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INFERTILITY Perceptions of women’s infertility: what do physicians see?

Rosario Ceballo, Ph.D.,a Antonia Abbey, Ph.D.,b and Deborah Schooler, Ph.D.a
a

University of Michigan, Ann Arbor; and b Wayne State University, Detroit, Michigan

Objective: To assess physicians’ awareness of the infertility risk associated with race, age, and education, and to elicit their clinical management recommendations for a hypothetical patient. Design: Cross-sectional survey. Setting: Surveys were mailed to 1,000 randomly selected primary care physicians in the state of Michigan. Patient(s): None. Interventions(s): None. Main Outcome Measure(s): Self-reported questionnaire asking the relative prevalence of infertility among women based on race, education, and age. Physicians were also asked what interventions they would recommend for one of four hypothetical female infertility patients who were either European American or African American and either a working professional or receiving Medicaid. Result(s): Although most physicians did not correctly identify the associations between age, race, and socioeconomic status and women’s infertility, their suggested clinical interventions did not vary based on a hypothetical patient’s race or socioeconomic status. Female physicians, obstetrician/gynecologists, and physicians with more infertility experience or who had seen more infertile patients recommended more components of a model standard of care. Conclusion(s): A questionnaire using a hypothetical patient model suggests that primary care physicians may not be sufficiently aware of the infertility risk of African American women and women with lower socioeconomic status to ensure that women in need of services are identified. (Fertil SterilÒ 2010;93:1066–73. Ó2010 by American Society for Reproductive Medicine.) Key Words: African American, gender, infertility, physicians, race, social class

To date, the preponderance of medical and psychologic research on infertility has relied on European American samples consisting of couples with middle to high socioeconomic status. Approximately 13% of married women between the ages of 15 and 44 have some form of fecundity impairment, with over 6 million women in the United States affected by infertility (1–3), the inability to conceive after 1 year of unprotected intercourse. Members of infertile couples typically experience a barrage of stressful psychologic sequelae following the diagnosis of an infertility problem (4–11). Couples who have participated in research studies tend to be those who can afford highly specialized medical treatments (4). Among infertile women, obtaining some type of medical treatment is positively associated with age, being married, graduating from college, having a high income, and being

Received June 19, 2008; revised November 6, 2008; accepted November 15, 2008; published online January 25, 2009. R.C. has nothing to disclose. A.A. has nothing to disclose. D.S. has nothing to disclose. Reprint requests: Rosario Ceballo, Ph.D., University of Michigan, Department of Psychology, 530 Church Street, Ann Arbor, MI 48109 (FAX: 734-615-0573; E-mail: rosarioc@umich.edu).

non-Hispanic White (12). Even in Massachusetts, a state with mandated comprehensive insurance coverage for infertility, couples accessing medical care for infertility tend to be European American, of upper socioeconomic status, and highly educated (13). For example, among 561 women who attended a large infertility clinic in Massachusetts (at Brigham & Women’s Hospital), none of the patients had less than a high school diploma compared with 15% in the state population. Additionally, about half of the patients had advanced degrees compared with 12% in the population (13). The obstacles that poor and racial minority women face in receiving infertility treatment are potentially numerous, including economic disadvantage, lack of referrals, little or no insurance coverage, racial discrimination, and cultural sanctions against infertility treatment (2, 14). When African American women do seek medical care, they tend to have experienced difficulty conceiving for a longer period of time before seeking medical attention compared with European American women (2). It is quite likely, therefore, that many women who struggle with infertility never go beyond a single visit or conversation with a general/family practitioner or their gynecologist. In a society that glamorizes highly technical, medical interventions, how then are African American women and women of lower
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Fertility and Sterilityâ Vol. 93, No. 4, March 1, 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.

