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RESEARCH ARTICLE
Patients’ and physicians’ gender and
perspective on shared decision-making: A
cross-sectional study from Dubai
Mohamad AlameddineID
1
, Farah OtakiID
2
, Karen Bou-Karroum
3
, Leon Du Preez
4
,
Pietie Loubser
5
, Reem AlGurgID
6
*, Alawi Alsheikh-Ali
6
1Department of Clinical Nutrition and Dietetics, College of Health Sciences, Research Institute of Medical &
Health Sciences (RIMHS), University of Sharjah, Sharjah, United Arab Emirates, 2Strategy and Institutional
Excellence, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab
Emirates, 3Department of Health Management and Policy, Faculty of Health Sciences, American University
of Beirut, Beirut, Lebanon, 4Cardiac Anesthesiology, The City Hospital, Dubai Health Care City, Dubai,
United Arab Emirates, 5Mediclinic Middle East, Dubai, United Arab Emirates, 6College of Medicine,
Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
*Reem.algurg@mbru.ac.ae
Abstract
Background
Delivering patient-centered care is a declared objective of many health delivery systems
globally, especially in an era of value-based health care. It entails the active engagement of
the patients in healthcare decisions related to their health, also known as shared decision
making (SDM). Little is known about the role of gender in shaping the perspective of patients
on their opportunity for engaging in SDM in the Arabian Gulf Region. The aim of this study is
to investigate the role of gender in shaping patients’ perspectives toward their opportunity
for SDM in Dubai, UAE.
Methods
This study utilized a cross-sectional survey consisting of sociodemographic questions and
the 9-item Shared Decision-Making Questionnaire (SDM-Q-9). A total of 50 physicians (25
females and 25 males), practicing at a large private healthcare delivery network in Dubai,
were recruited using convenience sampling. Ten patients of every recruited physician (5
male and 5 female) were surveyed (i.e., a total of 500 patients). Statistical analysis
assessed the differences in patients’ perceptions of physician SDM attitude scores by physi-
cians’ and patients’ gender using independent t-test, ANOVA-test, and Chi-square
analyses.
Findings
A total of 50 physicians and 500 patients (250 male patients and 250 female patients) partic-
ipated in this study. The odd of patients agreement was significantly lower for male physi-
cians, compared to their female counterparts, on the following elements of SDM: the doctor
precisely explaining the advantages and disadvantages of the treatment (OR = 0.55, 95%
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OPEN ACCESS
Citation: Alameddine M, Otaki F, Bou-Karroum K,
Du Preez L, Loubser P, AlGurg R, et al. (2022)
Patients’ and physicians’ gender and perspective
on shared decision-making: A cross-sectional
study from Dubai. PLoS ONE 17(9): e0270700.
https://doi.org/10.1371/journal.pone.0270700
Editor: Ravishankar Jayadevappa, University of
Pennsylvania, UNITED STATES
Received: October 13, 2021
Accepted: June 16, 2022
Published: September 1, 2022
Copyright: ©2022 Alameddine et al. This is an
open access article distributed under the terms of
the Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: The datasets
generated and/or analyzed during the current study
are not publicly available due privacy and ethical
restrictions as they contain potentially identifying
patient information. Access to this data can be
requested from the Institutional Review Boards of
Partners Human Research Committee,
Mohammad Bin Rashid University of Medicine and
Health Sciences (irb@mbru.ac.ae), Dubai
Healthcare City Authority-Regulatory Ethics Review
Committee, or Dubai Health Authority-Dubai
CI: 0.34–0.88, p = 0.012); the doctor helping them understand the information (OR = 0.47,
95%CI: 0.23–0.97, p = 0.038), the doctor asking about preferred treatment option (OR =
0.52, 95%CI: 0.35–0.77, p = 0.001), and the doctor thoroughly weighting the different treat-
ment options (OR = 0.60, 95%CI: 0.41–0.90, p = 0.013). No significant associations were
observed between patients’ gender and their perception of their opportunity for SDM. Like-
wise, no significant associations were observed between the same or different physician-
patient gender and patients’ perception of physicians’ SDM attitudes. Statistically significant
associations were observed between physician-patient gender and preferred treatment
option for patients (p = 0.012).
