A pilot prospective study on the consultation and relational empathy, patient enablement, and health changes over 12 months in patients going to the Glasgow Homoeopathic Hospital

Self-organizing biopsychosocial dynamics and the patient-healer relationship

The patient-healer relationship has an increasing area of interest for complementary and alternative medicine (CAM) researchers. This focus on the interpersonal context of treatment is not surprising as dismantling studies, clinical trials and other linear research designs continually point toward the critical role of context and the broadband biopsychosocial nature of therapeutic responses to CAM. Unfortunately, the same traditional research models and methods that fail to find simple and specific treatment-outcome relations are similarly failing to find simple and specific mechanisms to explain how interpersonal processes influence patient outcomes. This paper presents an overview of some of the key models and methods from nonlinear dynamical systems that are better equipped for empirical testing of CAM outcomes on broadband biopsychosocial processes. Suggestions are made for CAM researchers to assist in modeling the interactions among key process dynamics interacting across biopsychosocial scales: empathy, intra-psychic conflict, physiological arousal, and leukocyte telomerase activity. Finally, some speculations are made regarding the possibility for deeper cross-scale information exchange involving quantum temporal nonlocality.

State-space grid analysis: applications for clinical whole systems complementary and alternative medicine research

This paper presents state space grids (SSGs) as a mathematically less intensive methodology for process-oriented research beyond traditional qualitative and quantitative approaches in whole systems of complementary and alternative medicine (WS-CAM). SSGs, originally applied in developmental psychology research, offer a logical, flexible, and accessible tool for capturing emergent changes in the temporal dynamics of patient behaviors, manifestations of resilience, and outcomes. The SSG method generates a two-dimensional visualization and quantification of the inter-relationships between variables on a moment-to-moment basis. SSGs can describe dyadic interactive behavior in real time and, followed longitudinally, allow evaluation of how change occurs over extended time periods. Practice theories of WS-CAM encompass the holistic health concept of whole-person outcomes, including nonlinear pathways to complex, multidimensional changes. Understanding how the patient as a living system arrives at these outcomes requires studying the process of healing, e.g., sudden abrupt worsening and/or improvements, 'healing crises', and 'unstuckness', from which the multiple inter-personal and intra-personal outcomes emerge. SSGs can document the indirect, emergent dynamic effects of interventions, transitional phases, and the mutual interaction of patient and environment that underlie the healing process. Two WS-CAM research exemplars are provided to demonstrate the feasibility of using SSGs in both dyadic and within-patient contexts, and to illustrate the possibilities for clinically relevant, process-focused hypotheses. This type of research has the potential to help clinicians select, modify and optimize treatment plans earlier in the course of care and produce more successful outcomes for more patients.

Characterizing changes in student empathy throughout medical school

BACKGROUND

 Empathy is important in the physician-patient relationship. Prior studies suggest that medical student empathy declines with clinical training.

AIMS

 We examined the trend of empathy longitudinally; determined differences in empathy according to gender and medical specialty preferences; and determined empathy and career preference differences among students admitted through different medical school admission pathways.

METHOD

 The data for this study were collected using a longitudinal cohort design and included 2652 observations nested within 1162 individuals. Participants were medical students at a university-based medical school surveyed yearly from 2007 through 2010. Empathy was measured by the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a validated, 20-item self-administered questionnaire. Predictors of JSPE-S scores included gender, age, anticipated financial debt upon graduation and future career interest.

RESULTS

 Empathy scores of students in preclinical years were higher than in clinical years. Gender was a significant predictor of empathy, with women having higher empathy scores than men. Students preferring technology-oriented specialties had lower empathy scores. When career preference was controlled, higher levels of debt were significantly associated with greater empathy. Students with high baseline empathy decreased less than students with low baseline empathy during medical school. Students in traditional four-year medical school programs had higher baseline empathy than those in early pathway programs.

CONCLUSIONS

 Self-reported empathy for patients, a possibly critical factor in high-quality patient-centered care, wanes as students advance in clinical training, particularly among those entering technology-oriented specialties. In the era of new health care policy and primary care shortages, our research may have implications for the medical education system and admission policy.

Empathy decline and its reasons: a systematic review of studies with medical students and residents

PURPOSE

Empathy is a key element of patient-physician communication; it is relevant to and positively influences patients' health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency.

METHOD

The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size <30 were excluded.

RESULTS

Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the "hidden," "formal," and "informal" curricula as main reasons for empathy decline.

CONCLUSIONS

The results of the reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.

How do we evaluate outcome in an integrative oncology program?

