Vol.2, No.10, 1150-1155 (2010) Health
doi:10.4236/health.2010.210168
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Race, gender, and lifestyle discussions in geriatric
primary care medical visits
B. Mitchell Peck1*, Margo-Lea Hurwicz2, Marcia Ory3, Paula Yuma4, Mary Ann Cook5
1Department of Sociology, University of Oklahoma, Norman, USA; *Corresponding Author:
2Department of Anthropology, University of Missouri-St. Louis, St. Louis, USA;
3Department of Social and Behavioral Health, School of Rural Public Health, Texas A&M University System Health Science Center,
College Station, USA;
4Trauma Services, Dell Children’s Medical Center of Central Texas, Austin, USA;
5JVC Radiology and Medical Analysis, Clayton, USA;
Received 12 August 2010; revised 18 August 2010; accepted 24 August 2010.
ABSTRACT
Increasingly, healthcare providers are required
to spend more time and effort aimed at preven-
tion and lifestyle modification. Many argue that
providers are in a unique position to provide in-
formation for effective lifestyle and behavior ch-
ange. Yet, relatively little is known about how in-
terpersonal provider and patient characteristics,
such as race and gender, affect discussions of
lifestyle choices about public health issues. To
understand better how patient and physician ch-
aracteristics influence discussions of lifestyle
behaviors, we conducted a prospective, cohort
study of interactions between primary care phy-
sicians and their geriatric patients. We videotap-
ed 381 elderly patient visits with 35 primary care
physicians. We coded the encounters to indica-
te whether the patient and physician discussed
lifestyle issues around nutrition, physical activity,
and smoking. The independent variables were
patient and physician race, gender, and concor-
dant status. Discussions about nutrition were
the most common lifestyle topic (47.8%), foll-
owed by physical activity (40.3%) and smoking
(14.2%). Multivariate analysis indicate white pa-
tients are significantly less likely to have discu-
ssions with their physicians about nutrition (OR
= 0.32, p = 0.02) and same gender encounters
are also less likely to discuss diet/nutrition (OR
= 0.59, p = 0.04). There were no significant dif-
ferences for discussions about physical activity
or smoking. Previous research has shown that
differences persist in the quality of care and cer-
tain outcomes. Our results suggest these differ-
rences are not exclusively the result of differen-
ces in the prevalence of lifestyle discussions
based on patient and physician race or gender.
Keywords: Doctor-Patient Relations; Geriatrics;
Race; Gender
1. INTRODUCTION
The primary causes of mortality in the United States and
other industrialized nations have shifted from acute ill-
nesses to chronic conditions. The three leading causes of
mortality in the United States in 2006 were heart disease,
cancer, and stroke [1]. These deaths are attributed to tob-
acco use, poor diet, and physical inactivity [2]. Health
care delivery continues to change as a result of these
trends in mortality, and other factors like the aging U.S.
population [3]. Increasingly, health care providers spend
more time and effort aimed at prevention and lifestyle
modification [4]. Many argue that health care providers
are in a unique position to provide information and adv-
ice for effective lifestyle and behavior change [5,6]. Re-
cent research suggests that physicians and other health
care providers are important and effective facilitators for
change of health-related behaviors [7,8]. Relatively little
research, however, has been directed toward understand-
ing the role of interpersonal provider and patient charac-
teristics, such as race and gender, on discussions of life-
style choices about specific public health issues. This
study aims to answer two questions. First, what is the
prevalence of discussions about nutrition, physical activ-
ity, and smoking in geriatric primary care medical visits?
Second, does the prevalence of lifestyle discussions
*This manuscript was based on work supported by the Texas A & M
University System School of Rural Public Health, Scott and White He-
alth Plan Health Services Research Program, and NIA SBIR Contract
N
umber N43-AG-6-2118 and Grant Number R44AG15737.

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about nutrition, exercise, and smoking vary by patient
and/or physician race and gender? We focus on geriatric
patients because they represent an important and growing
segment of American society [3]. They are also less
likely than other groups to engage in regular physical
activity, and more vulnerable to the consequences of
unhealthy behaviors and poor nutrition [9].