Conclusion
Study findings suggest that while there were no differences in patients’ perspective on SDM
by the gender of patients, significant differences were observed by the gender of physicians.
Female physicians, compared to their male counterparts, were more engaged in SDM, with
both male and female patients. Male physician-female patient dyad received the lowest
scores on SDM. This could be explained by the cultural, social, and religious sensitivities
that infiltrate the physician-patient relationship in the Arab contexts. Despite the multi-cul-
tural nature of the country, some female patients may still experience some discomfort in
opening up and in discussion preferences with male physicians. For physicians, striking the
right balance between assertiveness and SDM is necessary within the cultural context,
especially among male providers. Offering targeted learning and development programs on
the importance and practice of SDM is also necessary to ensure equitable opportunity for
engagement in SDM for all patients irrespective of the gender of their provider.
Background
During the past few decades, healthcare organizations witnessed a growing shift from the tra-
ditional paternalistic model of decision making in clinical settings towards a patient-centered
care model [1]. This is especially true for value-based health care [2], where the main aspect of
patient-centered care entails active engagement of the patients in their own healthcare decision
making process, which is also known as shared decision making (SDM) [1,3]. SDM consti-
tutes three domains: information-sharing between patients and providers, deliberation about
the advantages and disadvantages of treatment options, and decision-making about a treat-
ment plan that is approved by both the patient and the physician [4,5]. In this model of
patient-provider communication, both patients and providers bring their own experiences,
health literacy, and identities to the encounter, with variable levels of discordance [4].
Implementing SDM in clinical practice has been associated with improved patients’ self-
reported outcomes and their understanding of risks, as well as greater satisfaction with the
consultation process [6–8]. In addition, SDM improves quality of care and patient adherence
to medication, and consequently contributes to the optimization of health costs [7]. As such,
the recent surge in emphasis on value-based health care is expected to be coupled with
increased attention to SDM, especially when using patient-reported outcome measures [9,10].
The employment of SDM requires major commitment from healthcare professionals with
robust communication skills [11–13]. In other words, physicians with active listening skills are
fundamental assets to establish SDM, and consequently, to encourage patients to share
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Scientific Research Ethics Committee. This
statement has been added to our cover letter.
Funding: This research was funded by the Harvard
Medical School, Centre for Global Health Delivery–
Dubai. The funders had no role in study design,
data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
information about their personal life style, living situation, and personal preferences of treat-
ment [1]. A study by Zisman-Ilani et. al, revealed several issues related to the patient-physician
relationship such as lack of time and training, the role of insurance companies, the incentive
structure, and lack of support for physicians [14]. Another study investigating the barriers to
communication between family physicians and patients in Dubai showed that female patients
experience more time limitations during consultation where not all their issues are addressed
as compared to their male counterparts [15]. That said, gender is known as an important vari-
able for communication styles, decision-making styles, values, and preferences [7]. As such,
the concordance or discordance between the gender of the physician and the patient was
found to play a key role in the interaction and communication between physicians and
patients [16,17].
Literature reports differences between gender dyads and SDM interactions. Female physi-
cian-female patient dyad is the most patient-centered, characterized by more psychosocial talk
(e.g., lifestyle, and social aspects), bio-medical talk (e.g., therapeutic and medical concerns),
and the longest consultations. In contrast, female physician-male patient interactions are char-
acterized by less ease, more tension around gender role conflict, and unfriendly voice tones
[18,19]. Gender concordance may also improve overall patient-physician interaction by
encouraging patients’ trust, and enhancing communication and patient satisfaction [20]. Stud-
ies showed that gender concordance may be linked to improved hypertension and diabetes
outcomes as well as to the delivery of preventative counseling [20]. Indeed, better patient-phy-
sician communication have a positive effect on the overall patient experience, and conse-
quently, improved health outcomes [20]. Available data on cross-gender encounters reveal
that female physicians display a more patient-centered attitude [21]. As a matter of fact, female
physicians were found to give more information and emotional support, talk more encourag-
ingly, and put greater effort into partnership building [22]. Moreover, patients of female physi-
cians, both male and female, were more engaged in discussions with their physician, expressed
themselves more freely, shared more information, and disclosed partnership statements [23].
