General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland--a pilot prospective study using structural equation modeling

Patient Involvement in Care and Breast Cancer Patients’ Quality of Life- a Structural Equation Modeling (SEM) Approach

In cancer patients, improving the quality of life is a basic goal of treatment, with the patient – physician relationship as a major factor. Therefore the aim of this structural equation modeling study was to analyze the influence of patient involvement in care on quality of life in 411 breast cancer patients undergoing outpatient chemotherapy and radiotherapy. Two questionnaires were used: 1-patient-physician questionnaire, 2-EORTC QLQC-30 (to measure QOL). The structural equation model exhibited an excellent data fit (Chi-Square= 31.04 / RMSEA= 0.042), T-values for all paths with the exception of that between patient satisfaction and emotional- cognitive function, were significant. According to the findings, various aspects of the physician-patient relationship are significantly and positively associated with quality of life and increasing patient involvement in care by increasing trust and satisfaction, was associated with marked improvement. The findings of this study emphasized the importance of an effective relationship between doctor and patient as a contributing factor for improving the quality of life. Therefore it is suggested that policymakers and decision-makers active in strategic planning for the health system and physicians responsible for treatment pay more attention to developing and improving relationships with patients as an approach to improving patient outcomes, particularly with reference to quality of life.

Differences between GP perception of delivered empathy and patient-perceived empathy: a cross-sectional study in primary care

BACKGROUND

Empathy has positive effects on a range of healthcare outcomes. It is therefore an important skill for a GP. However, the correlation between GP perception of delivered empathy and patient perception of GP empathic communication during consultations is still unclear.

AIM

To investigate the correlation between GP perception of delivered empathy and patient-perceived empathy.

DESIGN AND SETTING

Cross-sectional study in primary care in the Netherlands, between December 2016 and February 2017.

METHOD

GPs and their patients were asked to fill in an empathy questionnaire directly after a consultation. Patient perception of received empathy during the consultation was measured through the Dutch version of the Consultation and Relational Empathy (CARE) questionnaire. GP perception of delivered empathy during the consultation was measured with an adapted version of the CARE questionnaire.

RESULTS

The authors obtained questionnaires from 147 consultations by 34 different GPs in 16 primary care practices. A total of 143 consultations were eligible for inclusion in the analysis. Mean patient-perceived empathy score was significantly higher than mean GPs' empathy score (42.1, range 20.0 to 50.0 and 31.6, range 24.0 to 41.0, respectively, P<0.0001). Furthermore, a low correlation (r = 0.06) was found between GP empathy score and patient-perceived empathy score.

CONCLUSION

GPs rate the delivered empathy during consultations consistently and significantly lower than their patients experience empathy during consultations. Moreover, GPs' impressions of the empathy delivered during the consultation do not predict the actual amount of empathy perceived by their patients. Patients experience a great deal of empathy during their clinical encounter. GPs' self-reports on empathy delivered gives an inaccurate reflection, and underestimates patient-perceived empathy.

Nurse-led hypertension management was well accepted and non-inferior to physician consultation in a Chinese population: a randomized controlled trial

The objective of this study is to evaluate if nurse-led repeated prescription (NRP) could ensure non-inferior disease control and would be accepted in Chinese patients with controlled hypertension (HT) in primary care clinics. A 12-month follow-up non-inferiority randomized trial was conducted. The non-inferior margins for systolic and diastolic blood pressure were 6.6 mmHg and 3.7 mmHg, respectively. Eligible patients (>18 years of age) with HT were randomized to the NRP and usual care (UC) groups for their regular clinical follow-up. We used ANCOVA to study the difference-of-difference of the blood pressures between the two groups. The levels of patient acceptance and experience of NRP were assessed by the observed opt-out rate and a qualitative analysis. We found no statistically significant differences in BP blood pressure between the NRP (N = 194) and UC (N = 199) groups. Only 4 of the participants in the NRP group opted out due to a preference for assessment by a physician. The interviewed participants (N = 12) felt positive about NRP, because they experienced more relaxed communication with the nurse and believed that the eligibility to join the NRP program was an indication of optimal BP control. We observed no adverse events. The findings show that NRP was well accepted and found to be non-inferior to physician consultation for HT management.

Defense Styles Mediate the Association Between Empathy and Burnout Among Nurses

Research has extensively identified empathic skills as essential in health trainings, policies, and recommendations. However, there have been conflicting views of the impact of empathy on burnout. Some studies contend that empathy serves a protective role, whereas other studies have shown that burnout leads to a diminished capacity to empathize. To date, studies have not yet explored whether defense styles mediate associations between empathy and burnout. A total of 442 nurses completed questionnaire measures of empathy, burnout, and defense mechanisms as part of a large-scale research study on nurse burnout. Findings reflected very high levels of emotional exhaustion and depersonalization among the nursing staff. The nurses in this study endorsed a predominantly immature defense style. In addition, immature defense styles mediated the association between empathy and emotional exhaustion and between empathy and depersonalization. The study provides further knowledge about the role of defense styles in nurse burnout and empathy.

Coping better with health problems after a visit to the family physician: associations with patients and physicians characteristics

BACKGROUND

Good patient experience is recognized as an important component of a strong primary care system. Among the dimensions related to experience in family medicine, the ability to cope better with health problems is considered to be a measure of the quality of a consultation with a family physician (FP). The objective is to identify factors related to patients, physicians and practice, associated with patients' ability to cope better with their health problems after a family medicine consultation.

METHODS

The data stemmed from the Swiss part of the Quality and Costs of Primary Care (QUALICOPC) study, an international cross sectional survey aiming to compare quality, cost and equity in primary care. In Switzerland, a random sample of 199 FPs and 1791 patients participated. The negative answer to the question: "After this visit, I feel I can cope better with my health problems" was modeled using multilevel logistic regressions.

RESULTS

Difficulty to cope better with health problems was positively associated with the following: younger age (OR: 1.58, 95% CI [1.03-2.41]), cultural aspects related to the Swiss area of language (French speaking people declared higher inability than German and Italian ones), presence of chronic disease (OR: 1.54 95% CI [1.00-2.39]). Conversely an intermediate number (1-4) of visits during the last 6 months (OR: 0.37 95% CI [0.23-0.62]) and the satisfaction with the physician (OR: 0.18 95% CI [0.08-0.44]) are negative predictors of the patient inability to cope better with his health problems. A self-reported effort-reward imbalance at work (OR: 0.64 95% CI [0.41-1.00]) was the only predictive FP characteristic (negatively associated).