2. MATERIALS AND METHODS
2.1. Research Setting and Subjects
We videotaped 423 patient visits to 36 general medicine/
family medicine physicians at three separate health care
sites over a two-year period beginning August 1998. Pat-
ients were recruited in the waiting room of physician
offices before their visit to the doctor. To be eligible for
the study, patients had to be at least 65 years of age and
identify the physician as their usual source of care. Phy-
sicians were recruited from all practicing physicians at
the study sites.
Before the visit, patients completed a pre-visit questi-
onnaire that included sociodemographic information and
the reason for that day’s medical visit. We videotaped all
consented patients’ medical visit. Immediately after the
visit, patients completed a post-visit questionnaire that
included the SF-36 Health Status Questionnaire and sat-
isfaction with the visit. Participating physicians comple-
ted a brief demographic survey that assessed age, gender,
race, years of practice, specialty, and history of any geri-
atric training, including specialization, medical school
coursework, and continuing education activities.
Patients, companions accompanying the patient into
the exam room, and physicians provided written inform-
ed consent before participation in the study. The physi-
cian-patient pairs used for the study were restricted to
encounters in which patients had seen the physician at
least on one prior occasion. Physicians were aware of the
research project, but blinded to the hypotheses.
2.2. Measures
We examined three separate dependent variables: 1) ph-
ysician discussion of nutrition or diet; 2) discussion of
exercise or physical activity; and 3) discussion of tobac-
co smoking. Trained coders observed videotapes of the
medical encounters. Each coder received, on average, 40
hours of training for identifying and rating communica-
tion behaviors and documenting discussion of items in
the medical encounter. The coders noted the occurrence
of a topic if the physician made any mention of the abo-
ve named topics in any context. The variables are dicho-
tomous, indicating the presence or absence of discussion
of a topic at any time during the medical encounter.
2.3. Independent Variables
We collected patient demographic variables including age,
gender, race, education, and perception of income ade-
quacy (not enough, enough, comfortable). Because we
were interested in the racial concordance/discordance
and our sample included so few patients of races and
ethnicities other than Whites and African-Americans, we
excluded Hispanics, Asians, and all other non-White and
non-African-American patients from the analyses. Edu-
cation was coded as a binary variable indicating at least
some college education versus all others. Perception of
income adequacy was coded as a binary variable indi-
cating having a comfortable income level versus all oth-
ers. In addition to the demographic information, we as-
sessed the patients’ physical functioning using a sub-
scale from the SF-36 Health Status Questionnaire [10].
Physician variables include age, gender, race, specia-
lty, history of geriatric training (including specialization,
medical school coursework, and continuing education
activities), and years of practice. As with the patients, we
excluded all non-White and non-African-Ameri-can ph-
ysicians from the analyses.
Medical encounter or contextual variables included the
patients’ reason for the medical visit, the length of the
visit, and length of the relationship between doctor and
patient. Reason for the visit was coded as non-acute ve-
rsus acute, based on the patients’ statement of the reas-
on(s) for visiting the physician that day. Patients often
cited multiple reasons for that day’s visit. The visit was
coded as “acute” if any of the reasons were identified as
acute medical concerns. Length of the medical visit was
recorded in seconds and converted to minutes. Length of
the doctor-patient relationship was coded in years. Two
scales from the ADEPT Scale (Assessment of Doctor-El-
derly Patient Encounters) were used to assess the quality
of the encounters [11]. Physicians receive higher supp-
ortiveness scores for visual attentiveness, eliciting and
acknowledging patient verbal and nonverbal communi-
cations, and making empathetic statements. Informing
scores are affected by offering solutions, giving explana-
tions for instructions, and soliciting patients’ input for
treatment plans.
2.4. Data Analysis
The primary dependent variables are binary: lifestyle di-
scussions (yes/no) of nutrition, physical activity, and sm-
oking. We, therefore, present odds ratios from binary lo-
gistic regression analyses. Because the data are clus-
tered—patients clustered by physicians—the individual
observations are not independent, potentially affecting
estimates of the standard errors. We conducted all analy-
ses using the Huber-White sandwich correction for non-
independent observations [12,13].