Local context
The current investigation takes place in Dubai, a populous commercial and touristic hub on
the Eastern side of the Arabian Peninsula. Dubai is a multi-cultural cosmopolis with a popula-
tion of 3.5 million, and a large expatriate population coming from more than 200 countries
around the globe [24]. Dubai’s healthcare sector has developed remarkably in the past few
years, providing exceptional opportunities for both investors and patients. The healthcare sec-
tor in Dubai is divided between public and private providers, which are primarily regulated by
the Dubai Health Authority (DHA). It is characterized by a high-tech medical infrastructure
serving not only the local market, but also wider regional demand [25].
Participants were recruited from Mediclinic Middle East, a large private healthcare delivery
network in the UAE. Mediclinic Middle East offers several health services for both genders in
the UAE, and treats priority issues including hypertension, diabetes, obesity, and cardiovascu-
lar diseases [26,27].Within Dubai, the network is comprised of 3 hospitals and 10 independent
clinics.
Dubai’s culture is rooted in Islamic and Arabic traditions, one might expect that patients in
the city may feel more comfortable in interactions with physicians of their own gender [28].
Furthermore, according to Islamic doctrine, females are expected to seek care from a same
gender clinician, especially in gender sensitive specialties (e.g. OBSGYN), unless there is no
female clinician available to offer services to other females [29,30]. To date, rarely has gender
been examined as a potential factor influencing the extent of SDM during consultations in the
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Arab Region. Yet, the SDM literature lacks studies that represent different cultures from coun-
tries outside the US, Canada, EU, and Australia [31]. To the best knowledge of the authors, the
current investigation is the first of its kind in Dubai. As such, the current study aims at investi-
gating the role of gender in shaping the perspectives of patients on their opportunity to engage
with their physician in SDM. Study findings can be leveraged to help in shaping a better
patient experience and in ensuring equitable delivery of healthcare in Dubai and other similar
contexts.
Methodology
Research design
This study employs a non-experimental cross-sectional survey design to capture quantitative
data regarding the perception of patients and physicians in Dubai in relation to SDM. The
study leverages this data to investigate potential associations in relation to the effect of gender
on the perspective of patients of the opportunity of engaging in SDM.
Instruments
The study collected data from both patients and physicians using two questionnaires. The
questionnaire for patients was composed of two segments. The first segment included ques-
tions collecting basic socio-demographic data, including: age, gender, educational level, and
nationality of patients. In the second segment, patients were asked to complete the 9-item
SDM Questionnaire for patients (SDM-Q-9).
A second survey questionnaire collected similar data from physicians and included two sec-
tions. The first collected personal and professional information about the physician (age, gen-
der, specialty, nationality, years of experience, and type of practice institution). The second
section was composed of the SDM-Q-9 questionnaire, adjusted to capture the perspective of
physicians on their provision of the opportunity for SDM to their patients.
The response for each question in the SDM questionnaire ranged from 1 (Strongly Dis-
agree) to 5 (Strongly Agree). The 5-point Likert scale has been used in previous studies
employing the SDM-Q9 scale [32–34]. Additionally, as stated in the literature, Likert scales are
simple to construct, are likely to produce high reliable scales, and are easy to read and complete
[35]. Thus, for the nine questions, this instrument yields a score ranging from 9 (indicative of
a very poor perception of SDM), to 45 (indicative of a very strong perception of SDM) [36]. As
suggested, we rescaled the total SDM scores to a 0–100 range with higher values indicating
higher SDM [36]. The questionnaire used in this study have been demonstrated to have good
psychometric properties. For example, the reliability analysis of the SDM-Q-9 scale showed a
Cronbach’s αof 0.943 [36]. The questionnaire was reviewed by an expert panel including a cli-
nician, statistician, health services researcher, nurse, and a patient advocate to enhance the
content validity. The questionnaires of both patients and physicians were available in Arabic
and English. They were translated to Arabic and back translated to English by two different
certified translators. In addition to the questionnaires, a clinic information sheet, gathering
basic information about the physician and the clinic, was filled by the data collectors.