the research on infertility has virtually ignored racial minorities and couples of lower socioeconomic classes. fewer kidney and bone marrow transplants. insurance. such as pelvic inflammatory disease and ectopic pregnancies. women with less than a high school education also have higher rates of infertility than do women with more education (1). lower socioeconomic status is associated with receiving fewer preventative medical services such as papanicolaou tests. gynecologists. age. in particular. 4. with actors sharing identical demographic characteristics. were less likely to be referred for catheterization in comparison to European American men. and low-income couples who are most likely to struggle with infertility in the United States (1. For our mailing. A total of 720 doctors viewed 1 of 144 possible case scenarios that varied by patient race. clinical symptoms. The actors relied on scripted interviews about symptoms for three kinds of chest pain. For example.income backgrounds likely to be treated when they discuss infertility with a medical practitioner? RACE. respectively. heterosexual couples Fertility and Sterilityâ who can afford private fee-for-service health care (14). Age is also associated with infertility. and even less receipt of pain medication as part of routine hospital care (15–20). virtually nothing is known about the many people who experience infertility but do not seek medical treatment. 13. and immunizations. returning the survey represented a physician’s informed consent to participate in this study. and thus. patients’ race and gender interacted so that African American women. Further. level of coronary risk. 2. Participating physicians randomly viewed actors portraying patients in a video recorded interview of a patient with chest pain. The present study surveys physicians about their knowledge of infertility among different demographic groups of women and examines how patient and physician characteristics may influence physicians’ treatment responses to hypothetical infertile patients. In contrast to popularly held perceptions. fewer cardiovascular procedures. The survey was both anonymous and confidential. in comparison to European Americans (21–23). and to rate their visits with physicians as less participatory (24–26). Studies evaluating medical care for coronary artery disease consistently report lower quality treatment for African American patients. which can cause infertility (28). couples who are most likely to be infertile in the United States do not match the demographic profile of couples who are most likely to seek medical treatment and to participate in research investigations. relying instead on the sample of people who appear for treatment at medical clinics. [2] involved in patient care. The results showed that both women and African Americans were less likely to be referred for cardiac catheterization in comparison to men and European Americans. we randomly selected physicians who met all of the following four criteria: [1] members of the American Medical Association. African American women also experience high rates of reproductive problems. In 1988. The compelling nature of this study rests in the use of a randomized design. a greater proportion of African American and Hispanic women received a diagnosis of tubal factor infertility compared with European American women (2). about 15 minutes to complete the short questionnaire. internal medicine. less well-educated. family practice. 28. 1067 . 5. obstetricians. Hence. membership in a racial minority group is linked to less preventative care including breast cancer screening. and results of an exercise stress test. A total of 205 surveys were returned for a final response rate of 20%. We estimated that it would take doctors. 30–33). Further. such as inadequate access to treatment for sexually transmitted diseases and occupational hazards (34). Scholars have proposed several possible explanations for the racial disparity in infertility rates. 28). Schulman and colleagues (27) designed a computerized survey instrument to experimentally assess physicians’ treatment recommendations for managing chest pain in hypothetical patient/actors. many infertility clinics can selectively provide services to married. The cover letter explained that we were surveying general and family practitioners. type of chest pain. African Americans are more likely to be denied authorization for emergency care by managed care gatekeepers. A three-page survey was mailed to 1. and clinical presentations. Similarly. to encounter greater difficulties in accessing their primary care providers. less surgical treatment for cancers. Ironically. Likewise. By the same token. estimated to be almost half of all infertile couples (4). in comparison to European Americans. such that women over the age of 35 are much more likely to experience infertility than are younger women. among 561 women who sought medical care for infertility.000 physicians randomly selected from 6. compared with their European American counterparts. and internists because we were interested in the initial interactions that women have with medical professionals before some decide to consult with a fertility specialist. or obstetrics/gynecology). there is a startling mismatch between the demographic profile of women who seek medical care for infertility and women who are most likely to suffer with infertility. [3] finished with their medical training (residents and fellows were excluded). as well as lower quality hospital care (15). it is African American. No followup mailings were possible. for example.AND CLASS-BASED DISPARITIES IN HEALTH CARE In general. only 43% of all women with infertility reported having ever obtained any medical infertility service (29). Infertility: including race and social class Regrettably. glaring limitations exist in our understanding of the impact of infertility on racially and socioeconomically diverse groups of people (4. mammograms. and [4] affiliated with one of four specialties (general practice.000 physicians in the state of Michigan. Moreover. MATERIALS AND METHODS Participants and procedure All of the research undertaken in this study received approval from the institutional review board at the first investigator’s university. on average. Thus. sex.