B. M. Peck et al. / Health 2 (2010) 1150-1155
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
1152
We present both unadjusted and adjusted multivariate
models. In the multivariate models, we adjusted for pati-
ents’ age, education, insurance status, income, physical
functioning (SF-36), vitality (SF-36), physicians’ age,
years of practice, geriatric training, and length of visit, re-
ason for visit (acute), length of doctor-patient relation-
ship, presence of a patient companion, ADEPT supporti-
veness and informativeness. For the categorical indepen-
dent variables, we express the results in terms of odds
ratios based on referent categories. The continuous inde-
pendent variables results are presented in terms of unit
changes. We used Stata version 11 to perform all analy-
ses (Stata Corp, College Station, TX).
3. RESULTS
3.1. Sample Characteristics
As shown in Table 1, the patient population was primar-
ily female (66.4%), white (84.3%), fairly well educated
(three-quarters of the sample had at least a high school
education), with sufficient financial means (only 15.8%
reported their income was not enough to meet their ne-
eds). More than half the patients were younger than 73
years of age (median age 74), while 10% were 85 years
or older. The physical functioning score (median score
65) reflects the elderly study sample and is considerably
below the national average of 84.2 for all adults.
The physicians were mostly male (77.1%) and white
(83.9%). Most were under the age of 50 (median age 48).
Slightly more than a quarter reported having some geria-
tric training, either via specialization, medical school co-
ursework, or continuing education activities. The physi-
cians average 23 years of practice experience.
Most patients presented for non-acute reasons (78.4%).
The visits ranged in length from 4.5 to over 47 minutes
(median time 15.1 minutes). These were continuing patient
Table 1. Characteristics of the patient and physician subjects.†
Patient Characteristics Total
(n = 381)
White
(n = 321)
African-American
(n = 60)
Male
(n = 128)
Female
(n = 253)
Age, median 74.0 74.0 72.0 74.0 74.0
Gender Female 66.4 65.1 73.3 — —
Race African-American 15.7 — — 12.5 17.4
Education More than HS 45.7 48.9 29.3 54.7 41.1
Private Insurance 18.8 18.2 22.0 20.6 17.9
Comfortable Income 44.5 49.5 18.6 54.3 39.3
SF-36 Physical Function, median 65.0 65.0 65.0 80.0 55.2
SF-36 Vitality, median 55.0 55.0 57.5 55.0 55.0
Gender of Physician Seen
Male 75.1 77.6 61.7 85.9 69.6
Female 24.9 22.4 38.3 14.1 30.4
Race of Physician Seen
White 83.7 97.2 11.7 87.5 81.8
African-American 16.3 2.8 88.3 12.5 18.2
Length of Visit (Minutes), median 15.1 16.1 13.1 14.4 15.8
Acute Care Visit 21.6 22.8 15.0 18.0 23.4
Companion in the room 16.8 19.3 3.3 13.3 18.6
Years with Physician, median 3.0 3.0 8.0 5.0 3.0
Physician Characteristics Total
(n = 35)
White
(n = 29)
African-American
(n = 6)
Male
(n = 27)
Female
(n = 8)
Age, median 48.0 44.0 57.0 47.0 49.5
Gender Female 22.9 17.2 50.0 — —
Race African-American 17.1 — — 11.1 37.5
Years of Practice, median 23.0 22.0 25.0 23.0 18.5
Geriatric Training 25.7 20.7 50.0 18.5 50.0
Encounter Characteristics Total
(n = 381)
White
(n = 321)
African-American
(n = 60)
Male
(n = 128)
Female
(n = 253)
Length of Visit (minutes), median 15.1 16.1 13.1 14.4 15.8
Non-acute Reason for Visit 78.4 77.2 85.0 82.0 76.6
Years with Physician, median 3.0 3.0 8.0 5.0 3.0
Presence of Companion 16.8 19.3 3.3 13.3 18.6
Rating of Physician Supportiveness
Low 29.6 26.1 49.1 39.4 24.6
Medium 38.4 38.4 38.6 37.8 38.7
High 32.0 35.5 12.3 22.8 36.7
Rating of Physician Informativeness
Low 31.5 28.3 49.1 35.4 29.4
Medium 38.1 38.7 35.1 41.7 36.3
High 30.4 33.0 15.8 22.8 34.3
†Data are percentages except where noted.

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visits with an average length of doctor-patient relationsh-
ip of three years. However, almost a third of the patients
(32%) had been seeing the doctor less than a year and
nearly a fifth (18.4%) had been seeing the same doctor
for 10 years or more. Table 1 also presents the sample
characteristics by patient race and gender.