Sampling strategy
To be able to detect a difference of 5 units between two groups (effect size of 0.3) [37], with a
power of 90%, and a type I error of 5%, the needed sample size is 470 patients. Accordingly,
the research team recruited 500 patient participants. This sample allows running a factorial
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analysis of variance with enough power (80%) to detect a small effect size (0.2) at the main
effect with interactions included in the model.
To obtain the 500 patient participants, a total of 50 physicians were recruited in the study
(25 male physicians and 25 female physicians). Both groups of stakeholders were recruited
using convenience sampling (Fig 1).
Inclusion/Exclusion criteria
All physicians were included in the study except those who provide care for patients of a single
gender (e.g., obstetrics and gynecology, and urology). Moreover, specialties that were likely to
be dealing with critical cases were excluded: Emergency Medicine, Intensive Care Unit, Anes-
thesiology, and Psychiatry. Pediatricians were also excluded since the principles of SDM differ
when dealing with children [38]. Patients were included in the study if they were adult aged 18
+, understand Arabic or English, and are either new patients or returning patients with a new
complaint (to ensure the occurrence of decision-making during the visit).
Data collection
Convenience sampling, in two sequential recruitment phases, was utilized to achieve the
desired sample size. The first phase of recruitment started with obtaining a complete list of all
licensed physicians working in the target facilities. All the eligible physicians (around 200)
were approached initially through the Chief Medical Officer monthly meeting in each of the
included units. During the meeting, the project coordinator introduced the project and
addressed any concerns. Following that, personalized emails were sent out to all the eligible
physicians. The first 50 physicians (25 male and 25 female) who expressed interest to partici-
pate, and in turn submitted signed consent forms, were included in the study.
The second phase of the sampling included reaching out directly to patients of the 50 partic-
ipating physicians. A total of 10 data collectors underwent a thorough training to equip them
with the knowledge and skills needed to carry out data collection as per the approved research
protocol of this study. They collected data from the clinics of participating physicians during
the working days and hours of the physician, with data collection alternating between the
morning and afternoon/evening shifts. No more than five patients were surveyed in a single
visit.
The data collectors approached the individual patients after completing their consultations
and prior to leaving the out-patient clinic. The patients agreeing to participate in the study
were asked to provide written consents prior to completing the study questionnaire. The
patients completed the questionnaires in a quiet and private space. The first ten patients (5
male and 5 female patients) who consented to participating in this study were selected. The
data collectors approached a total of 714 patients out of whom 500 agreed to participate.
Patients who did not agree to participate were either not in the mood to evaluate their experi-
ence, did not feel (physiologically and/ or psychologically) well enough to do so, or did not
have the time to complete the questionnaire.
Pilot study
Pilot testing was conducted on two randomly selected physicians and four patients (two for
each physician). No changes were necessary to the survey questionnaire as a result of this pilot
test.
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Data analysis
Collected data were coded and analyzed using IBM SPSS statistics software version 25.
Descriptive analysis was carried out to summarize patient characteristics such as socio-demo-
graphics and medical conditions. Differences in SDM scores of patients by physicians’ or
patients’ gender were conducted using independent t-test and ANOVA-test. Proportion of
patients who strongly agreed/agreed with each statement in the SDM scale was compared
between female and male patients using Chi-square test. A p-value of 0.05 was used to detect
significance in all analyses used in the present study.
Ethical approval and considerations
This study was approved by four Institutional Review Boards: Partners Human Research Com-
mittee, Mohammad Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare
City Authority-Regulatory Ethics Review Committee, and Dubai Health Authority-Dubai
25 male
physicians
5 male
patients
5 female
patients
25 female
physicians
5 male
patients
5 female
patients
Male physicians-Male patients:
125
Male physicians-Female
patients: 125
Female physicians-Male
patients: 125
Female physicians-Female
patients: 125
500
patients
50
physicians
Fig 1. Recruitment plan for this study.
https://doi.org/10.1371/journal.pone.0270700.g001
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Scientific Research Ethics Committee. The participation of both patients and physicians was
entirely voluntary, and written consent forms were obtained prior to any data collection initia-
tive. Participants had the right to refuse participation, to withdraw at any point in time, and to
refrain from answering any question(s). There were no incentives for participation or penalties
for non-participation. The data collected was secured in a locked cabinet and in turn on a pass-
word protected computer. Anonymity and confidentiality of the respondents was guaranteed,
where no personal identifiers were recorded at any stage of the study.