Integrative oncology focuses on the roles of complementary therapies to increase the effectiveness of conventional cancer treatment programs by improving defined outcomes such as symptom control, quality of life, rehabilitation, and prevention of recurrence. Implementation of integrative oncology programs should be based on the best evidence and must continually be evaluated to ensure quality, optimization of techniques, collection of new data, and cost-effectiveness. Useful domains that can be evaluated include symptom control, adherence to treatment protocols, quality of life, individual outcomes, prevention, rehabilitation, potential advantages of a whole-systems health approach, and economics of health services.

The Patient Enablement Instrument-French version in a family practice setting: a reliability study

Background

Patient enablement can be defined as the extent to which a patient is capable of understanding and coping with his or her health issues. This concept is linked to a number of health outcomes such as self-management of chronic diseases and quality of life. The Patient Enablement Instrument (PEI) was designed to measure this concept after a medical consultation. The instrument, in its original form and its translations into several languages, has proven to be reliable and valid. The purpose of this study was to evaluate the reliability of the French version of the PEI (PEI-Fv) in a family practice setting.

Methods

One hundred and ten participants were recruited in a family medicine clinic in the Saguenay region of Quebec (Canada). The PEI-Fv was completed twice, immediately after consultation with a physician (T1) and 2 weeks after the consultation (T2). The internal consistency of the tool was assessed with Cronbach's α and test-retest reliability by intraclass correlation coefficient.

Results

The mean score for the PEI-Fv was 5.06 ± 3.97 (95% confidence interval [CI]: 4.30-5.81) at T1 and 4.63 ± 3.90 (95% CI: 3.82-5.44) at T2. Cronbach's α was high at T1 (α₁ = 0.93; 95% CI: 0.91-0.95) and T2 (α₂ = 0.93; 95% CI: 0.91-0.95). The intraclass correlation coefficient was 0.62 (95% CI: 0.48-0.74), indicating a moderate test-retest reliability.

Conclusions

The internal consistency of the PEI-Fv is excellent. Test-retest reliability was moderate to good. Test-retest reliability should be examined in further studies at a less than 2-week interval to reduce maturation bias. This instrument can be used to measure enablement after consultation in a French-speaking family practice setting.

Evaluation of the "Consultation and Relational Empathy" (CARE) measure by means of Rasch-analysis at the example of cancer patients

OBJECTIVE

The aims of this study are: (1) analysis of unidimensionality of the German version of the "Consultation and Relational Empathy" (CARE) measure and (2) identification of moderating variables affecting the scale structure.

METHODS

The CARE-measure was evaluated by means of Rasch-analysis in a sample of N=326 cancer patients. Association of diagnosis and treatment as well as patients' characteristics was analyzed by person-fit measures and Differential Item Functioning.

RESULTS

Nine of the original 10 CARE items fit to the Rasch-model. For breast and prostate cancer, as well as for patients taking complementary and alternative medicine treatment, item biases affect the scale structure. Furthermore, older patients and patients with higher social support exhibit substantial deviations from model predictions.

CONCLUSIONS

Only the nine-item version of the CARE-measure allows for the unidimensional assessment of physician empathy. Especially for specific diagnosis and treatment groups, the CARE-items indicate variations in the underlying latent construct of physician empathy.

PRACTICE IMPLICATIONS

The CARER-measure provides a theory-based and psychometrically sound basis for the assessment of PE. It can be used to enhance the fairness of the assessment and to further identify valuable information about the influence of patient characteristics on the structure of the construct PE.

Research on integrative healthcare: context and priorities

It is important that integrative healthcare research be conducted to optimize the effectiveness, safety, costs, and social and economic impact of prospective, personalized, patient-centered, comprehensive, and holistic healthcare that focuses on well-being as well as disease management, and that the research itself be well understood. The scope of this research extends beyond evaluation of specific therapies, to include evaluations of multimodality whole system intervention, practitioner-patient relationships, patient goals and priorities, promoting self-care and resilience, personalized diagnostic and therapeutic measures, practitioner well-being, the comparative effectiveness of different educational and outreach strategies in improving health and healthcare, and the environmental/social causes and consequence of health and healthcare. In this paper, we describe the state of the science of research on integrative healthcare, research needs, and opportunities offered by cutting-edge research tools. We propose a framework for setting priorities in integrative health research, list areas for discussion, and pose a few questions on a future research agenda.