3.2. Prevalence of Lifestyle Discussions
Descriptive analyses of the full sample revealed no sing-
le lifestyle topic mentioned in more than half of the enc-
ounters (Table 2). Discussions about nutrition were the
most common lifestyle topic. Almost half (47.8%) of the
visits included a discussion about diet/nutrition, follow-
ed by exercise or physical activity (40.3%) and smoking
(14.2%).
Bivariate analyses showed there were few differences
in discussions based on patient or physician gender and
race. Discussions about nutrition occurred more often
with African-American patients (66.7% versus 44.4%, p
= 0.002). Nutrition discussions were more prevalent in
encounters with African-American physicians compared
to their white counterparts (61.3% versus 45.3%, respec-
tively). There were no bivariate differences in discussi-
ons about physical activity based on race, gender, or con-
cordance status. The only significant difference in discu-
Table 2. Percent of medical encounters with lifestyle discus-
sions by patient and physician gender and race (P value)†.
Characteristic Nutrition
47.8%
Physical Activity
40.3%
Smoking
14.2%
Patient Gender
Male 43.8 46.1 16.4
Female 50.0 37.3 13.1
(.27) (.12) (.43)
Patient Race
White 44.4 42.2 14.7
African-American 66.7 30.0 11.7
(0.00) (0.08) (0.68)
Physician Gender
Male 46.7 41.8 12.9
Female 51.6 35.8 17.9
(0.41) (0.33) (0.23)
Physician Race
White 45.3 42.1 15.1
African-American 61.3 30.7 9.7
(0.02) (0.11) (0.32)
Gender Concordance
No 52.2 37.3 11.4
Yes 43.3 43.3 17.1
(0.08) (0.25) (0.14)
Race Concordance
No 62.5 43.8 43.8
Yes 47.3 40.1 12.9
(0.30) (0.79) (0.00)
Gender & Race Concordance
No 52.2 37.4 12.8
Yes 42.9 43.5 15.8
(0.08) (0.24) (0.46)
†Standard errors are corrected using Huber-White sandwich matrix estima-
tor that does not assume independence of cases within clusters.
ssions about smoking was between racially concordant
and discordant encounters. Almost half (43.8%) of the en-
counters in which the patient and physician were of a
different race discussed smoking, compared to only 12.9%
of the racially concordant encounters.
3.3. Gender, Race, and Concordance on
Lifestyle Discussions
Table 3 presents the analyses examining the relationsh-
ips between gender, race, and concordant status on lifes-
tyle discussions. Unadjusted (bivariate) and adjusted (mu-
ltivariate) results are presented. Like the bivariate rela-
tionships presented above, most of the significant asso-
ciations in the unadjusted models involve the race vari-
ables. Of the 13 significant associations in the unadju-
sted models, only 3 involve gender variables. After adju-
sting for the patient, physician, and encounter/contextual
variables, few relationships remained statistically sign-
ificant. The adjusted models show that the only signifi-
cant differences are in discussions about diet/nutrition.
White patients are significantly less likely to have discu-
ssions with their physicians about nutrition (OR = 0.32,
p = 0.02). Encounters with same gender patients and
physicians are also less likely to discuss diet or nutrition
(OR = 0.59, p = 0.04).
4. DISCUSSION
Given the increasing importance of prevention and life-
style modification in the clinical encounter, especially
for aging and other vulnerable populations, it is impor-
tant to understand the factors that contribute or inhibit
discussion of lifestyle and health-related behaviors. Our
study found that fewer than half of physicians even disc-
ussed nutrition, physical activity, or smoking issues with
their elderly patients. Most of the differences in the pre-
valence of discussions were the result of the racial com-
position of the patient and physician. Fewer differences
based on gender existed. Few of the racial differentces,
however, persisted after adjusting for potential confou-
nders.
Previous studies, in general, have found racial and/or
gender differences in various aspects of the clinical enco-
unter. For example, medical visits with female physici-
ans are, on average, longer than those of male physicians
and typically engage in more communication that can be
considered patient-centered [14]. Likewise, racial differ-
ences in health outcomes [15], quality of care [16], and
style of communication [17] have been observed. Our
study did not provide as clear or consistent findings as
these previous findings.