Results
A total number of 50 physicians and 500 patients participated in this study. The demographic
characteristics of respondents are described in Table 1. The mean (±SD) age of patients was
44.5 (±14.4), equally divided by gender (by virtue of the research design). Most of the patients
(84%) had attained at least an undergraduate university education level. Physicians had an
average age of 52.0 (±14.3). Most physicians were practicing at hospital-based clinics (82%),
and had an average of 20.6 (±13.8) years of experience. The mean SDM-Q-9 score for the
patients in this sample was 83.46 (±12.82) and that for the physicians was 88.71 (±12.07).
Using simple logistic regression, Table 2 displays the association between the gender of phy-
sicians and the perspective of patients on their opportunity to engage with SDM. Compared to
patients cared for by female physicians, patients cared for by male physicians were less likely to
strongly agree/agree that the doctor precisely explained the advantages and disadvantages of
the treatment (78.3 vs. 86.6%, OR = 0.55, 95%CI: 0.34–0.88, p = 0.012). Similarly, patients of
male physicians were less likely to strongly agree/agree that the doctor helped them under-
stand the information (90.4 vs 95.2%, OR = 0.47, 95%CI: 0.23–0.97, p = 0.038), asked them
about their preferred treatment option (63.7 vs. 77.1%, OR = 0.52, 95%CI: 0.35–0.77,
Table 1. Demographic characteristics of study sample.
Patients N = 500
Age 44.51 ±14.42
Female 43.52 ±14.53
Male 45.51 ±14.25
Gender
Female 250(50.0)
Male 250(50.0)
Education level
�High school 78(16.0)
University degree 286(58.8)
Higher education 122(25.1)
Physicians N = 50
Age 52.02 ±14.27
Female 48.75 ±16.00
Male 55.28 ±11.73
Gender
Female 25(50.0)
Male 25(50.0)
Years of experience 20.62 ±13.75
Clinic type
Hospital-based 41(82.0)
Polyclinic 9(18.0)
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p = 0.001), and thoroughly weighted the different treatment options (67.7 vs. 77.5%,
OR = 0.60, 95%CI: 0.41–0.90, p = 0.013).
No significant associations were observed between patients’ gender and their perception on
their opportunity to engage in SDM with their physician. Likewise, no significant associations
were observed between same or different physician-patient gender and their perception on the
opportunity to engage in SDM with their physician (S1 Table).
Table 3 reveals that the only significant associations across the different physician-patient
gender dyads and the perspective of patients on their opportunity to engage with SDM was
observed on the doctor discussing the preferred treatment option with their patient
(p = 0.012). Male patients of female physicians perceived the highest levels related to this
dimension of SDM, and the female patients of male physicians had relatively lowest perception
on this dimension of SDM.
Discussion
This was the first study in the UAE to assess the effect of the gender of patients and physicians
on the perspective of patients on their opportunity to engage in SDM. Findings of this study
revealed an overall high rating of opportunity for SDM by all patients and physicians. It, how-
ever, also suggested that the areas where SDM is better exercised by female physicians include:
supporting patients in understanding technical information, explaining the advantages and
Table 2. Associations between the gender of physicians and the perspective of patients on their opportunity to engage with SDM.
Patients’ score Physicians’ gender p-
value
Simple logistic
regression
Total (n = 500)/N
(%)
Females (n = 250)/
N(%)
Males (n = 250)/ N
(%)
OR (95%CI)
My doctor made clear that a decision needs to be made.
Strongly Agree or Agree 460(92.0) 230(92.0) 230(92.0) 1.000 -
My doctor wanted to know exactly how I want to be involved in
making the decision.
Strongly Agree or Agree 419(84.0) 211(84.7) 208(83.2) 0.639 -
My doctor told me that there are different options for treating my
medical condition.
Strongly Agree or Agree 362(72.8) 187(75.4) 175(70.3) 0.199 -
My doctor precisely explained the advantages and disadvantages of
the treatment options.