Recommended treatment for hypothetical patient Physicians were asked how they would treat a fictional female patient. ‘‘provide educational information about basal body temperature charts (if the patient has not done this already)’’ or ‘‘perform an endometrial biopsy’’ to receive credit for checking the patient’s ovulation. laparoscopy. and physicians acquired one point for each component of the workup by checking off any one of the acceptable methods. The patient’s race and social class varied across the surveys that were mailed in a 2 Â 2 design. we did not consider making referrals to be part of a medical standard of care. ever discussed the costs of fertility treatments with a patient. [2] a European American woman on Medicaid.58) was used as a scale of acceptable nonmedical interventions. A scale of acceptable nonmedical interventions included two items: suggest educational reading. or over 35 years. an index of specialized referral care included two items about providing referrals to infertility specialists [1] in hospital settings or [2] in private practice. with possible scores ranging from 0 to 2 (mean ¼ . because it implies that their worries and anxiety may cause their infertility. and evaluation of tubal patency. 31 to 35 years. assessment of thyroid functioning. Most couples interpret the recommendation to ‘‘relax’’ as hurtful. provide assurance that there is no need to worry yet. or Asian American. 93. Intervention choices included a list of possible medical tests (e. they were asked which racial group had the highest prevalence of infertility: European American. and ever referred a patient with infertility to a support group. and [4] an African American woman on Medicaid. Physicians’ characteristics and experiences Physicians were asked to identify their area of medical specialty. documentation of ovulation. thereby clearly meeting the medical standard for a diagnosis of infertility. 32 years of age. how many years they had been in practice. March 1. Following a fertility history and physical examination. a physician who checked solely basal body temperature and a physician who checked basal body temperature and endometrial biopsy would both receive one point for assessing ovulation on the standard of care scale. Because some patients in Michigan may wish to avoid physician offices or infertility clinics located in urban hospitals. 36).70. SD ¼ 1. they were asked which age group of women had the highest prevalence of infertility: women under 25 years. Physicians were instructed to 1068 Ceballo et al. 4. these experts recommend that the basic workup include four components: a semen analysis. In other words. Perceptions of women’s infertility check as many or as few of the interventions that they would typically conduct with such a patient. Physicians were asked what interventions they would typically make if presented with the hypothetical infertile patient briefly described in their survey. Immediate referral to a specialist is not usually recommended (unless there are special circumstances) without first completing standard tests.9. We constructed a scale assessing physicians’ infertility experience by summing their affirmative responses to five dichotomous (yes/no) questions. Finally. Scores ranged from 0 to 4 (mean ¼ 1. Three methods may be used to assess ovulation: basal body temperature. To assess the adequacy of a physician’s treatment plan.g. and surveys with different patient profiles were randomly distributed throughout the mailing. We also omitted the item about suggesting adoption or a child-free lifestyle because these options seem premature before any medical tests are completed or the cause of the infertility understood. and semen analysis). First. and the number of infertile patients that they had seen in the past year. or women with a professional degree. Hispanic. The American College of Obstetricians and Gynecologists technical bulletin specifically advises physicians against giving couples ‘‘nonspecific reassurance’’ or admonitions to relax. postcoital test. 2010 . hyspterosalpingogram. discuss options of adoption or child-free lifestyle) and making referrals to infertility specialists. ever discussed a child-free lifestyle with a patient. Different educational groups were used to reflect social class differences among women. Intervention choices also incorporated engaging in nonmedical interventions (e. African American. Response rates were generally equivalent across the patient profile types. ever discussed adoption with a patient. Vol. recommend counseling services. No. standards developed by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine were used (35. 25 to 30 years. thus. Third. endometrial biopsy. with possible scores ranging from 0 to 2 (mean ¼ . We excluded the option of assuring the patient that there is no need to worry as an acceptable response. Each survey presented a physician with only one of the possible patient profiles for consideration. suggest educational reading. SD ¼ . SD ¼ . resulting in four possible patient profiles: [1] a European American professional woman. we specified the setting of specialist referrals to capture all types of referrals.70). Second. they were asked which educational group of women had the highest prevalence of infertility: women without a high school degree.g..4). Based on this information. and suggest psychologic or counseling services. a hysterosalpingogram or a laparoscopy. an acceptable medical standard of care score was created by summing participating physicians’ responses to the appropriate items.Measures Knowledge about the prevalence of infertility among different groups of women Physicians were asked three questions about the prevalence of infertility among women in the United States. may be performed to evaluate tubal patency. who had been trying to get pregnant for 14 months without success. [3] an African American professional woman. A sum of the two nonmedical interventions. basal body temperature charts. a postcoital test. serum progesterone. women with a college degree. The scores on these items were summed. or endometrial biopsy and two methods.35. Doctors could endorse either of the two interventions. These questions regarded whether or not they had ever made a referral to an infertility specialist.. women with a high school degree.