A grounded theory study of homeopathic practitioners' perceptions and experiences of the homeopathic consultation

Research into the homeopathic consultation has largely focused on patients' experiences, although the practitioner is a crucial component of the therapeutic context and may have an important part in optimizing health outcomes. Therefore the aim of this qualitative research was to gain an in-depth understanding of homeopathic practitioners' perceptions and experiences of the consultation. Medical and non-medical homeopaths were sampled from the registers of the Faculty and Society of Homeopaths. Two phases of data collection were employed. Phase 1 used in depth face-to-face interviews enabling the development of an initial model of the homeopathic consultation. Phase 2 involved observations of homeopathic consultations and practitioner reflective diaries in order to confirm, refute, or enlarge the model. Using the constant comparative method of grounded theory five main categories emerged, exploring the journey, finding the level, responding therapeutically, understanding self, and connecting, forming a model entitled "a theoretical model of a UK classical homeopathic consultation" which describes how homeopaths view and enact the consultation process. This study suggests that the process of identifying and prescribing the remedy is embedded in the consultation, highlighting the interconnectedness of the whole homeopathic consultation and aspects of the consultation that are unique and specific to homeopathy.

Comparing a self-administered measure of empathy with observed behavior among medical students

PURPOSE

Studies show that measures of physician and medical students' empathy decline with clinical training. Presently, there are limited data relating self-reported measures to observed behavior. This study explores a self-reported measure and observed empathy in medical students.

METHOD

Students in the Class of 2009, at a university-based medical school, were surveyed at the end of their 2nd and 3rd year. Students completed the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a self-administered scale, and were evaluated for demonstrated empathic behavior during Objective Structured Clinical Examinations (OSCEs).

RESULTS

97.6% and 98.1% of eligible students participated in their 2nd and 3rd year, respectively. The overall correlation between the JSPE-S and OSCE empathy scores was 0.22, p < 0.0001. Students had higher self-reported JSPE-S scores in their 2nd year compared to their 3rd year (118.63 vs. 116.08, p < 0.0001), but had lower observed empathy scores (3.96 vs. 4.15, p < 0.0001).

CONCLUSIONS

Empathy measured by a self-administered scale decreased, whereas observed empathy increased among medical students with more medical training.

An evaluation of the impact of a large group psycho-education programme (Stress Control) on patient outcome: does empathy make a difference?

Large psycho-education groups are being increasingly used in mental-health promotion and the treatment of common mental-health problems. In individual therapy there is a well-established link between therapist empathy, therapeutic relationship and patient outcome but the role of empathy within large psycho-educational groups is unknown. This service evaluation investigated the impact of a 6-week large psycho-education group on patient outcome and the role of perceived therapist empathy on outcome. Within a before–after experimental design, 66 participants completed baseline and endpoint measures; Clinical Outcome Routine Evaluation (CORE), Patient Enablement Instrument (PEI), and the modified Consultation and Relational Empathy (CARE) measure. The results showed that the intervention had a positive impact on patient outcome; the CORE score reduced significantly over the 6 weeks by 0.63 (95% CI 0.82–1.14) (t= 9.18, d.f. = 55,p= <0.001) and attendees felt highly enabled. Attendees perceived the course leader as highly empathetic. However, the relationship between perceived empathy and attendee outcome was less clear; no significant relationship was found with the main outcome measure (the change in CORE score). Factors that influenced the main outcome included age, symptom severity at baseline, having a long-term illness or disability, and whether attendees tried the techniques at home (homework). These findings suggest that large group psycho-education is an effective treatment for mild to moderate mental-health problems, at least in the short term. The role of therapist empathy remains ambiguous but may be important for some patient outcomes.

Reliability and validity of the Chinese version of the CARE Measure in a primary care setting in Hong Kong

BACKGROUND

The Consultation and Relational Empathy (CARE) Measure is a validated patient-rated measure of consultation quality in the UK.

OBJECTIVES

To provide preliminary evidence of the reliability and validity of a Chinese version of the CARE Measure in a primary care setting in Hong Kong.

METHODS

Following translation, back-translation and pilot testing, a Chinese version of the CARE Measure was developed and tested on 253 unselected primary care patients in Hong Kong.

RESULTS

The Chinese-CARE Measure was regarded by patients as being relevant to their consultations, with on average only 5.5% of patients rating the items as not important (range 3.6-10.2% for individual items), suggesting high acceptability and face validity. This was also supported by the relatively low number of 'not applicable' responses recorded for the measure (average 8.2%, range 0.4-21.7% for individual items). Internal reliability was high (Cronbach's alpha 0.962) and was reduced by the removal of any of the 10 items, and homogeneity was indicated by high corrected item-total correlations (0.786-0.876). Factor analysis showed a single solution for the Chinese-CARE Measure items with high item loadings (0.821-0.891). Construct validity was further supported by significant hypothesized relationships with other variables (patient enablement and patient satisfaction). Consultation length and continuity of care were independent predictors of Chinese-CARE Measure score in stepwise multiple regression analysis but together explained <10% of variation in CARE score.