CONCLUSIONS

Although the design of the study does not allow causal inference, this study showed that the predictors of patient difficulties to cope better with health problem are mainly centered on the patients' characteristics. The patient-physician relationship both in terms of quality and frequency of visits is probably also important. Organizational practice characteristics do not seem to play a major role but stress at work among physicians should be further investigated.

Let's talk about empathy!

BACKGROUND

Research faces a challenge to find a shared, adequate and scientific definition of empathy.

OBJECTIVE

Our work aimed to analyze what clinical empathy is in the specific context of cancer care and to identify the effect of empathy in it.

METHOD

This study gives voice to physicians with extensive experience in cancer care. This original research combines qualitative data collection and quantitative data analysis. Semi-structured individual interviews were conducted with 25 physicians. The content of the interviews was analyzed according to the Content Analysis Technique.

RESULTS

Empathy is described according to six dimensions that give a strong role to interpersonal and cognitive skills. This description integrates previous and various conceptualizations of clinical empathy. Physicians detail the beneficial effects of clinical empathy on patients' outcomes and well-being as well as physicians' practices. Physician interviews also revealed the relationship between empathic concerns and physicians' emotional difficulties.

CONCLUSION

Empathy in cancer care is a complex process and a multicomponent competence.

PRACTICE IMPLICATIONS

This operational description of clinical empathy has three main implications: to draw up a training program for physicians, to detail recommendations for physicians' work-related quality of life and to develop new tools to measure empathy.

Assessing the Consultation and Relational Empathy (CARE) Measure in sexual health nurses' consultations

Background

Increasingly healthcare policies emphasise the importance of person-centred, empathic care. Consequently, healthcare professionals are expected to demonstrate the ‘human’ aspects of care in training and in practice. The Consultation and Relational Empathy (CARE) Measure is a patient-rated measure of the interpersonal skills of healthcare practitioners. It has been widely validated for use by healthcare professionals in both primary and secondary care. This paper reports on the validity and reliability of the CARE Measure with sexual health nurses.

Methods

Patient questionnaires were collected for 943 consultations with 20 sexual health nurses. Participating patients self-completed the questionnaire immediately after the encounter with the nurse. The questionnaire included the ten item CARE Measure, the Patient Enablement Index, and overall satisfaction instruments. Construct validity was assessed through Spearman’s correlation and principal component analysis. Internal consistence was assessed through Cronbach’s alpha and the inter-rater reliability through Generalisability Theory. Data were collected in 2013 in Scotland.

Results

Female patients completed 68% of the questionnaires. The mean patient age was 28.8 years (standard deviation 9.8 years). Two of the 20 participating nurses withdrew from the study. Most patients (71.7%) regarded the CARE Measure items as very important to their consultation and the number of ‘not applicable’ and missing responses’ were low (2.6% and 0.1% respectively). The participating nurses had high CARE Measure scores; out of a maximum possible score of 50, the overall mean CARE measure score was 47.8 (standard deviation 4.4). The scores were moderately correlated with patient enablement (rho = 0.232, p = 0.001) and overall satisfaction (rho = 0.377, p = 0.001. Cronbach’s alpha showed the measure’s high internal consistency (Cronbach’s alpha coefficient = 0.95), but the inter-rater reliability could not be calculated due to the high achieved CARE Measure scores that varied little between nurses.

Conclusions

Within this clinical context the CARE Measure has high perceived relevance and face validity. The findings support construct validity and some evidence of reliability. The high CARE Measure scores may have been due to sample bias. A future study which ensures a representative sample of patients on a larger group of nurses is required to determine whether the measure can discriminate between nurses.

Predisposition for Empathy, Intercultural Sensitivity, and Intentions for Using Motivational Interviewing in First Year Pharmacy Students

Objective. To assess first-year pharmacy (P1) students' predispositions (eg, perceptions for empathy, intercultural sensitivity, and motivational interviewing (MI) as a patient-centered communication skillset) and identify potential curricula content/communication skills training needs. Methods. A cross-sectional survey was used to collect students' self-reported perceptions for empathy, intercultural sensitivity, counseling contexts, and projected future MI use. Relationships between variables were explored and logistic regression was used to evaluate intention for using MI in future patient encounters. Results. There were 134 students who participated. Higher predisposition for empathy and for intercultural sensitivity were significantly correlated. Significant predictors for applying MI in future patient encounters were sex, confidence with counseling skills, and current use of MI. Conclusion. Results suggest the need to incorporate innovative training strategies in communication skills curricula. Potential areas include empathy, intercultural sensitivity and significant predictor variables for future MI use. Further investigation in other schools is needed.

Dying From Cancer: Communication, Empathy, and the Clinical Imagination

Medical oncologists and patients with advanced cancer struggle to discuss prognosis, goals, options, and values in a timely fashion. As a consequence, many patients die receiving aggressive treatment potentially inconsistent with their fully informed preferences and experience increased symptom burden and distress. The goals of patient - oncologist communication include exchanging information, building relationship, and engaging in shared decisions. Empathy is perhaps especially essential to effective patient - oncologist communication when the end of life is approaching. We speculate that, in addition to being a skilled response to a patient’s negative emotions, empathy is an emergent property of the relationship that allows the patient and oncologist to imagine what it will be like to navigate the transition from living with to dying from cancer; and to prepare for the transition. We propose that effective empathy: 1) requires an attentive, curious and imaginative physician; 2) acknowledges the complex and shifting goals as the end of life approaches; and 3) begins with a willingness of physicians to check in and find out what she may have misunderstood or misperceived. Empathy in end of life conversations cultivates the shared experiences necessary to co-create the new goals of care that underlie excellent end of life care.

Patient perceptions of clinical care in complementary medicine: A systematic review of the consultation experience

OBJECTIVE

This review aims to describe the prevalence of empathy, empowerment and patient-centred clinical care experienced by patients in complementary medicine (CM) consultations.

METHODS

A systematic review was undertaken of original research exploring patient perceptions of CM clinical care. Ten databases were searched: Alt HealthWatch, AMED, CINAHL Plus, MEDLINE Complete, Cochrane Library, PubMed, Proquest Medical Collection, PsycInfo, Social Sciences Citation Index and Psychology Collection. Studies were included which reported patient perceptions of consultation with CM practitioners and were excluded where experimental methods controlled the nature of consultation processes.

