary I. O’Connor, and medical anthropologist Kanwal H. Haq. Dr. Mazure’s contribution provides context about the history and progress of medical research involving women and sex-and-gender differences that women can use to ask questions and develop more effective relationships with their care providers.