CONCLUSION

These preliminary data support the reliability and validity of the Chinese version of the CARE Measure in primary care in Hong Kong.

Empirical research on empathy in medicine-A critical review

OBJECTIVE

There is a growing amount of empirical research on empathy in medicine. This critical review assesses methodological limitations in this body of research that have not received adequate attention.

METHODS

Scientific publications presenting empirical research on medical students' or physicians' empathy were systematically searched for.

RESULTS

206 publications were identified and critically reviewed. Multiple empirical approaches have been used. However, there are some remarkable tendencies given the complexity of the study object: empathy is often not defined. Qualitative approaches are rarely used and the predominant quantitative instruments have a relatively narrow or peripheral scope. For example, the concrete experiences, feelings, and interpretations of the physician and the patient, and empathy in clinical practice, are often neglected. Furthermore, possible influences of medical training and working conditions on empathy have not been adequately explored.

CONCLUSION

The empirical studies of empathy in medicine tend to separate empathy from main parts of clinical perception, judgment, and communication. Thus, important aspects and influences of empathy have been relatively neglected.

PRACTICE IMPLICATIONS

Future studies should include transparent concepts, more than one method and perspective, qualitative approaches, the physician's and the patient's concrete experiences and interpretations, and the context in which empathy is developed and practiced.

The potential of complementary and alternative medicine in promoting well-being and critical health literacy: a prospective, observational study of shiatsu

Background

The potential contribution of complementary and alternative medicine (CAM) modalities to promote and support critical health literacy has not received substantial attention within either the health promotion or the CAM literature. This paper explores the potential of one CAM modality, shiatsu, in promoting well-being and critical health literacy.

Methods

Data are drawn from a longitudinal, 6 months observational, pragmatic study of the effects and experience of shiatsu within three European countries (Austria, Spain and the UK). Client postal questionnaires included: advice received, changes made 6 months later, clients 'hopes' from having shiatsu and features of the client-practitioner relationship.

Result

At baseline, three-quarters of clients (n = 633) received advice, on exercise, diet, posture, points to work on at home or other ways of self-care. At 6 months follow-up, about four-fifths reported making changes to their lifestyle 'as a result of having shiatsu treatment', including taking more rest and relaxation or exercise, changing their diet, reducing time at work and other changes such as increased body/mind awareness and levels of confidence and resolve. Building on the findings, an explanatory model of possible ways that a CAM therapy could contribute to health promotion is presented to guide future research, both within and beyond CAM.

Conclusion

Supporting individuals to take control of their self-care requires advice-giving within a supportive treatment context and practitioner relationship, with clients who are open to change and committed to maintaining their health. CAM modalities may have an important role to play in this endeavour.

Impact of communication training on physician expression of empathy in patient encounters

OBJECTIVE

To examine whether an educational intervention that focused on physician communication training influenced physician empathic expression during patient interactions.

METHODS

This study used a quantitative research method to investigate the influence of communication training on physician-expressed empathy using two measures (global and hierarchical) of physician empathic behavior.

RESULTS

The differences in global empathy scores in the physician training group from baseline to follow-up improved by 37%, and hierarchical scores of physician empathic expression improved by up to 51% from baseline scores for the same group.

CONCLUSIONS

The results strongly supported the hypotheses that training made a significant difference in physician empathic expression during patient interactions demonstrated by both outside observer measures of global ratings and hierarchical ratings of physician empathic behavior.

PRACTICE IMPLICATIONS

These findings have significant implications for program design and development in medical education and professional training with the potential to improve patient outcomes.

A qualitative study of patients' views on quality of primary care consultations in Hong Kong and comparison with the UK CARE Measure

BACKGROUND

Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population.

METHODS

Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1-3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7-10).

RESULTS

Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs).

CONCLUSION

These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required.

How healthy are chronically ill patients after eight years of homeopathic treatment?--Results from a long term observational study

Background

Homeopathy is a highly debated but often used medical treatment. With this cohort study we aimed to evaluate health status changes under homeopathic treatment in routine care. Here we extend former results, now presenting data of an 8-year follow-up.

Methods

In a prospective, multicentre cohort study with 103 homeopathic primary care practices in Germany and Switzerland, data from all patients (age >1 year) consulting the physician for the first time were observed. The main outcome measures were: The patients' perceived change in complaint severity (numeric rating scales from 0 = no complaint to 10 = maximal severity) and quality of life as measured by the SF-36 at baseline, and after 2 and 8 years.