RESULTS

Findings of included studies (n=34) were categorised under the a priori themes of empathy, empowerment and patient-centred care. This produced a substantial pool of qualitative data detailing patient-reported experiences which consistently confirmed occurrence of these themes in CM consultation. Quantitative data was correlative, yet was insufficient to definitively describe prevalence of such experiences.

CONCLUSION

While it is evident that CM consultations provide a patient experience of empathy, empowerment and patient-centredness, further research is warranted to quantify this experience before it can be defined as characteristic of CM clinical care.

PRACTICE IMPLICATIONS

This review draws attention to the potential role of CM as a resource for patients' psychosocial health needs.

The Perception of Physician Empathy by Patients with Inflammatory Bowel Disease

Background and Aims

This study focused on the difference between perceived and desired physician empathy (pPE and dPE) in the eye of patients with inflammatory bowel disease (IBD). It was investigated if a discrepancy (ΔPE) correlates with trust and satisfaction of patients. At the same time the aim was to gain detailed information about the subjective burden of disease and the resources of IBD patients, in order to better understand them.

Methods

A modified version of the German Version of the Consultation and Relational Empathy (CARE) measure was completed as a paper-and-pencil questionnaire by IBD patients attending our facility (n = 32) and as an online survey by IBD patients at other locations throughout Germany (n = 89). Patients were in average 36.3±12 years old.

Results

The mean (SD) rating of pPE was 3.93 (0.96) on a scale of 1 to 5 (“poor” to “excellent”); however, the mean (SD) dPE was 4.38 (0.48) on the same scale. ΔPE correlated with perceived empathy and with patients’ satisfaction with treatment and trust in their health care providers. Patients reported quite a high subjective burden (mean [SD]: 2.93 [.63]) and named family, friends, and support groups as resources.

Conclusions

Rather than assessing patient satisfaction with treatment and trust in their physician only with perceived PE, we suggest ΔPE as a useful additional parameter.

Evaluation of the outcomes of care of nurse-led continence care clinics for Chinese patients with lower urinary tract symptoms, a 2-year prospective longitudinal study

AIM

The aim of this study was to evaluate the 24-month outcomes of a nurse-led continence care service for Chinese primary care patients with lower urinary tract symptoms.

BACKGROUND

Most studies evaluating the outcomes of continence care services have had short follow-up durations with limited knowledge on whether benefits are sustained beyond 12 months.

DESIGN

Twenty-four month cohort study.

METHODS

Two comparison groups were recruited: (1) Patients with lower urinary tract symptoms attending a nurse-led community-based continence care programme; (2) Primary care patients with lower urinary tract symptoms identified by screening, receiving usual medical care. Self-reported symptom severity, health-related quality of life, patient enablement and general health perception were measured at baseline and 24 months. Data collection occurred from March 2013-August 2015.

RESULTS

Baseline and 24-month data were available for 170 continence care and 158 usual care subjects. After controlling for baseline characteristics, the continence care group was observed to have greater reductions in symptom severity and larger improvements in disease-specific health-related quality of life, patient enablement and general health perception than the usual care group. Deterioration in the mental components of generic health-related quality of life was observed in the usual care group, but not in the continence care group.

CONCLUSION

Over 24 months, when compared with usual medical care, nurse-led continence care services were effective in reducing symptom severity and improving health-related quality of life, patient enablement and general health perception and provided protection against deterioration in the mental components of health-related quality of life in patients with lower urinary tract symptoms.

The impact of general practice nursing care on patient satisfaction and enablement in Australia: A mixed methods study

BACKGROUND

The numbers of nurses in general practice in Australia tripled between 2004 and 2012. However, evidence on whether nursing care in general practice improves patient outcomes is scarce. Although patient satisfaction and enablement have been examined extensively as outcomes of general practitioner care, there is little research into these outcomes from nursing care in general practice. The aim of this study was to examine the relationships between specific general practice characteristics and nurse consultation characteristics, and patient satisfaction and enablement METHODS: A mixed methods study examined a cross-section of patients from 21 general practices in the Australian Capital Territory. The Patient Enablement and Satisfaction Survey was distributed to 1665 patients who received nursing care between September 2013 and March 2014. Grounded theory methods were used to analyse interviews with staff and patients from these same practices. An integrated analysis of data from both components was conducted using multilevel mixed effect models.

RESULTS

Data from 678 completed patient surveys (response rate=42%) and 48 interviews with 16 nurses, 23 patients and 9 practice managers were analysed. Patients who had longer nurse consultations were more satisfied (OR=2.50, 95% CI: 1.43-4.35) and more enabled (OR=2.55, 95% CI: 1.45-4.50) than those who had shorter consultations. Patients who had continuity of care with the same general practice nurse were more satisfied (OR=2.31, 95% CI: 1.33-4.00) than those who consulted with a nurse they had never met before. Patients who attended practices where nurses worked with broad scopes of practice and high levels of autonomy were more satisfied (OR=1.76, 95% CI: 1.09-2.82) and more enabled (OR=2.56, 95% CI: 1.40-4.68) than patients who attended practices where nurses worked with narrow scopes of practice and low levels of autonomy. Patients who received nursing care for the management of chronic conditions (OR=2.64, 95% CI: 1.32-5.30) were more enabled than those receiving preventive health care.

CONCLUSIONS

This study provides the first evidence of the importance of continuity of general practice nurse care, adequate time in general practice nurse consultations, and broad scopes of nursing practice and autonomy for patient satisfaction and enablement. The findings of this study provide evidence of the true value of enhanced nursing roles in general practice. They demonstrate that when the vision for improved coordination and multidisciplinary primary health care, including expanded roles of nurses, is implemented, high quality patient outcomes can be achieved.

The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation

OBJECTIVES

To develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas.

METHODS

Six co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients.

RESULTS

Participants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients.

DISCUSSION

We have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial.

The CARE Plus study - a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis

BACKGROUND

Multimorbidity is common in deprived communities and reduces quality of life. Our aim was to evaluate a whole-system primary care-based complex intervention, called CARE Plus, to improve quality of life in multimorbid patients living in areas of very high deprivation.

METHODS

We used a phase 2 exploratory cluster randomised controlled trial with eight general practices in Glasgow in very deprived areas that involved multimorbid patients aged 30-65 years. The intervention comprised structured longer consultations, relationship continuity, practitioner support, and self-management support. Control practices continued treatment as usual. Primary outcomes were quality of life (EQ-5D-5L utility scores) and well-being (W-BQ12; 3 domains). Cost-effectiveness from a health service perspective, engagement, and retention were assessed. Recruitment and baseline measurements occurred prior to randomisation. Blinding post-randomisation was not possible but outcome measurement and analysis were masked. Analyses were by intention to treat.

