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

Reflections on empathy in medical education: What can we learn from social neurosciences?

The role of empathy in human social interaction has been examined in several research fields, including medical education (ME) and social neuroscience (SN). SN yields insights into empathy based on neurobiological processes, and such information may also be relevant to ME. In this reflection article, the authors first critically review current definitions and concepts of empathy in ME and link them to recent SN findings. In the light of recent evidence from SN, research in ME regarding the positive and negative effects of empathy for physicians and patients is discussed, as well as the question whether (future) physicians differ from the general population with regard to empathic skills. Commonly used SN paradigms and ME approaches to assess empathy are contrasted, a joint approach is advocated, and implications for further interdisciplinary studies are outlined. Finally, the authors delineate the contribution of SN to the question of whether empathy is teachable, and argue that SN findings represent a potential for new ME training approaches. In conclusion, the authors discuss how the incorporation of perspectives on empathy from different research areas would benefit ME, and suggest the translation and integration of such findings into ME research approaches.

Assessing empathy development in medical education: a systematic review

CONTEXT

Empathy in doctor-patient relationships is a familiar topic for medical scholars and a crucial goal for medical educators. Nonetheless, there are persistent disagreements in the research literature concerning how best to evaluate empathy among physicians, and whether empathy declines or increases across medical education. Some researchers have argued that the instruments used to study 'empathy' may not measure anything meaningful to clinical practice or patient satisfaction.

METHODS

We performed a systematic review to learn how empathy is conceptualised in medical education research. We examined how researchers define the central construct of empathy and what they choose to measure, and investigated how well definitions and operationalisations match.

RESULTS

Among the 109 studies that met our search criteria, 20% failed to define the central construct of empathy at all and only 13% used an operationalisation that was well matched to the definition provided. The majority of studies were characterised by internal inconsistencies and vagueness in both the conceptualisation and operationalisation of empathy, constraining the validity and usefulness of the research. The methods most commonly used to measure empathy relied heavily on self-report and cognition divorced from action, and may therefore have limited power to predict the presence or absence of empathy in clinical settings. Finally, the large majority of studies treated empathy itself as a 'black box', using global construct measurements that are unable to shed light on the underlying processes that produce an empathic response.

CONCLUSIONS

We suggest that future research should follow the lead of basic scientific research that conceptualises empathy as relational - an engagement between a subject and an object - rather than as a personal quality that may be modified wholesale through appropriate training.

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.

Cancer patients' emotional distress, coping styles and perception of doctor-patient interaction in European cancer settings

OBJECTIVE

As a part of a European study, we cross-culturally examined the rate of emotional distress and maladaptive coping and their association with cancer patients' satisfaction with their interactions with the physician responsible for their care.

METHODS

Cancer patients (n = 302) from one Middle European (Austria) and two Southern European (Italy, Spain) countries completed the NCCN Distress Thermometer (DT), the Mini-Mental Adjustment to Cancer (Mini-MAC) Anxious Preoccupation (AP) and Hopelessness (H) sub-scales, and the Physician Patient Satisfaction with Doctors Questionnaire (PSQ).

RESULTS

The prevalence of emotional distress (DT caseness) was 60% (26.1% mild, 18.8% moderate, and 14.9% severe distress). Maladaptive coping (Mini-MAC cases) was found in 22.8% (hopeless cases), and 22.5% (anxious preoccupation cases). PSQ-MD was significantly correlated with Mini-MAC/H and Mini-Mac/AP, while PSQ-PS was negatively correlated with Mini-MAC/H. DT cases and those with higher levels of hopelessness reported higher scores on PSQ-MD and lower on PSQ-PS than non-cases. Some differences were found between countries both as far as patients' coping and perception of the interaction with doctors. In hierarchical multiple regression analysis, after adjusting for socio-demographic and medical variables, Mini-MAC/H significantly predicted the scores on PSQ-MD (positive direction) and PSQ-PS (negative direction).