Results

A total of 3,709 patients were studied, 73% (2,722 adults, 72.8% female, age at baseline 41.0 ± 12.3; 819 children, 48.4% female, age 6.5 ± 4.0) contributed data to the 8-year follow-up. The most frequent diagnoses were allergic rhinitis and headache in adults, and atopic dermatitis and multiple recurrent infections in children. Disease severity decreased significantly (p < 0.001) between baseline, 2 and 8 years (adults from 6.2 ± 1.7 to 2.9 ± 2.2 and 2.7 ± 2.1; children from 6.1 ± 1.8 to 2.1 ± 2.0 and 1.7 ± 1.9). Physical and mental quality of life sores also increased considerably. Younger age, female gender and more severe disease at baseline were factors predictive of better therapeutic success.

Conclusion

Patients who seek homeopathic treatment are likely to improve considerably. These effects persist for as long as 8 years.

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

OBJECTIVE

The aim of this pilot prospective study was to investigate the relationships between general practitioners (GPs) empathy, patient enablement, and patient-assessed outcomes in primary care consultations in an area of high socio-economic deprivation in Scotland.

METHODS

This prospective study was carried out in a five-doctor practice in an area of high socioeconomic deprivation in Scotland. Patients' views on the consultation were gathered using the Consultation and Relational Empathy (CARE) Measure and the Patient Enablement Instrument (PEI). Changes in main complaint and well-being 1 month after the contact consultation were gathered from patients by postal questionnaire. The effect of GP empathy on patient enablement and prospective change in outcome was investigated using structural equation modelling.

RESULTS

323 patients completed the initial questionnaire at the contact consultation and of these 136 (42%) completed and returned the follow-up questionnaire at 1 month. Confirmatory factor analysis confirmed the construct validity ofthe CARE Measure, though omission of two ofthe six PEI items was required in order to reach an acceptable global data fit. The structural equation model revealed a direct positive relationship between GP empathy and patient enablement at contact consultation and a prospective relationship between patient enablement and changes in main complaint and well-being at 1 month.

CONCLUSION

In a high deprivation setting, GP empathy is associated with patient enablement at consultation, and enablement predicts patient-rated changes 1 month later. Further larger studies are desirable to confirm or refute these findings.

PRACTICE IMPLICATIONS

Ways of increasing GP empathy and patient enablement need to be established in order to maximise patient outcomes. Consultation length and relational continuity of care are known factors: the benefit of training and support for GPs needs to be further investigated.

The role of complementary and alternative medicine (CAM) in Germany - a focus group study of GPs

BACKGROUND

There has been a marked increase in the use of complementary and alternative medicine (CAM) in recent years worldwide. In Germany, apart from 'Heilpraktiker' (= state-licensed, non-medical CAM practitioners), some general practitioners (GPs) provide CAM in their practices. This paper aims to explore the attitudes of GPs about the role of CAM in Germany, in relation to the healthcare system, quality of care, medical education and research. Furthermore, experiences of GPs integrating CAM in their daily practice were explored.

METHODS

Using a qualitative methodological approach 3 focus groups with a convenience sample of 17 GPs were conducted. The discussions were transcribed verbatim and analysed using qualitative content analysis.

RESULTS

The majority of the participating GPs had integrated one or more CAM therapies into their every-day practice. Four key themes were identified based on the topics covered in the focus groups: the role of CAM within the German healthcare system, quality of care, education and research. Within the theme 'role of CAM within the healthcare system' there were five categories: integration of CAM, CAM in the Statutory Health Insurance, modernisation of the Statutory Health Insurance Act, individual healthcare services and 'Heilpraktiker'. Regarding quality of care there were two broad groups of GPs: those who thought patients would benefit from standardizing CAM and those who feared that quality control would interfere with the individual approach of CAM. The main issues identified relating to research and education were the need for the development of alternative research strategies and the low quality of existing CAM education respectively.

CONCLUSION

The majority of the participating GPs considered CAM as a reasonable complementary approach within primary care. The study increased our understanding of GPs attitudes about the role of CAM within the German healthcare system and the use of 'Heilpraktiker' as a competing CAM-provider. It seems to be a need for increased funding for research, better education and remuneration by the Statutory Health Insurance in order to improve access to 'Integrative medicine' in Germany.

Does the presence of medical students affect quality in general practice consultations?

CONTEXT

Previous studies have suggested that the patient's experience of a consultation with a doctor is not affected by the presence of medical students. However, no study has looked at the effect of student presence on conventional UK general practice consultations.