only 13% of those who responded to the question (N ¼ 150) identified women without a high school degree as being most at risk for infertility. however. SD ¼ 1.38). these doctors did not report having more experience with infertility patients than the rest of the sample.01. with an average age of 46 years (SD ¼ 11. physicians were more likely to endorse other types of interventions. We found that female physicians (mean ¼ 2. SD ¼ .74. P<. no significant interaction effects were found.56. 23% were internists. The extent to which physicians recommended the medical standard of care was not significantly different for the African American female patients (mean ¼ 1. and 12% indicated that they would refer the patient to specialists in both settings. Once again. only 16% of the responding physicians correctly identified African Americans as the racial group most at risk for infertility.07.00. these 24 physicians’ infertility experience score and mean number of infertile patients seen in the last year were equivalent to those of the rest of the sample.44) compared with the European American patients (mean ¼ 1. of the responding sample identified themselves as European American. Twenty-five percent of the physicians would refer the hypothetical patient to a specialist in private practice. A dichotomous medical specialty variable was created where 1 represented an Ob/Gyn specialty and 0 represented all other specialties.09.5). t (203) ¼ 2. Physicians’ ages ranged from 25 to 73. 90%. Of the 24 doctors who correctly identified African American women as being most at risk for infertility. Physicians’ knowledge about the prevalence of infertility among different groups Out of our total sample of 205 doctors. Compared with the medical standard of care. 20% would refer to a specialist at a hospital.93. P<.RESULTS Physician characteristics Sixty-eight percent of the responding physicians were male. Fertility and Sterilityâ Treatment recommendations and physician characteristics Only 16% of the physicians indicated that they would provide the full standard of care. In addition.30).65). Including their residency years. P¼. The socioeconomic class and race of the hypothetical patient were not significantly related to the nonmedical interventions proposed.38) t (201) ¼ 2. We examined whether the extent to which physicians would make nonmedical interventions (suggest educational reading and counseling services) and refer to specialists varied by the patient’s race and socioeconomic class. Likewise. Once again. t (203) ¼ À.34) and patients using Medicaid (mean ¼ 1. SD ¼ 1.68) to an infertility specialist compared with the patient using Medicaid (mean ¼ . SD ¼ 1. It is worth noting that only two physicians.71. As illustrated in Table 1. suggesting referrals to specialists did not vary by the patient’s race. were accurate on all three questions.79. 32% were female. SD ¼ 1. ns.81.26) provided more components of the medical standard of care for an infertility evaluation than did male physicians (mean ¼ 1. performing medical tests to assess all four components for the patient. The variables tested included doctors’ age.93.05. SD ¼ 1. For example. Compared with the rest of the sample. Thirty-one percent identified women with college degrees and 40% identified women with professional degrees as most likely to be infertile. Among the 19 doctors who correctly identified women without a high school degree as being most at risk for infertility. 155 responded to the question about which racial group of women has the highest prevalence of infertility.78) and the median number of infertile patients seen was 5. SD ¼ 1. a larger number of physicians. However.01. Similarly. 19 were male and only one was an obstetrician/gynecologist. and 44% of the 135 physicians who answered all three questions did not provide an accurate response on any of the questions. physicians were significantly more likely to refer the professional female patient (mean ¼ . participating physicians had been in practice for an average of 19 years (SD ¼ 17. and 17% identified as obstetricians or gynecologists.3). Treatment recommendations and patient characteristics Table 2 provides information on the percentages of physicians who endorsed specific types of interventions for a hypothetical infertile patient. 186 (91%) reported that they had at some time made a referral to a fertility specialist for a patient. no interaction effects between patients’ race and socioeconomic status were found. and only marginally significant between professional patients (mean ¼ 2. and 136 (66%) had made at least one such referral in the past year. 23% were in general practice. All four specialties were represented in the responding sample. a 44-yearold female general practitioner and a 47-year-old male family practitioner. medical specialty. t (193) ¼ 1.48. years in practice. Out of these 205 physicians. We used independent samples t tests and correlational analyses to determine whether physicians’ characteristics were associated with the standard of care provided to the hypothetical female patient. with some physicians having multiple affiliations. Forty-two percent of the physicians were in family practice. The majority. correctly identified people over the age of 35 as being most vulnerable to infertility. SD ¼ . 43%. Physicians with a specialty in obstetrics and 1069 . 28% of the doctors reported that they would recommend educational reading for the patient. Finally. sex.82. and experience with infertility issues. Eightytwo percent of the participating physicians reported that European Americans were most likely to experience infertility. There were 12 doctors who accurately identified both African American women and women without high school degrees as most likely to experience infertility.29. Analysis of variances (ANOVAs) were conducted to test for possible interaction effects between patients’ race and socioeconomic status. number of infertile patients seen in the past year. the mean number of infertile patients seen in the past year was 12 (SD ¼ 22. 15 were male and 17 were not specialists in obstetrics or gynecology.