SIGNIFICANCE OF RESULTS

The study confirms that about one out of three cancer patients have moderate to high level of emotional distress and about one out of four, clinically significant maladaptive coping. Also, patients showing hopelessness and distress tended to perceive their doctors as both disengaged and less supportive. These results highlights the need for physicians to monitor their patient's level of distress and coping mechanisms and to adjust their own relational and communication style according to patients' psychological condition. Also, cross-cultural issues should be taken into account when exploring psychosocial variables and cancer patients' perception of and satisfaction with the interaction with their doctors.

How does a physician's accurate understanding of a cancer patient's unmet needs contribute to patient perception of physician empathy?

OBJECTIVE

Unmet supportive care needs of patients decrease patient perception of physician empathy (PE). We explored whether the accurate physician understanding of a given patient's unmet needs (AU), could buffer the adverse effect of these unmet needs on PE.

METHODS

In a cross-sectional design, 28 physicians and 201 metastatic cancer patients independently assessed the unmet supportive care needs of patients. AU was calculated as the sum of items for which physicians correctly rated the level of patient needs. PE and covariates were assessed using self-reported questionnaires. Multilevel analyses were carried out.

RESULTS

AU did not directly affect PE but acted as a moderator. When patients were highly expressive and when physicians perceived poor rapport with the patient, a high AU moderated the adverse effect of patient unmet needs on PE.

CONCLUSION

Physician AU has the power to protect the doctor-patient relationship in spite of high patient unmet needs, but only in certain conditions.

PRACTICE IMPLICATIONS

Physicians should be encouraged toward AU but warned that high rapport and patient low emotional expression may impede an accurate reading of patients. In this latter case, they should request a formal assessment of their patients' needs.

Empathy: what does it mean for GPs? A qualitative study

BACKGROUND

Research has highlighted empathy as an important and effective factor in patient-physician communication. GPs have extensive practical experience with empathy. However, little is known about the personal views of GPs regarding the meaning and application of empathy in daily practice.

OBJECTIVES

To explore GP's experiences and the application of empathy in daily practice and to investigate the practical use of empathy. Facts such as preconditions, barriers and facilitating possibilities are described.

METHODS

Qualitative interview study; 30 in-depth interviews were performed between June 2012 and January 2013 with a heterogeneous sample of Dutch GPs. Interviews were recorded and transcribed verbatim; content analysis was performed with the help of ATLAS-ti.

RESULTS

Empathy was seen as an important quality-increasing element during the patient-GP consultation. The application of non-verbal and verbal techniques was described. Attention to cues and references to previous consults were reported separately. Required preconditions were: being physically and mentally fit, feeling no time pressure and having an efficient practice organization. Not feeling connected to the patient and strict medical guidelines and protocols were identified as obstacles. A key consideration was the positive contribution of empathy to job satisfaction.

CONCLUSIONS

The opinions of GPs in this research can be considered as supplementing and strengthening the findings of previous researches. The GPs in this study discussed, in particular, ideas important to the facilitation of empathy. These included: longer consultations, smaller practices, efficient telephonic triage by practice assistants, using intervision to help reflect on their work and drawing financiers' attention to the effectiveness of empathy.

[Quality of life and visceral surgery]

Quality of life (QOL) is becoming more and more relevant in clinical research. An increasing number of publications each year confirmed this. The aim of this review is to summarize current data of QOL after surgical procedures. The results are represented by two examples each of malignant and benign diseases. The evaluation of QOL for patients with cancer is only possible with respect to the prognosis. Prospective randomized trials comparing laparoscopic and open surgery for early gastric cancer are only available from Asia. Data from the USA show that the QOL after gastrectomy was worse regardless of the surgical procedure. During the next 6 months the QOL improved but about one third of the patients had severe impairment during longer follow-up periods. Patients with R1 resection of pancreatic cancer showed only a slightly better prognosis but significantly better QOL compared to patients without resection. The results for the various procedures of cholecystectomy or hernia repair are not always consistent.

Seven Guiding Commitments: Making the U.S. Healthcare System More Compassionate

Despite the current focus on patient centeredness, healthcare professionals face numerous challenges that impede their ability to provide compassionate care that ameliorates concerns, distress, or suffering. These include fragmentation and discontinuity of care, technologies that both help and hinder communication and relationship-building, burgeoning operational and administrative requirements, inadequate communication skills training, alarming rates of burnout, and increased cost and market pressures. A compassionate healthcare system begins with compassionate people, but the organizations in which they train and work must reliably enable them to express and act on their compassion rather than impede it. We present a set of guiding commitments and recommendations to foster a more compassionate healthcare system. We urge healthcare organizations to adopt these commitments and take action to embed compassionate care in all aspects of training, research, patient care and organizational life.