RESULTS

Of 76 eligible practices contacted, 12 accepted, and eight were selected, randomised and participated for the duration of the trial. Of 225 eligible patients, 152 (68 %) participated and 67/76 (88 %) in each arm completed the 12-month assessment. Two patients died in the control group. CARE Plus significantly improved one domain of well-being (negative well-being), with an effect size of 0.33 (95 % confidence interval [CI] 0.11-0.55) at 12 months (p = 0.0036). Positive well-being, energy, and general well-being (the combined score of the three components) were not significantly influenced by the intervention at 12 months. EQ-5D-5L area under the curve over the 12 months was higher in the CARE Plus group (p = 0.002). The incremental cost in the CARE Plus group was £929 (95 % CI: £86-£1788) per participant with a gain in quality-adjusted life years of 0.076 (95 % CI: 0.028-0.124) over the 12 months of the trial, resulting in a cost-effectiveness ratio of £12,224 per quality-adjusted life year gained. Modelling suggested that cost-effectiveness would continue.

CONCLUSIONS

It is feasible to conduct a high-quality cluster randomised control trial of a complex intervention with multimorbid patients in primary care in areas of very high deprivation. Enhancing primary care through a whole-system approach may be a cost-effective way to protect quality of life for multimorbid patients in deprived areas.

TRIAL REGISTRATION

TRIAL REGISTRATION

ISRCTN 34092919 , assigned 14/1/2013.

Impact of Perceived Weight Stigma among Underserved Women on Doctor-Patient Relationships

Objective

The aim of this study was to evaluate how perception of weight stigma among underserved women with obesity impacts doctor–patient relationships.

Methods

This study consisted of an interviewer‐administered survey of 149 women with obesity (body mass index (BMI) > 30 kg m⁻²) immediately after their physician visit at four Federally Qualified Health Centers. Perceptions of weight stigma and physician empathy were measured using the Stigma Situations in Health Care instrument and Consultation and Relational Empathy (CARE) measure, respectively. Associations of CARE and Stigma scores with BMI and patient characteristics were analysed using Mantel–Haenszel chi‐squared test and ordinal logistic regression.

Results

The mean CARE score was 42.1 (standard deviation 8.4; range 11.0–50.0), and mean stigma score was 4.6 (standard deviation 7.6; range 0–43.0). Each increase in BMI category was associated with almost twofold increased odds of higher perception of stigma (odds ratio, 1.90, 95% confidence interval 1.30–2.78, P = 0.001). BMI was not associated with CARE. However, for each increase in stigma category, the odds of lower CARE score doubled (odds ratio, 0.52, 95% confidence interval 0.36–0.75, P = 0.0005).

Conclusions

While BMI was not associated with perception of physician empathy, higher frequency of weight stigmatizing situations was negatively associated with perception of physician empathy. Reducing weight stigma in primary care could improve doctor–patient relationships and quality of care in patients with obesity.

Patient Perceptions of Expression of Empathy From Chinese Medicine Clinicians in a Chinese Population: A Cross-Sectional Study

This study aims to examine the level of empathy perceived by patients receiving care from herbalists, acupuncturists and massage therapists and to investigate the factors that influence levels of perceived empathy.Participants who were 18 years or above; able to provide written informed consent; and able to read and write in Chinese without assistance were included. A total of 514 participants sampled from charity and semipublic Chinese medicine (CM) clinics in Hong Kong were recruited to assess levels of empathy perceived during various length of consultations (1-20 minutes) by the Chinese Consultation and Relational Empathy Measure (Chinese CARE). Multiple linear regressions were conducted to evaluate the associations between perceived levels of empathy and the type of CM practitioner consulted and participants' demographic and health characteristics.The average Chinese CARE total score for participants consulting CM practitioners was 34.3 of a maximum of 50. After adjusting for participants' health and demographic characteristics, acupuncturists received the highest ratings (P < 0.001), whereas massage therapists (P < 0.001) scored the lowest of the 3 modalities. Participants receiving social benefits (P = 0.013), those with longer waiting times (P = 0.002), and those with shorter consultation durations (P = 0.020) scored significantly lower on the Chinese CARE.The level of empathy perceived by participants using CM was similar to results found for those in conventional care, in contrast to findings in other geographical settings, where a high level of perceived empathy was a major motivator for participants to choose complementary medicine.

Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels

PURPOSE

We aimed to identify the strategies used to support patient behavior change by clinicians whose patients had an increase in patient activation.

METHODS

This mixed methods study was conducted in collaboration with Fairview Health Services, a Pioneer Accountable Care Organization. We aggregated data on the change in patient activation measure (PAM) score for 7,144 patients to the primary care clinician level. We conducted in-depth interviews with 10 clinicians whose patients' score increases were among the highest and 10 whose patients' score changes were among the lowest. Transcripts of the interviews were analyzed to identify key strategies that differentiated the clinicians whose patients had top PAM change scores.

RESULTS

Clinicians whose patients had relatively large activation increases reported using 5 key strategies to support patient behavior change (mean = 3.9 strategies): emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients. Clinicians whose patients had lesser change in activation were far less likely to describe using these approaches (mean = 1.3 strategies). Most clinicians, regardless of group, reported developing their own approach to support patient behavior change. Those whose patients showed high activation change reported spending more time with patients on counseling and education than did those whose patients showed less improvement in activation.

CONCLUSIONS

Clinicians vary in the strategies they use to promote behavior change and in the time spent with patients on such activities. The 5 key strategies used by clinicians with high patient activation change are promising approaches to supporting patient behavior change that should be tested in a larger sample of clinicians to validate their effectiveness.

Burned Out at the Bedside: Patient Perceptions of Physician Burnout in an Internal Medicine Resident Continuity Clinic

BACKGROUND

Burnout is high among resident physicians and may be associated with suboptimal patient care and reduced empathy.

OBJECTIVE

To investigate the relationship between patient perceptions of empathy and enablement and physician burnout in internal medicine residents.

DESIGN

Cross-sectional, survey-based observational study between December 2012 and March 2013 in a resident continuity clinic located within a large urban academic primary care practice in Baltimore, Maryland.

PARTICIPANTS

Study participants were 44 PGY1-3 residents and a convenience sample of their English-speaking adult primary care patients (N = 244).