such that all numbers above 1070 Ceballo et al. gynecology (mean ¼ 2. P<. A dummy variable for the number of infertile patients seen in the past year was created to handle this variable’s skewed distribution. All variables were entered into the regression simultaneously. and infertility experience.15. P<.40) also provided the hypothetical patient with more elements of the standard of care compared with the other respondents (mean ¼ 1. The results of the regression analyses are presented in Table 3. SD ¼ . P<.01. 93. No. Physician characteristics used as predictors included physicians’ sex.TABLE 1 Response frequencies: infertility prevalence among different demographic groups of women.05) endorsed more nonmedical recommendations for the infertile patient presented to them in the survey. this is the demographic group most at risk for infertility. A dummy variable was created for patient’s race.01. Percentage of physicians endorsed (%) 65 72 26 25 34 15 28 7 Multivariate predictors of physicians’ treatment recommendations A standard multiple regression analysis was performed to assess the simultaneous contributions of patient and physician characteristics in predicting the extent to which the medical standard of care was endorsed for the patient.00 were given a value of 1 and all those equal to or <5. coding Medicaid patients as 0 and patients with professional occupations as 1. Perceptions of women’s infertility.71). t (201) ¼ 3.28. SD ¼ . % 82 16 1 1 Professional degree College degree High school degree No high school degreea 40 30 17 13 Age (n [ 164).55. P<. % European American African Americana Hispanic American Asian American a Education (n [ 150). endorsed more nonmedical interventions for the hypothetical patient presented to them. 2010 .26. Neither race nor socioeconomic status of the patient was a significant predictor of the medical standard of care. Fertil Steril 2010.001) provided more components of the standard of care.28) t (202) ¼ 4. number of infertile patients seen in the past year. 4. P<. March 1. y (%) >35 (43)a 31–35 (38) 25–30 (15) <25 (4) Within the categories of race.001) and physicians who had seen more infertile patients in the past year (r ¼ . Physicians’ age and number of years in practice were not related to the medical standard of care score. Perceptions of women’s infertility 20 25 12 18 5 19 7 Vol. Race (n [ 155). Only those physician characteristics that were significantly associated with the standard of care in bivariate analyses were included in the regression analysis. SD ¼ 1. Perceptions of women’s infertility.86. Ceballo. SD ¼ 1. A dummy variable was also created for patient’s socioeconomic status.49). Physicians with more infertility experience (r ¼ . physicians who had seen more infertile patients in the past year (r ¼ .001) and who had greater experience with infertility issues (r ¼ . coding African American patients as 0 and European American patients as 1.41. P<. specialty. Fertil Steril 2010. education. Similarly. We based this variable on a median split.001.37. in comparison to male physicians (mean ¼ .75. 5. Physicians’ sex and infertility experience were significantly related to the endorsement of nonmedical interventions.00 were assigned a value of 0. and age.58. Intervention recommended Medical standard of care Semen analysis Basal body temperature Endometrial biopsy Postcoital test Hyspterosalpingogram Laparoscopy Nonmedical interventions Suggest educational reading Suggest psychological or counseling services Provide referral to infertility specialist Specialist in a hospital Specialist in private practice Specialists in both settings Other interventions Assure no reason to worry yet Make no referrals Raise option of adoption in future Raise option of child-free lifestyle in future Ceballo. Female physicians (mean ¼ . TABLE 2 Physicians’ treatment recommendations for the hypothetical patient.