OBJECTIVES

This study aimed to measure the quality of the consultation as experienced by patients when students are present, to explore patients' attitudes to the presence of medical students, and to look at the relationships between these factors.

METHODS

We conducted a cross-sectional questionnaire study in general practices in north-east England. General practitioners (GPs) from practices teaching fourth and final year students administered questionnaires to patients who were seen in either teaching or non-teaching consultations. The questionnaire comprised previously validated measures of empathy and enablement as measures of quality, attitudinal statements regarding the presence of students, a scale rating pertaining to the patient's degree of acquaintance with the doctor, and items on demographic data.

RESULTS

Results showed no significant differences in enablement scores between the 2 groups. Consultations with student presence last longer. Empathy scores were significantly lower in the 'student present' group, but the size of the difference was small. Attitudinal statements regarding the presence of students showed a high proportion of positive responses, and some groupings of negative ones. Further analysis demonstrated some significant links between attitudinal statements and enablement and empathy scores.

CONCLUSIONS

The quality of general practice consultations was not adversely affected by medical student presence. However, significant numbers of patients who agreed to be seen with a student present were resistant to the student's presence.

Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modelling approach

OBJECTIVE

The aim of the present cross-sectional study was to explore patient- and physician-specific determinants of physician empathy (PE) and to analyse the influence of PE on patient-reported long-term outcomes in German cancer patients.

METHODS

A postal survey was administered to 710 cancer patients, who had been inpatients at the University Hospital Cologne (response rate 49.5%). PE was measured with the German translation of the consultation and relational empathy (CARE) measure, and patient-reported long-term outcomes were assessed using the major (ICD-10) depression inventory (MDI) and the EORTC quality of life (Qol) questionnaire QLQ-C30. Hypotheses were tested by structural equation modelling.

RESULTS

PE had (a) a moderate indirect effect on "depression" and a smaller indirect effect on "socio-emotional-cognitive Qol" by affecting "desire for more information from the physician regarding findings and treatment options" and (b) a moderate indirect effect on "socio-emotional-cognitive Qol" and a smaller effect on "depression" via "desire for more information about health promotion". The determinant with the greatest importance was "patient-perceived general busyness of hospital staff": it had a strong negative influence on PE, indirectly influencing "desire for more information from the physician regarding findings and treatment options" and also patients' "depression".

CONCLUSION

PE seems to be an important pre-requisite for information giving by physicians and through this pathway having a preventive effect on depression and improving Qol. Conversely, physicians' stress negatively influences these relationships.

PRACTICE IMPLICATIONS

The research findings suggest that reducing physicians' stress at the organizational and individual may be required to enhance patient-physician communication. Empathy, as an outcome-relevant professional competence needs to be assessed and developed more intensively in medical students and physicians.

The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland

PURPOSE

The inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served, but there is little research on how the inverse care law actually operates.

METHODS

A questionnaire study was carried out on 3,044 National Health Service (NHS) patients attending 26 general practitioners (GPs); 16 in poor areas (most deprived) and 10 in affluent areas (least deprived) in the west of Scotland. Data were collected on demographic and socioeconomic factors, health variables, and a range of factors relating to quality of care.

RESULTS

Compared with patients in least deprived areas, patients in the most deprived areas had a greater number of psychological problems, more long-term illness, more multimorbidity, and more chronic health problems. Access to care generally took longer, and satisfaction with access was significantly lower in the most deprived areas. Patients in the most deprived areas had more problems to discuss (especially psychosocial), yet clinical encounter length was generally shorter. GP stress was higher and patient enablement was lower in encounters dealing with psychosocial problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation.

CONCLUSIONS

The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities.

Treatment appraisals and beliefs predict adherence to complementary therapies: a prospective study using a dynamic extended self-regulation model

OBJECTIVES

Complementary and alternative medicine (CAM) is used by large numbers of the general public and is increasingly becoming integrated into the mainstream. An understanding of why people use CAM in general has been developed in the literature, but relatively little is known specifically about adherence to CAM. We tested hypotheses (derived from a dynamic extended version of Leventhal's common-sense model) that patients' beliefs about treatment, perceptions of illness, and treatment appraisals would predict adherence to CAM.

DESIGN

A prospective self-report questionnaire study was carried out with a 3-month follow-up period.

METHODS

A total of 240 patients from five CAM clinics completed self-report questionnaire measures of treatment beliefs, illness perceptions, and treatment appraisals at baseline. Three months later, they completed self-report measures of adherence to therapists' recommendations concerning attendance, remedy use, and life-style changes.