MAIN MEASURES

Patients rated their resident physicians using the Consultation and Relational Empathy Measure (CARE) and the Patient Enablement Instrument (PEI). Residents completed the Maslach Burnout Inventory (MBI). We tested for associations between resident burnout and patients' perceptions of resident empathy (CARE) and enablement (PEI) using multilevel regression analysis.

KEY RESULTS

Multilevel regression analyses indicated significant positive associations between physician depersonalization scores on the MBI and patient ratings of empathy (B = 0.28, SE = 0.17, p < 0.001) and enablement (B = 0.11, SE = 0.11, p = 0.02). Emotional exhaustion scores on the MBI were not significantly related to either patient outcome.

CONCLUSIONS

Patients perceived residents who reported higher levels of depersonalization as more empathic and enabling during their patient care encounters. The relationship between physician distress and patient perceptions of care has important implications for medical education and requires further study.

The Association of Types of Training and Practice Settings with Doctors' Empathy and Patient Enablement among Patients with Chronic Illness in Hong Kong

BACKGROUND

The increase in non-communicable disease (NCD) is becoming a global health problem and there is an increasing need for primary care doctors to look after these patients although whether family doctors are adequately trained and prepared is unknown.

OBJECTIVE

This study aimed to determine if doctors with family medicine (FM) training are associated with enhanced empathy in consultation and enablement for patients with chronic illness as compared to doctors with internal medicine training or without any postgraduate training in different clinic settings.

METHODS

This was a cross-sectional questionnaire survey using the validated Chinese version of the Consultation and Relational Empathy (CARE) Measure as well as Patient Enablement Instrument (PEI) for evaluation of quality and outcome of care. 14 doctors from hospital specialist clinics (7 with family medicine training, and 7 with internal medicine training) and 13 doctors from primary care clinics (7 with family medicine training, and 6 without specialist training) were recruited. In total, they consulted 823 patients with chronic illness. The CARE Measure and PEI scores were compared amongst doctors in these clinics with different training background: family medicine training, internal medicine training and those without specialist training. Generalized estimation equation (GEE) was used to account for cluster effects of patients nested with doctors.

RESULTS

Within similar clinic settings, FM trained doctors had higher CARE score than doctors with no FM training. In hospital clinics, the difference of the mean CARE score for doctors who had family medicine training (39.2, SD = 7.04) and internal medicine training (35.5, SD = 8.92) was statistically significant after adjusting for consultation time and gender of the patient. In the community care clinics, the mean CARE score for doctors with family medicine training and those without specialist training were 32.1 (SD = 7.95) and 29.2 (SD = 7.43) respectively, but the difference was not found to be significant. For PEI, patients receiving care from doctors in the hospital clinics scored significantly higher than those in the community clinics, but there was no significant difference in PEI between patients receiving care from doctors with different training backgrounds within similar clinic setting.

CONCLUSION

Family medicine training was associated with higher patient perceived empathy for chronic illness patients in the hospital clinics. Patient enablement appeared to be associated with clinic settings but not doctors' training background. Training in family medicine and a clinic environment that enables more patient doctor time might help in enhancing doctors' empathy and enablement for chronic illness patients.

Measuring empathic, person-centred communication in primary care nurses: validity and reliability of the Consultation and Relational Empathy (CARE) Measure

Background

Empathic patient-centred care is central to high quality health encounters. The Consultation and Relational Empathy (CARE) Measure is a patient-rated experience measure of the interpersonal quality of healthcare encounters. The measure has been extensively validated and is widely used by doctors in primary care but has not been validated in nursing. This study assessed the validity and reliability of the CARE Measure in routine nurse consultations in primary care.

Methods

Seventeen nurses from nine general medical practices located in three Scottish Health Boards participated in the study. Consecutive patients (aged 16 years or older) were asked to self-complete a questionnaire containing the CARE Measure immediately after their clinical encounter with the nurse. Statistical analysis included Spearman’s correlation and principal component analysis (construct validity), Cronbach’s alpha (internal consistency), and Generalisability theory (inter-rater reliability).

Results

A total of 774 patients (327 male and 447 female) completed the questionnaire. Almost three out of four patients (73 %) felt that the CARE Measure items were very important to their current consultation. The number of ‘not applicable’ responses and missing values were low overall (5.7 and 1.6 % respectively). The mean CARE Measure score in the consultations was 45.9 and 48 % achieved the maximum possible score of 50. CARE Measure scores correlated in predicted ways with overall satisfaction and patient enablement in support of convergent and divergent validity. Factor analysis found that the CARE Measure items loaded highly onto a single factor. The measure showed high internal consistency (Cronbach’s alpha coefficient = 0.97) and acceptable inter-rater reliability (G = 0.6 with 60 patients ratings per nurse). The scores were not affected by patients’ age, gender, self-perceived overall health, living arrangements, employment status or language spoken at home.

Conclusions

The CARE Measure has high face and construct validity, and internal reliability in nurse consultations in primary care. Its ability to discriminate between nurses is sufficient for educational and quality improvement purposes.

Evaluation of the Effectiveness of Nurse-Led Continence Care Treatments for Chinese Primary Care Patients with Lower Urinary Tract Symptoms

Background

The aim of this study was to evaluate whether community-based nurse-led continence care interventions are effective in improving outcomes for adult Chinese primary care patients with lower urinary tract symptoms (LUTS).

Research Design and Subjects

A case-controlled intervention study was conducted. An intervention group of 360 primary care patients enrolled into a nurse-led continence care programme were recruited by consecutive sampling. A control group of 360 primary care patients with LUTS identified by screening were recruited from the waiting rooms of primary care clinics by consecutive sampling. Both groups were monitored at baseline and at 12 months.

Measures

Outcome measures included symptom severity, health-related quality of life (HRQOL), self-efficacy, global health and self-reported health service utilization at 12-months. The effect of the continence care programme on symptom severity and HRQOL was assessed by the difference-in-difference estimation, using independent t-test and multiple liner regression. Chi-square test was used to compare the self-efficacy, global health and self-reported health service utilization between the two groups at 12-months.

Results

After adjusting for baseline severity and socio-demographics, the intervention group had significant improvements in LUTS severity (P<0.05) and HRQOL (P<0.05). Improvements in the amount of urine leakage were not significantly different between the two groups. A higher proportion of subjects in the intervention group reported increased self-efficacy (43.48% vs. 66.83%), improved global health condition (17.74% vs. 41.5%), having doctor consultation (18.5% vs. 8.06), having medication due to LUTS (26.50% vs.11.29%) and having non-drug therapy due to LUTS (59.5% vs.9.68%).