Parallel multiple regression analyses were conducted to examine the predictors for providing nonmedical interventions and referrals to infertility specialists. Ceballo.01 . Medical standard of care Predictor variables Characteristics of physicians Sexa Ob/Gyn specialtyb Number of infertile patients in past yearc Infertility experience Characteristics of patients Patient’s raced Patient’s social classe 2 R ¼ F¼ df ¼ a Nonmedical interventions b . However. Women of childbearing age should routinely be asked if they have been trying to become pregnant. physicians who had seen fewer infertile patients in the past year were more likely to refer the hypothetical patient to a specialist. It is not surprising that many physicians are unaware of the most common risk profile for infertility given societal portrayals of infertile women as hard driving professionals in their 30s. physician’s sex and infertility experience were significant. however.TABLE 3 Multiple regression analyses predicting standard of care and nonmedical interventions. * P%.08 . When asked about age.05.001.01.11 . ** P%.06 À.00 À.20** . and if so.08 . Some of these women might assume that nothing can be done for them or that they cannot afford treatment. c 1 ¼ more than five patients. 12] and may internalize stereotypes about African American women’s fecundity (38).18 .09 b . When Fertility and Sterilityâ asked about ethnicity.03 .16 15. for how long. and gynecologists to be aware of the high rates of infertility among ethnic minority women. 0 ¼ five patients or less.04 . 0 ¼ Medicaid use. These four physician characteristics explained 33% of the variance in making recommendations along an acceptable medical standard of care.09 .06 . As shown in the middle column of Table 3.09 .18 . and physicians who had greater experience with infertility recommended more components of the medical standard of care.15* . Finally. The patient’s social class was a significant factor in the specialist referrals recommended by the doctors. DISCUSSION This study’s findings suggest that many physicians are unaware of demographic risk factors associated with infertility. all four physician characteristics remained significant.07 À.06 À. only 43% identified women age 35 and older as being at highest risk. 0 ¼ African American. 192 SE B . physicians who had seen more infertile patients. d 1 ¼ European American.30*** .21** . the patient’s race and social class were not significant predictors of nonmedical interventions. 0 ¼ male. it is easy to understand why many physicians assume that these women are at greatest risk. only 13% identified women without a high school degree as being at highest risk.10 .23 . a White woman’s problem’’ [(37).25*** À.19** . p. European American women with high incomes and educational levels are also most likely to seek treatment for infertility (4. e 1 ¼ professional degree. These findings demonstrate the importance of providing more information to physicians who are not infertility specialists about the characteristics of women with infertility and the unfortunate discontinuity between those who are most likely to seek treatment and those who are most likely to be experiencing a problem becoming pregnant.13 . When asked about education.09 3.54*** 6. and low income women to ensure that they identify women in need of services.16 . 0 ¼ not Ob/Gyn specialist. b 1 ¼ Ob/Gyn. internists. 192 SE B . Even some African American women who are struggling with infertility believe that infertility is ‘‘a White thing.27*** À. Perceptions of women’s infertility.33 SE B .03 .09 .30*** 6.08 Referral to specialists b . Physicians were more likely to endorse referrals to infertility specialists when the hypothetical patient had a professional career compared with the patient who relied upon Medicaid.02 . Female physicians. *** P%. It is particularly important for physicians with general practices such as family practioners. so they do not mention 1071 .21*** . less educated women.11 .77*** 6. thus.04 .03 . Fertil Steril 2010. 30). Female physicians and physicians with greater infertility patient experience reported that they would provide more nonmedical interventions. only 16% identified African American women as being at highest risk. This will facilitate identification of individuals who might be having a fertility problem but who do not request treatment. Ob/Gyn specialists. 192 1 ¼ female.12 4.