RESULTS

Logistic regression analyses showed that positive perceptions of one's therapist and belief that mental factors do not cause illness independently predicted adherence to appointments. Positive beliefs in holistic health and finding it difficult to travel to appointments predicted adherence to remedy use. Using homeopathy was the only independent predictor of adherence to life-style changes.

CONCLUSIONS

Treatment appraisals, treatment beliefs, and illness perceptions explain modest proportions of the variance in adherence to CAM. This study highlights the value of operationalizing the appraisal element of the common-sense model when investigating adherence to treatment.

A cross-sectional measurement of medical student empathy

BACKGROUND

Empathy is important in the physician-patient relationship. Prior studies have suggested that physician empathy may decline with clinical training.

OBJECTIVE

To measure and examine student empathy across medical school years.

DESIGN AND PARTICIPANTS

A cross-sectional study of students at Boston University School of Medicine in 2006. Incoming students plus each class near the end of the academic year were surveyed.

MEASUREMENTS

The Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a validated 20-item self-administered questionnaire with a total score ranging from 20 to 140. JSPE-S scores were controlled for potential confounders such as gender, age, anticipated financial debt upon graduation, and future career interest.

RESULTS

658 students participated in the study (81.4% of the school population). The first-year medical student class had the highest empathy scores (118.5), whereas the fourth-year class had the lowest empathy scores (106.6). Measured empathy differed between second- and third-year classes (118.2 vs 112.7, P < .001), corresponding to the first year of clinical training. Empathy appears to increase from the incoming to the first-year class (115.5 vs 118.5, P = .02). Students preferring people-oriented specialties had higher empathy scores than students preferring technology-oriented specialties (114.6 vs 111.4, P = .002). Female students were more likely than male students to choose people-oriented specialties (51.5 vs 26.9%, P < .001). Females had higher JSPE-S scores than males (116.5 vs 112.1, P < .001). Age and debt did not affect empathy scores.

CONCLUSIONS

Empathy scores of students in the preclinical years were higher than in the clinical years. Efforts are needed to determine whether differences in empathy scores among the classes are cohort effects or represent changes occurring in the course of medical education. Future research is needed to confirm whether clinical training impacts empathy negatively, and, if so, whether interventions can be designed to mitigate this impact.

Outcome related to impact on daily living: preliminary validation of the ORIDL instrument

Background

The challenge of finding practical, patient-rated outcome measures is a key issue in the evaluation of health care systems and interventions. The ORIDL (Outcome in Relation to Impact on Daily Living) instrument (formerly referred to as the Glasgow Homoeopathic Hospital Outcomes Scale or GHHOS) has been developed to measure patient's views of the outcome of their care by asking about change, and relating this to impact on daily life. The aim of the present paper is to describe the background and potential uses of the ORIDL, and to report on its preliminary validation in a series of three studies in secondary and primary care.

Methods

In the first study, 105 patients attending the Glasgow Homoeopathic Hospital (GHH) were followed-up at 12 months and changes in health status were measured by the EuroQol (EQOL) and the ORIDL. In the second study, 187 new patients at the GHH were followed-up at 3, 12, and 33 months, using the ORIDL, the Short Form 12 (SF-12), and the Measure Yourself Medical Outcome Profile (MYMOP). In study three, 323 patients in primary care were followed for 1 month post-consultation using the ORIDL and MYMOP. In all 3 studies the Patient Enablement Instrument (PEI) was also used as an outcome measure.

Results

Study 1 showed substantial improvements in main complaint and well-being over 12 months using the ORIDL, with two-thirds of patients reporting improvements in daily living. These improvements were not significantly correlated with changes in serial measures of the EQOL between baseline and 12 months, but were correlated with the EQOL transitions measure. Study 2 showed step-wise improvements in ORIDL scores between 3 and 33 months, which were only weakly associated with similar changes in SF-12 scores. However, MYMOP change scores correlated well with ORIDL scores at all time points. Study 3 showed similar high correlations between ORIDL scores and MYMOP scores. In all 3 studies, ORIDL scores were also significantly correlated with PEI-outcome scores.

Conclusion

There is significant agreement between patient outcomes assessed by the ORIDL and the EQOL transition scale, the MYMOP, and the PEI-outcome instrument, suggesting that the ORIDL may be a valid and sensitive tool for measuring change in relation to impact on life.

A systematic review of tests of empathy in medicine

BACKGROUND

Empathy is frequently cited as an important attribute in physicians and some groups have expressed a desire to measure empathy either at selection for medical school or during medical (or postgraduate) training. In order to do this, a reliable and valid test of empathy is required. The purpose of this systematic review is to determine the reliability and validity of existing tests for the assessment of medical empathy.