Conclusions

Community-based nurse-led continence care can effectively alleviate symptoms, improve health-related quality of life, and enhance self-efficacy and the global health condition of Chinese male and female primary care patients with LUTS.

Changes in wellbeing and professional values among medical undergraduate students: a narrative review of the literature

BACKGROUND

Educators are concerned by the high prevalence of emotional distress among medical students, and by the alleged decline in their humanitarian values.

OBJECTIVE

To re-examine these concerns by reviewing studies of medical students' wellbeing and development.

METHOD

Narrative review of the literature.

MAIN FINDINGS

(a) Medical students' emotional distress increases during their undergraduate training. However, although higher than in the general population, the prevalence of distress among medical students is similar to that among other university students. (b) Medical students' distress is independently related to endogenous factors (personality traits and life events) and to their perception of the medical learning environment. (c) Medical students do not display a measurable increase in moral reasoning, empathy and tolerance of uncertainty. (d) Students' wellbeing, moral development, reflectivity and tolerance of uncertainty have been shown to be interrelated, and associated with clinical performance.

CONCLUSIONS

The findings of this review endorse the concerns about the wellbeing and development of undergraduate medical students. The design of the reviewed studies does not permit inferences about causality. Yet, these findings are consistent with the hypothesis that medical training causes emotional distress that delays students' development and affects their clinical performance.

Having a Family Doctor is Associated with Some Better Patient-Reported Outcomes of Primary Care Consultations

Background: Hong Kong (HK) has pluralistic primary care that is provided by a variety of doctors. The aim of our study was to assess patient-reported outcomes of primary care consultations in HK and whether having a family doctor (FD) made any difference.

Methods: We interviewed by telephone 3148 subjects from 5174 contacted households (response rate 60.8%) randomly selected from the general population of HK about the experience of their last primary care consultations in September 2007 and April 2008. We compared the patient-reported outcomes (PRO) and patient-centered process of care in those with a FD, those with other types of regular primary care doctors (ORD) and those without any regular primary care doctor (NRD). PRO included patient enablement, global improvement in health, overall satisfaction, and likelihood of recommending their doctors to family and friends. Patient-centered process of care indicators was explanations about the illness, and address of patient’s concerns.

Results: One thousand one hundred fifty, 746, and 1157 reported to have FD, ORD, and NRD, respectively. Over 80% of those with FD consulted their usual primary care doctors in the last consultation compared with 27% of those with NRD. Compared with subjects having ORD or NRD, subjects with FD reported being more enabled after the consultation and were more likely to recommend their doctors to family and friends. Subjects with FD and ORD were more likely than those having NRD to report a global improvement in health and satisfaction. FD group was more likely than the other two groups to report receiving an explanation on the diagnosis, nature, and expected course of the illness, and having their concerns addressed. Patient enablement was associated with explanation of diagnosis, nature, and expected course of illness, and address of patient’s concerns.

Conclusion: People with a regular FD were more likely to feel being enabled and to experience patient-centered care in consultations.

Greater professional empathy leads to higher agreement about decisions made in the consultation

OBJECTIVE

To examine the relationship between professional expression of empathy and agreement about decisions made in the consultation.

METHODS

Consultations between 86 individuals with diabetes and four dieticians were audio-recorded. Immediately following consultations patients and dieticians independently reported decisions made in a booklet. Audio-recordings were coded directly for empathy using an amended version of the empathic communication coding system (ECCS).

RESULTS

Empathy correlated significantly with patient and professional agreement about decisions made in the consultation (τ=.283, p=.0005). Multiple regression analysis indicates that for each dietician the greater the empathy the higher the level of agreement about decisions (p<.0005). Professional empathic response to patients statements of challenge was a significant factor in increasing agreement about decisions (p=.008).

CONCLUSION

Results support the hypothesis that greater professional empathy will result in greater agreement about decisions made in consultations.

PRACTICE IMPLICATIONS

Findings have implications for empathy training and provide guidance on the communication skills needed to support expression of empathy. Patient and professional agreement about decisions made provides a simple marker of effectiveness and highlights the importance of empathy as a seminal component of professional communication skills during a patient consultation.

Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians

BACKGROUND

Empathy is an outcome-relevant physician characteristic and thus a crucial component of high-quality communication in health care. However, the factors that promote and inhibit the development of empathy during medical education have not been extensively researched. Also, currently there is no explicit research on the perspective of practicing physicians on the subject. Therefore the aim of our study was to explore physicians' views of the positive and negative influences on the development of empathy during their medical education, as well as in their everyday work as physicians.

METHOD

We administered a written Qualitative Short Survey to 63 physicians in seven specialties. They were able to respond anonymously. Our open-ended question was: "What educational content in the course of your studies and/or your specialist training had a positive or negative effect on your empathy?" We analyzed the data using thematic content analysis following Mayring's approach.

RESULTS

Forty-two physicians took part in our survey. All together, they mentioned 68 specific factors (37 positive, 29 negative, 2 neutral) from which six themes emerged: 1. In general, medical education does not promote the development of empathy. 2. Recognizing the psycho-social dimensions of care fosters empathy. 3. Interactions with patients in medical practice promote empathy. 4. Physicians' active self-development through reflective practice helps the development of empathy. 5. Interactions with colleagues can both promote and inhibit empathy through their role modeling of empathic and non-empathic behavior. 6. Stress, time pressure, and adverse working conditions are detrimental to empathy development.

CONCLUSIONS

Our results provide an overview of what might influence the development of clinical empathy, as well as hypothetical conclusions about how to promote it. Reflective practice seems to be lacking in current medical curricula and could be incorporated. Raising physicians' awareness of the psycho-social dimension of disease, and of the impact of peer influence and role modeling, seems promising in this regard, too. Stress and well-being seem to be closely related to physician empathy, and their modulation must take into account individual, social, and organizational factors. Further research should investigate whether or how these hypothetical conclusions can deepen our understanding of the determinants of physician empathy in order to help its promotion.

Physician empathy and subjective evaluation of medical treatment outcome in trauma surgery patients

OBJECTIVE

To analyze whether patients' perception of their medical treatment outcome is higher among patients who experienced a higher empathy by trauma surgeons during their stay in hospital.