Strongly Agree or Agree 412(82.6) 217(86.6) 195(78.3) 0.012 0.55 (0.34,0.88)
My doctor helped me understand all the information.
Strongly Agree or Agree 464(92.8) 238(95.2) 226(90.4) 0.038 0.47 (0.23,0.97)
My doctor asked me which treatment option I prefer.
Strongly Agree or Agree 350(70.4) 192(77.1) 158(63.7) 0.001 0.52 (0.35,0.77)
My doctor and I thoroughly weighed the different treatment
options.
Strongly Agree or Agree 362(72.5) 193(77.5) 169(67.6) 0.013 0.60 (0.41,0.90)
My doctor asked me which treatment option I prefer.
Strongly Agree or Agree 391(78.4) 203(81.2) 188(75.5) 0.122 -
My doctor and I thoroughly weighed the different treatment
options.
Strongly Agree or Agree 447(89.6) 229(92.0) 218(87.2) 0.081 -
Overall, I was happy with my interaction with the physician
Strongly Agree or Agree 466(93.2) 234(93.6) 232(92.8) 0.722 -
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disadvantages of the treatment options, and thoroughly weighing them, and jointly selecting
the preferred treatment option. In this study, no significant association was found between
same or different physician-patient gender dyads and the perspective of patients on their
opportunity to engage in SDM. Therefore, the concordance/discordance of gender between
patients and physicians did not seem to make a difference in patients’ perceived opportunity
for SDM.
Since the days Abraham Flexner prepared his seminal report on the future of medical edu-
cation in 1910, SDM has been at the forefront of discussions. Flexner emphasized on the syn-
ergy between scientism and humanism, urging all medical schools to teach the emotional as
well as the scientific [39]. More than a century later, the medical and scientific communities
are still striving to strike the right balance to ensure equitable and standardized care to patients
while controlling for the inevitable differences in the characteristics of the patients and their
providers. Understanding the variables that influence the opportunity that physicians extend
to their patient to participate in SDM is of pivotal importance. Such variables include physi-
cian-specific characteristics, patient-related antecedents, the environment, and the interper-
sonal dynamic between the physicians and their patients [40]. The gender of the physician is
indeed a significant determinant of SDM since it influences clinical practice, and thus, the
patient-physician relationship [41].
The current study’s findings which highlight that the patients of female physicians tend to
perceive a better opportunity for SDM, is in synch with previous investigation. Similar to this
study, female physicians were reported to provide more subjective and objective information,
engage more in psychosocial counseling, and involve patients more in decision making [18].
Table 3. Associations of physician-patient gender and the perspective of patients on their opportunity to engage with SDM.
SDM attitudes of patients MM (N = 125)/ N
(%)
MF (N = 125)/ N
(%)
FM (N = 125)/ N
(%)
FF (N = 125)/ N
(%)
p-value
My doctor made clear that a decision needs to be made.
Strongly Agree or Agree 115(92.0) 115(92.0) 113(90.4) 117(93.6) 0.833
My doctor wanted to know exactly how I want to be involved in making
the decision.
Strongly Agree or Agree 101(80.8) 107(85.6) 103(82.4) 108(87.1) 0.511
My doctor told me that there are different options for treating my
medical condition.
Strongly Agree or Agree 83(66.4) 92(74.2) 90(73.2) 97(77.6) 0.243
My doctor precisely explained the advantages and disadvantages of the
treatment options.
Strongly Agree or Agree 97(77.6) 98(79.0) 107(85.6) 110(88.0) 0.087
My doctor helped me understand all the information.
Strongly Agree or Agree 113(90.4) 113(90.4) 120(96.0) 118(94.4) 0.208
My doctor asked me which treatment option I prefer.
Strongly Agree or Agree 80(64.5) 78(62.9) 98(78.4) 94(75.8) 0.012
My doctor and I thoroughly weighed the different treatment options.
Strongly Agree or Agree 85(68.0) 84(67.2) 96(77.4) 97(77.6) 0.104
My doctor asked me which treatment option I prefer.
Strongly Agree or Agree 93(74.4) 95(76.6) 103(82.4) 100(80.0) 0.427
My doctor and I thoroughly weighed the different treatment options.