. allowing female doctors to provide a more comprehensive evaluation in an abstract scenario. informational reading and counseling services). Physicians were less likely to provide referrals to specialists when they were told that the hypothetical patient relied upon Medicaid. In a practical sense. However. Fertil Steril 2006. Although van Ryn and Burke (40) found that physicians offer less information (e. we did not find evidence for that conclusion using this particular survey instrument. PA: Brunner-Routledge. No. there may be options available that a well-informed physician can recommend. Several of the physicians’ characteristics were related to both the medical standard of care and the nonmedical interventions endorsed for the hypothetical patient. Mosher WD. 3. Perceptions of women’s infertility toward meeting a medical standard of care. Female physicians and doctors with more infertility experience were more likely to endorse nonmedical interventions as well. they are likely to recommend comparable treatments for patients regardless of race or socioeconomic status. Vol. talk more about psychological issues. eds. reading about infertility offers patients a low-cost. In the complex and dynamic encounters between patients and physicians. Jain T. For example. Chandra A. but rather implicit stereotypes of African Americans that accounted for racially discrepant treatment of patients with coronary artery disease. Pratt WF. particularly when one considers the preponderance of research which documents racial and class-based inequalities in health care (15. feedback. and they are all members of the American Medical Association.the problem. We found that female physicians reported that they would provide a hypothetical infertility patient with more medical tests as well as nonmedical recommendations compared with their corresponding male physicians. we cannot ignore the demographic characteristics of the physicians themselves. 1965–88. Socioeconomic and racial disparities among infertility patients seeking care. Results from our multivariate analyses revealed that all of the physician characteristics studied contributed to recommendations 1072 Ceballo et al. 192. 25.45:1679–704. MD: National Center for Health Statistics: Vital and Health Statistics: Advance Data Reports. Fecundity and infertility in the United States. we expected that the medical interventions suggested for the hypothetical European American professional patient would be most complete. These results highlight the importance of attending to the demographic characteristics among all people involved in medical exchanges. thereby limiting the generalizability of our results. As with all studies. Soc Sci Med 1997. 2000:331–44. informative strategy for coping with their infertility. several other limitations must be acknowledged. 93. Acknowledgment: The authors wish to acknowledge the invaluable support. Miller ED. Additionally.g. Additionally. educational reading) to racial minorities and low-income patients compared with their European American and more financially advantaged counterparts. 4. van Ryn and Burke (40) found that physicians perceived African American and poor patients more negatively than European American patients on a number of dimensions. Abbey A. Green and colleagues (23) reported that it was not explicit racial biases. An important direction for future research includes replicating our findings with data from actual rather than hypothetical patients. we found that physicians’ suggested medical treatments did not vary based on hypothetical patients’ race or socioeconomic status. Physicians’ reluctance to refer Medicaid patients to infertility specialists is understandable given the great expense of specialized infertility services and the lack of Medicaid insurance coverage for such services. This lack of bias is admirable. Impaired fecundity in the United States: 1982– 1995. 1990:1–9. 5. 2. Providing patients with informational reading seems quite appropriate regardless of a patients’ race or social class background. Female physicians and Ob/Gyn specialists recommended more of the medical tests incorporated in the medical standard of care.g. Greil AL. As there is evidence that female physicians engage in more discussion with patients. This suggests that once physicians know that infertility is a problem. selfselected sample of physicians. March 1. Stephen EH. Instead. Even more recently. Hyattsville.. Loss and trauma: general and close relationship perspectives. and provide more counseling than their male colleagues (41–43). Our study used a nonrandomized. 4. Infertility and psychological distress: a critical review of the literature. the physicians surveyed in this study may share certain biases because of the fact that they all practice medicine in the state of Michigan. and assistance provided by Professor Abigail Stewart at every stage of this research project. Vol.85:876–81. It is not surprising that physicians with greater infertility experience and specialization in a related area would provide more comprehensive medical care during an initial patient evaluation stage. REFERENCES 1. 21. Although the hypothetical patient’s race and social class were not related to medical interventions or nonmedical recommendations in our study. professional women are more likely to seek medical treatment for infertility and because they have been the focus of most infertility research. 2010 . It is also logical that those with more infertility patient experience would feel more adept at suggesting nonmedical resources (e. these recommendations did not vary by the patient’s race or socioeconomic status in our survey. physicians who had seen more infertile patients in the past year and those with more infertility patient experience also recommended more interventions meeting the standard of care.30:34–42. Fam Plann Perspect 1998. Philadelphia. 39). Adjusting to infertility. Although data certainly exists that suggest that race and class can affect physicians’ treatment of their patients. we conjecture that female physicians may feel greater empathy and affinity toward a hypothetical female patient. In: Harvey JH. 17. Both because European American. Nonmedical recommendations for the hypothetical patient included suggesting educational reading and suggesting that seeking psychological services might be helpful. the hypothetical patient’s social class did emerge as a factor in predicting physicians’ referrals to infertility specialists.

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