METHODS

127 patients were surveyed six weeks after discharge from the trauma surgical general ward. Subjective evaluation of medical treatment outcome was measured with the corresponding scale from the Cologne Patient Questionnaire. Clinical empathy was assessed by using the CARE measure. The influence of physician empathy and control variables on a dichotomized index of subjective evaluation of medical treatment outcome was identified with a logistic regression.

RESULTS

120 patients were included in the logistic regression analysis. Compared to patients with physician empathy ratings of less than 30 points, patients with ratings of 41 points or higher have a 20-fold higher probability to be in the group with a better medical treatment outcome on the CPQ-scale (α-level<.001, R(2) 46.9).

CONCLUSION

Findings emphasize the importance of a well-functioning relationship between physician and patient even in a surgical setting where the focus is mostly on the bare medical treatment.

PRACTICE IMPLICATIONS

Communication trainings i.e. in surgical education can be an effective way to improve the ability to show empathy with patients' concerns.

Effectiveness of empathy in general practice: a systematic review

BACKGROUND

Empathy as a characteristic of patient-physician communication in both general practice and clinical care is considered to be the backbone of the patient-physician relationship. Although the value of empathy is seldom debated, its effectiveness is little discussed in general practice. This literature review explores the effectiveness of empathy in general practice. Effects that are discussed are: patient satisfaction and adherence, feelings of anxiety and stress, patient enablement, diagnostics related to information exchange, and clinical outcomes.

AIM

To review the existing literature concerning all studies published in the last 15 years on the effectiveness of physician empathy in general practice.

DESIGN AND SETTING

Systematic literature search.

METHOD

Searches of PubMed, EMBASE, and PsychINFO databases were undertaken, with citation searches of key studies and papers. Original studies published in English between July 1995 and July 2011, containing empirical data about patient experience of GPs' empathy, were included. Qualitative assessment was applied using Giacomini and Cook's criteria.

RESULTS

After screening the literature using specified selection criteria, 964 original studies were selected; of these, seven were included in this review after applying quality assessment. There is a good correlation between physician empathy and patient satisfaction and a direct positive relationship with strengthening patient enablement. Empathy lowers patients' anxiety and distress and delivers significantly better clinical outcomes.

CONCLUSION

Although only a small number of studies could be used in this search, the general outcome seems to be that empathy in the patient-physician communication in general practice is of unquestionable importance.

Short- and long-term subjective medical treatment outcome of trauma surgery patients: the importance of physician empathy

PURPOSE

To investigate accident casualties' long-term subjective evaluation of treatment outcome 6 weeks and 12 months after discharge and its relation to the experienced surgeon's empathy during hospital treatment after trauma in consideration of patient-, injury-, and health-related factors. The long-term results are compared to the 6-week follow-up outcomes.

PATIENTS AND METHODS

Two hundred and seventeen surgery patients were surveyed at 6 weeks, and 206 patients at 12 months after discharge from the trauma surgical general ward. The subjective evaluation of medical treatment outcome was measured 6 weeks and 12 months after discharge with the respective scale from the Cologne Patient Questionnaire. Physician Empathy was assessed with the Consultation and Relational Empathy Measure. The correlation between physician empathy and control variables with the subjective evaluation of medical treatment outcome 12 months after discharge was identified by means of logistic regression analysis under control of sociodemographic and injury-related factors.

RESULTS

One hundred and thirty-six patients were included within the logistic regression analysis at the 12-month follow-up. Compared to the 6-week follow-up, the level of subjective evaluation of medical treatment outcome was slightly lower and the association with physician empathy was weaker. Compared to patients who rated the empathy of their surgeon lower than 31 points, patients with ratings of 41 points or higher had a 4.2-fold higher probability to be in the group with a better medical treatment outcome (3.5 and above) on the Cologne Patient Questionnaire scale 12 months after discharge from hospital (P=0.009, R (2)=33.5, 95% confidence interval: 1.440-12.629).

CONCLUSION

Physician empathy is the strongest predictor for a higher level of trauma patients' subjective evaluation of treatment outcome 6 weeks and 12 months after discharge from the hospital. Interpersonal factors between surgeons and their patients are possible key levers for improving patient outcomes in an advanced health system. Communication trainings for surgeons might prepare them to react appropriately to their patients' needs and lead to satisfactory outcomes for both parties.

Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care

Background

There is limited evidence to support the use of facemasks in preventing infection for primary care professionals. Negative effects on communication has been suggested when the physician wears a facemask. As communication skills and doctor patient relationship are essential to primary care consultations, the effects of doctor’s facemask wearing were explored.

Method

A randomised controlled study was conducted in primary care to explore the effects of doctors wearing facemasks on patients’ perception of doctors’ empathy, patient enablement and patient satisfaction. Primary care doctors were randomized to mask wearing and non mask wearing clinical consultations in public primary care clinics in Hong Kong. Patients’ views were gathered using the Consultation and Relational Empathy (CARE) Measure, Patient Enablement Instrument (PEI) and an overall satisfaction rating scale. The effects of face mask wearing were investigated using multilevel (hierarchical) modelling.

Results

1,030 patients were randomised to doctor-mask wearing consultations (n = 514) and non mask wearing consultations (n = 516). A significant and negative effect was found in the patients’ perception of the doctors’ empathy (CARE score reduction -0.98, p-value = 0.04). In the more established doctor-patient relationship, the effect of doctors’ mask wearing was more pronounced (CARE score reduction -5.67, p-value = 0.03).

Conclusion

This study demonstrates that when doctors wearing a facemask during consultations, this has a significant negative impact on the patient’s perceived empathy and diminish the positive effects of relational continuity. Consideration should be taken in planning appropriate use of facemasks in infectious disease policy for primary care and other healthcare professionals at a national, local or practice level.

Clinical trial registration

This trial was registered on Chinese Clinical Trial Register (ChiCTR). Registration no.: ChiCTR-TTRCC-12002519. URL: http://www.chictr.org/en/proj/show.aspx?proj=3486. Due to administrative error, registration of trial did not take place until after the trial started on 1^st August 2011 and registration number was released on 21^st September 2012.

Writing letters to patients as an educational tool for medical students

BACKGROUND

Despite rapid growth and development of medical technology, personal relationship between the patient and physician remains the basis of high quality treatment. The aim of our study was to develop, implement and evaluate patient therapeutic letters written by students as a tool in teaching family medicine.