Strongly Agree or Agree 108(86.4) 110(88.0) 113(91.1) 116(92.8) 0.335
Overall, I was happy with my interaction with the physician
Strongly Agree or Agree 119(95.2) 113(90.4) 118(94.4) 116(92.8) 0.449
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In contrast, male physicians were relatively more focused on the technical aspects of the clini-
cal consultation (e.g., physical examination), are more assertive, and give more advice [18].
Studies also showed that female physicians spend more time with patients, relative to male
physicians, and that patients are more satisfied with their communication and interaction with
female physicians [42]. It is worth noting that physicians in our study, work within the same
healthcare system, consequently there is no difference in the time allocated to patients by the
gender of physicians.
Furthermore, it has been suggested that females, as a group, are more likely to respond to
unspoken demands and implicit discomfort than males [43]. A recent study among diabetic
patients, showed that patients assume that female physicians would be more empathetic and
caring, whereas male physicians are usually more reluctant to discuss personal matters [44].
Therefore, it was concluded that patients have different expectations of care and SDM
approach based on their physician’s gender. Knowing that physicians in this study were work-
ing within the same environment in terms of organizational values, incentives, and design, it
seems that gendered social norms were also pervasive. Having said that, it must be noted that
cultural, social, and religious sensitivities still infiltrate the physician-patient relationship in
the Arab contexts [28,29]. A study from Saudi Arabia, Bahrain, and the UAE showed that
employee’s gender has a significant interaction effect on customer’s comfort, feedback willing-
ness, and satisfaction with service encounter [28]. Female physicians are expected to motivate
the patients and assist in finding external peer support programs, whereas male physicians are
expected to only deliver services related to their professional roles such as referrals and pre-
scriptions [44]. Future studies could investigate if there is an interaction effect of gender and
communicative behavior of physicians on patients’ perceived opportunity for SDM. Perhaps
the communication style of physicians has a stronger impact than gender itself [45,46].
Interestingly, in this study, female physician-male patient dyad received the highest SDM
scores on treatment options, followed by female physician-female patient. Knowing that treat-
ment options is at the core of patient-centered care, this further indicates that female physi-
cians are more likely to be involved in the SDM process. It seems that female physicians are
successfully collaborating and engaging with male patients to remove the tension surrounding
having a female in the dominant professional role. In contrast, the male physician-female
patient dyad received the lowest scores on SDM. This could be attributed to factors related to
patients and physicians. On the patients’ front, and despite the multi-cultural nature of the
UAE, the country’s culture remains rooted in Islamic and Arabic traditions, this suggests that
some female patients may feel more comfortable in opening up and interacting with female
physicians. On the physicians’ front, striking the right balance between assertiveness and SDM
is necessary within the cultural context, especially among male providers [28–30]. Future stud-
ies should systematically investigate the above mentioned observations, and suggest contextu-
alized evidence-based policy and practice recommendations.
While this finding is not a novel discovery as it has been supported by previous studies [18,
42], establishing this gender pattern in an Arab-Islamic context is quite novel. This could also
be explained by the efforts of the UAE government towards elimination of discrimination
against women, gender equality, and supporting women who are playing a role in the develop-
ment of economy [47]. According to the World Economic Forum’s Global Gender Gap Report
2017, the UAE is at the forefront of gender equality [48]. The finding could also be explained
by the high educational level of the patient population in this study which may have shaped
their acceptance of gender roles in a professional setting [49].
The findings of this study need to be translated and celebrated to help break any existing
cultural biases related to the gender of the healthcare professional. While all physicians in this
study are found to provide a good level of SDM to their patients, female physicians were better
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rated on several SDM attributes. On that front, the findings challenge two cultural assump-
tions. First, the performance of female physicians is not inferior to their male counterpart, but
rather superior when it gets to patients’ evaluation of their opportunity to engage in SDM. Sec-
ond, in specialties catering for both genders, the concordance of the gender of patients and
providers does not ensure a higher satisfaction with care. In contrast, the male patients of
female physicians had the highest score on the treatment options attribute of SDM. Having
said that, the findings of this study do not by any means suggest that the care of male physi-
cians is inferior to that of their female counterparts, it rather suggests that some male physi-
cians could benefit from learning how to enhance their practice of SDM from their female
colleagues as part of developing gender-sensitive and high-quality medical services. This is
expected to translate into better outcomes of care which will directly feed into the attainment
of value-based health care [9,10]. Raising awareness on gender behavior patterns and imple-
menting training sessions in communication and SDM skills among physicians are essential,
particularly for male physicians [19]. Medical education must continue to teach compassionate
and patient-centered care [50,51]. Furthermore, future qualitative research is needed to
develop a deeper understanding of what leads a patient to label a decision as shared.