That our study did not produce findings consistent with
previous research is likely due to one of several factors.

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1154
Table 3. Relationship of patient and physician race, gender, and concordance to lifestyle discussions.†
Nutrition Physical Activity Smoking
Characteristic Odds
Ratio‡ P Odds Ratio§P Odds Ratio‡P Odds Ratio§P Odds Ratio‡ P Odds Ratio§P
Patient Female 1.28 0.26 1.42 0.23 0.69 0.08 0.89 0.60 0.76 0.33 0.69 0.23
Patient White 0.39 0.00 0.32 0.02 1.70 0.03 1.30 0.56 1.30 0.64 1.31 0.73
Physician Female 1.21 0.42 1.28 0.50 0.77 0.30 0.91 0.78 1.46 0.29 0.61 0.34
Physician White 0.52 0.00 0.57 0.23 1.64 0.04 1.30 0.54 1.65 0.35 1.66 0.25
Gender Concordance 0.69 0.06 0.59 0.04 1.28 0.19 1.14 0.47 1.60 0.05 1.20 0.49
Male Dyad 0.63 0.04 0.56 0.06 1.58 0.04 1.17 0.48 1.27 0.46 1.54 0.21
Female Dyad 1.00 0.97 0.90 0.80 0.81 0.47 0.99 0.98 1.46 0.23 0.64 0.22
Male/Female 1.24 0.29 1.46 0.16 0.82 0.29 0.90 0.61 0.59 0.07 0.84 0.56
Female/Male 2.25 0.06 2.40 0.06 0.73 0.45 0.80 0.36 1.21 0.58 0.85 0.71
Racial Concordance 0.53 0.33 0.55 0.52 0.86 0.76 0.96 0.94 0.19 0.00 0.28 0.12
White Dyad 0.45 0.00 0.41 0.08 1.55 0.08 1.25 0.58 0.97 0.95 0.99 0.99
African-American Dyad 2.16 0.00 2.26 0.09 0.54 0.00 0.71 0.50 0.32 0.06 0.35 0.10
White/African-American 0.86 0.27 0.62 0.42 1.19 0.17 1.03 0.92 3.13 0.00 1.86 0.15
African-American/White 6.71 0.12 7.35 0.12 1.11 0.92 1.02 0.98 8.61 0.01 5.10 0.15
Gender & Race Concordance 0.68 0.08 0.59 0.07 1.28 0.19 1.16 0.42 1.27 0.33 0.92 0.82
†Standard errors are corrected using Huber-White sandwich matrix estimator that does not assume independence of cases within clusters; ‡Unadjusted odds
ratios; §Adjusted for patients’ age, education, insurance status, income, physical functioning (SF-36), vitality (SF-36), physicians’ age, years of practice, geriat-
ric training, and length of visit, reason for visit (acute), length of doctor-patient relationship, presence of a patient companion, ADEPT supportiveness, ADEPT
informativeness.
First, our outcome is different from many previous stud-
ies. Our study examined neither actual outcomes (such
as readmissions, satisfaction health status) nor the style
or process of communication in the encounter (empathy,
patient-centered, participatory decision making). Rather,
we examined the content of the encounter, whether or not
the patient and physician discussed lifestyle behaviors.
Another possible explanation for the difference in findi-
ngs is the patient population. There is a substantial body
of literature examining race and gender differences in the
clinical encounter, as well as studies that examine diffe-
rences in adult and elderly patient populations. There
have been many fewer studies that account for both dif-
ferences. Finally, our finding may differ from previous
results because of limitations of our study. Most impor-
tantly, the study was observational in nature, with no ra-
ndomization of patients to physicians. It is reasonable,
that patients self-select to a physician of a particular race
or gender. A further limitation is the size of the sample.
There are significantly fewer African-American and fe-
male physicians than white and male physicians.
Despite these limitations, this study provides a better
understanding of the prevalence of discussions about lif-
estyle and health-related behaviors in geriatric medical
visits and potential sources of variation in those discussi-
ons. Our study suggests that physicians discuss nutrition,
physical activity and smoking behavior in fewer than half
of all geriatric visits. There are relatively few differences
in the prevalence of these discussions based on race and
gender of the patient or physician.
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