METHODS

The study included all 6th year students attending their rounds in family medicine, structured into two 10-day cycles, one in urban offices and one in offices on the Adriatic islands (rural). After receiving detailed instructions, students wrote letters to two patients after a consultation in the office. The letters were audited by patients and 3 family medicine experts who used a grading instrument (scale 0 - poor, 1 - medium, 2 - good) for 1) adequacy and clarity of description of patients' disease/state, 2) knowledge, 3) adequacy of recommendations, 4) courtesy and respect and 5) language and style. Patients and experts were also asked to underline phrases they thought would be difficult to understand; the underlined text was subjected to content analysis.

RESULTS

Both the patients and the experts gave high scores for the value and quality of the letters in terms of the description of the problem, adequacy of recommendations given, and courtesy and respect (mean (±standard deviation) 5.65 ± 0.79 for patients vs. 4.87 ± 0.79 for experts out of maximum score of 6). Family medicine experts were stricter than patients in their evaluation of the content of the letters (adequacy and clarity of disease description (P < 0.001) and adequacy of recommendations (P < 0.001). Both the patients and the experts seemed to like longer letters as the length of the letter showed significant positive correlation with the quality summary score (correlation r = 0.492 vs. r = 0.338, respectively, P < 0.010). Overlapping of the text underlined as difficult to understand by patients and experts was found in 10 (11.6%) out of 86 letters. The highest overlap (20 terms) was found for the category "Technical terms unclear to a lay reader".

CONCLUSIONS

Writing of a letter to their first patients may be a useful tool for students to personally experience the practice of medicine and establish better partnership with patients in health care.

Preferences, predictions and patient enablement: a preliminary study

BACKGROUND

The widely used patient enablement instrument (PEI) is sometimes contrasted against measures of patient satisfaction as being a more objective measure of consultation quality, in that it is less likely to be positively influenced by fulfilling pre-existing expectations for specific consultation outcomes (such as prescriptions or referrals). However the relationship between expectation and enablement is underexplored, as is the relationship between 'expectation' understood as a patient preference for outcome, and patient prediction of outcome. The aims of the study are to 1) assess the feasibility of measuring the relationship between expectation fulfilment and patient enablement, and 2) measure the difference (if any) between expectation understood as preference, and expectation understood as prediction.

METHODS

A questionnaire study was carried out on 67 patients attending three General Practices in the Australian Capital Territory. Patient preferences and predictions for a range of possible outcomes were recorded prior to the consultation. PEI and the actual outcomes of the consultation were recorded at the conclusion of the consultation. Data analysis compared expectation fulfilment as concordance between the preferred, predicted, and actual outcomes, with the PEI as a dependant variable.

RESULTS

No statistically significant relationship was found between either preference-outcome concordance and PEI, or prediction-outcome concordance. Statistically insignificant trends in both cases ran counter to expectations; i.e. with PEI (weakly) positively correlated with greater discordance. The degree of concordance between preferred outcomes and predicted outcomes was less than the concordance between either preferred outcomes and actual outcomes, or predicted outcomes and actual outcomes.

CONCLUSIONS

The relationship between expectation fulfilment and enablement remains uncertain, whether expectation is measured as stated preferences for specific outcomes, or the predictions made regarding receiving such outcomes. However the lack of agreement between these two senses of 'patient expectation' suggests that explicitly demarcating these concepts during study design is strongly advisable.

Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment acceptance in medical rehabilitation using a structural equation modeling approach

OBJECTIVES

The aims of the study are: (1) To develop and test a theory-based model for the predictive power of "Shared decision making (SDM)", "Empathy" and "Team interaction" for "Patient satisfaction" and "Treatment acceptance". (2) To identify mediating effects of "Compliance" and "Satisfaction with decision".

METHODS

Within a multi-center cross-sectional study (11 inpatient rehabilitation clinics at different indication fields), the model was evaluated in descriptive and structure analytical terms based on survey data of N=402 inpatients.

RESULTS

The structural equation model proved to exhibit an appropriate data fit. A high proportion of variance of "Patient satisfaction" (61%) and "Treatment acceptance" (67%) can be predicted by "SDM", "Empathy", "Satisfaction with decision" and "Team interaction". While no mediating effects were found for the two subcomponents of "Compliance" ("Patient cooperation", "Adherence"), "Satisfaction with decision" showed a full mediation for "Treatment acceptance" and a partial mediation for "Patient satisfaction".

CONCLUSION

"Team interaction" should be considered as an important predictor of process and patient-centered outcome characteristics.

PRACTICE IMPLICATIONS

The current findings can be used to derive measures as well as interventions to optimize the organization of participatory care within teams in order to strengthen patient centeredness and to ensure a high quality of care.

Two principal components, coping and independence, comprise patient enablement in Japan: cross sectional study in Tohoku area

The concept of "patient enablement" involves patients' perceptions of ability to understand and cope with illness. Improving enablement is an important goal of medical consultations for patients with chronic illness. To measure "enablement," a post-medical-consultation patient-reported questionnaire was developed and named "Patient Enablement Instrument (PEI)" in the United Kingdom. Unfortunately, there has been no tool to evaluate patient enablement in Japan. Therefore, this study aimed to develop PEI Japanese version, to examine its validity and reliability, and to clarify the constitution of concept about patient enablement among Japanese patients. The translation process included forward translation, expert panel back-translation, following the standard WHO process. Participants were 256 individuals (157 men and 99 women; mean age 62.9 ± 11.8 years) receiving a regular outpatient treatment due to chronic illness at the Department of Cardiology, Respiratory, or Endocrinology and Metabolism in a regional hospital. To assess validity, we compared PEI with Medical Interview Satisfaction Scale (MISS) by correlation coefficient, which was 0.55 (P < 0.01). Furthermore, factor analysis indicated that PEI had two principal factors labeled "coping with illness and health maintenance" and "confidence in oneself and independence". For an evaluation of reliability, internal consistency was calculated (Cronbach's alpha = 0.875). In conclusion, two principal factors comprise patient enablement measured by PEI with satisfactory validity and reliability. PEI Japanese version will be a useful tool to evaluate and improve medical consultations in Japan.

The role of empathy in therapy and the physician-patient relationship

This paper seeks to give an overview of the role of clinical empathy in therapy and in the physician-patient relationship. Researchers have offered definitions of empathy in the clinical context, and a number of validated measures exist. There is evidence from the health-related research literature to support the positive association of clinical empathy with improved therapeutic outcomes in a wide range of clinical settings. Clinical empathy is also understood to be a crucial component of the physician-patient therapeutic relationship. Barriers to the development and expression of empathy in the clinical context are explored, and ways of enhancing empathy discussed.