Limitations
Several shortcomings were noted in this study. First, the external validity of the findings may
be limited to patient care systems that are similar to the large private provider network where
the data collection took place. Yet, it must be noted that private provider networks, like the
one included in this study, provide a substantial proportion of care in Dubai and the UAE. Sec-
ond, although the selected network serves a diverse population, patients are usually white-col-
lar professionals (and their families) working in Dubai and may not be representative of low-
income populations or those who are underprivileged. As such, future studies should include a
sample from governmental and public clinics to be more representative of the whole popula-
tion. Third, this study only included a subjective assessment of patients’ perspectives regarding
physicians’ SDM attitudes. It would be worthwhile for future studies to include an objective
assessment of the SDM attitudes of the patients (e.g., the time spent by each physician with a
patient). Fourth, as data was self-reported, it is possible that patients might have overempha-
sized their positive views of SDM. However, the research team tried to minimize social desir-
ability bias through assuring the confidentiality of the collected data. Fifth, although there was
no indication of selection bias during data collection and the selection of physicians was most
often related to their availability, this possibility cannot be ruled out. Finally, the specialization
of the male and female physicians participating in this study could not be matched which
could introduce a bias due to the innate differences in practicing SDM by specialty. Future
studies should include exploratory qualitative analysis, such as data from focus group sessions
with random selection of patients, to develop a more thorough understanding of the reasons
underlying the findings generated by this study.
Conclusion
Gender is one of the various factors affecting the physician-patient relationship. Findings of
this study suggest that while there were no differences in patients’ perspective on SDM by the
gender of patients, significant differences were observed by the gender of physicians. Patients
of female physicians perceived more engagement in SDM as compared to male physicians.
Results also showed that the concordance/discordance of gender between patients and physi-
cians did not seem to make a difference in patients’ perceived opportunity for SDM, suggesting
that gender dyads may not act as barriers to SDM in the current study’s context. These results
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call for appropriate strategies to improve SDM skills among physicians, particularly male phy-
sicians, as well as raise awareness on gendered behavior patterns to ensure high quality and
gender-sensitive healthcare. All this will inevitably lead to better patient outcomes of care.
Supporting information
S1 Table. Output of the inferential analysis.
(DOCX)
Acknowledgments
We would like to extend gratitude to all the data collectors who supported, on a volunteering
basis, in interviewing patients in the respective research study; MBRU MBBS students: Ame-
neh Baghestani, Aya Akhras, Eman Khalaf, Ghadah Al-Sharif, Maryam AlObeidli, Maryam
Jafari, Sarah AlKabbani, Seyed Ali Safizadeh Shabestari, and Nadaa Kemmou. Others: Ghausia
Begum and Nour Abu Mahfouz.
Author Contributions
Conceptualization: Mohamad Alameddine, Farah Otaki, Reem AlGurg, Alawi Alsheikh-Ali.
Data curation: Mohamad Alameddine, Reem AlGurg.
Formal analysis: Reem AlGurg.
Methodology: Mohamad Alameddine, Farah Otaki.
Project administration: Mohamad Alameddine.
Software: Karen Bou-Karroum.
Supervision: Mohamad Alameddine.
Writing – original draft: Mohamad Alameddine, Farah Otaki, Karen Bou-Karroum, Reem
AlGurg, Alawi Alsheikh-Ali.
Writing – review & editing: Mohamad Alameddine, Farah Otaki, Karen Bou-Karroum, Leon
Du Preez, Pietie Loubser, Reem AlGurg, Alawi Alsheikh-Ali.
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