METHODS

A systematic review of research papers relating to the reliability and validity of tests of empathy in medical students and doctors. Journal databases (Medline, EMBASE, and PsycINFO) were searched for English-language articles relating to the assessment of empathy and related constructs in applicants to medical school, medical students, and doctors.

RESULTS

From 1147 citations, we identified 50 relevant papers describing 36 different instruments of empathy measurement. As some papers assessed more than one instrument, there were 59 instrument assessments. 20 of these involved only medical students, 30 involved only practising clinicians, and three involved only medical school applicants. Four assessments involved both medical students and practising clinicians, and two studies involved both medical school applicants and students. Eight instruments demonstrated evidence of reliability, internal consistency, and validity. Of these, six were self-rated measures, one was a patient-rated measure, and one was an observer-rated measure.

CONCLUSION

A number of empathy measures available have been psychometrically assessed for research use among medical students and practising medical doctors. No empathy measures were found with sufficient evidence of predictive validity for use as selection measures for medical school. However, measures with a sufficient evidential base to support their use as tools for investigating the role of empathy in medical training and clinical care are available.

Homeopathy--what are the active ingredients? An exploratory study using the UK Medical Research Council's framework for the evaluation of complex interventions

Background

Research in homeopathy has traditionally addressed itself to defining the effectiveness of homeopathic potencies in comparison to placebo medication. There is now increasing awareness that the homeopathic consultation is in itself a therapeutic intervention working independently or synergistically with the prescribed remedy. Our objective was to identify and evalute potential "active ingredients" of the homeopathic approach as a whole, in a prospective formal case series, which draws on actual consultation data, and is based on the MRC framework for the evaluation of complex interventions.

Methods

Following on from a theoretical review of how homeopathic care might mediate its effects, 18 patients were prospectively recruited to a case series based at Bristol Homeopathic Hospital. Patients, who lived with one of three index conditions, were interviewed before and after a five visit "package of care". All consultations were recorded and transcribed verbatim. Additional data, including generic and condition-specific questionnaires, artwork and "significant other" reports were collected. Textual data was subject to thematic analysis and triangulated with other sources.

Results

We judged that around one third of patients had experienced a major improvement in their health over the study period, a third had some improvement and a third had no improvement. Putative active ingredients included the patients' "openness to the mind-body connection", consultational empathy, in-depth enquiry into bodily complaints, disclosure, the remedy matching process and, potentially, the homeopathic remedies themselves.

Conclusion

This study has has identified, using primary consultation and other data, a range of factors that might account for the effectiveness of homeopathic care. Some of these, such as empathy, are non-specific. Others, such as the remedy matching process, are specific to homeopathy. These findings counsel against the use of placebo-controlled RCT designs in which both arms would potentially be receiving specific active ingredients. Future research in homeopathy should focus on pragmatic trials and seek to confirm or refute the therapeutic role of constructs such as patient "openness", disclosure and homeopathicity.

Practitioner empathy, patient enablement and health outcomes: a prospective study of acupuncture patients

OBJECTIVE

To measure acupuncture patients' perceptions of practitioner empathy at the initial consultation and its relationship with patient enablement, and prospectively reported changes in symptoms.

METHODS

Fifteen acupuncturists asked consecutive new patients to complete a questionnaire within 2 days of the first consultation. The questionnaire included the Consultation and Relational Empathy (CARE) measure (a consultation process measure), the Patient Enablement Instrument (PEI, a consultation outcome measure) and the Measure Yourself Medical Outcome Profile (MYMOP), a patient-centred symptom, well-being and activity outcome measure. A postal follow-up questionnaire was completed at 8 weeks, which repeated these measures.

RESULTS

Fifty-two patients (58% of all new patients) completed the initial questionnaire. Of these, 41 (79%) completed the follow-up questionnaire. From a multiple regression analysis, which controlled for known confounders, empathy was found to be associated with enablement at the initial consultation (Beta coefficient=0.16, 95% CI: 0.02-0.31, p=0.03) and empathy-predicted changes in health outcome (MYMOP) at 8 weeks (Beta=0.07, 95% CI: 0.004-0.13, p=0.04).

CONCLUSION

Patients' perception of practitioner empathy was associated with patient enablement at initial consultation and predicted changes in health outcome at 8 weeks.

PRACTICE IMPLICATIONS

The empathy of practitioners, as perceived by patients, has a direct impact on patient enablement and health outcome.