The physician's role and empathy - a qualitative study of third year medical students

BACKGROUND

Empathy is important in ensuring the quality of the patient-physician relationship. Several studies have concluded that empathy declines during medical training, especially during the third year. However, there is little empirical research on what may influence a medical student's empathy. In addition, studies of empathy in medicine have generally been dominated by quantitative approaches, primarily self-assessment questionnaires. This is a paradox given the complexity and importance of empathy. In this paper we explore medical students' opinions of what may foster or inhibit empathy during medical school, with a particular emphasis on how empathy is influenced by the initiation into the physician's role.

METHODS

We performed semi-structured qualitative interviews with 11 third year medical students. Content analysis was used to analyse the transcribed interviews.

RESULTS

Five aspects of the the physician's role and the students' role acquisition emerged when the students were asked to describe what may influence their empathy: 1) Becoming and being a professional, 2) Rules concerning emotions and care, 3) Emotional control, 4) The primary importance of biomedical knowledge, and 5) Cynicism as a coping strategy.

CONCLUSION

This study suggest that the described inhibitors of empathy may originate in the hidden curriculum and reinforce each other, creating a greater distance between the physician and the patient, and possibly resulting in decreased empathy. Mastering biomedical knowledge is an important part of the students' ideals of the physician's role, and sometimes objective and distanced ideals may suppress empathy and the students' own emotions.

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.

Surgical inpatient satisfaction: what are the real drivers?

BACKGROUND

Inpatient satisfaction is a key element of hospital pay-for-performance programs. Communication and pain management are known to influence results, but additional factors may affect satisfaction scores. We tested the hypothesis that patient factors and outcome parameters not considered previously are clinically important drivers of inpatient satisfaction.

METHODS

Medical records were reviewed for 1,340 surgical patients who returned nationally standardized inpatient satisfaction questionnaires. These patients were managed by 41 surgeons in seven specialties at two academic medical centers. Thirty-two parameters based on the patient, surgeon, outcomes, and survey were measured. Univariate and multivariable analyses were performed.

RESULTS

Inpatients rated their overall experience favorably 75.7% of the time. Less-satisfied patients were more likely to be female, younger, less ill, taking outpatient narcotics, and admitted via the emergency department (all P < .02). Less-satisfied patients also were more likely to have unresected cancer (P < .001) or a postoperative complication (P < .001). The most relevant independent predictors of dissatisfaction in multivariable analyses were younger age, admission via the emergency department, preoperative narcotic use, lesser severity of illness, unresected cancer, and postoperative morbidity (all P < .01).

CONCLUSION

Several patient factors, expectations of patients with cancer, and postoperative complications are important and clinically relevant drivers of surgical inpatient satisfaction. Programs to manage expectations of cancer patient expectations and decrease postoperative morbidity should improve surgical inpatient satisfaction. Further efforts to risk-adjust patient satisfaction scores should be undertaken.

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.

Validity and reliability of the Japanese version of the CARE measure in a general medicine outpatient setting

BACKGROUND

Empathy is an important attribute in medicine, influencing both the process and outcome of consultations. However, there are no validated tools available in Japan to gather patient feedback on physicians' empathy. The Consultation and Relational Empathy (CARE) Measure developed in the UK is widely used internationally.

OBJECTIVES

To investigate the psychometric properties of a Japanese version of the CARE Measure.

METHOD

Following two cycles of translation and back translation, the Japanese CARE Measure was completed by 317 patients in a primary medical care clinic in Japan. Tests of internal reliability and validity included Cronbach's alpha, item-total correlations and factor analysis. Predicted associations between CARE Measure score and other variables were assessed by Spearman's rho.

RESULTS

Low numbers of missing values (8.2-9.8%) and 'not applicable' responses (0-1.3%) suggested high acceptability and face validity of the Japanese CARE Measure. Internal reliability was high (Cronbach's alpha 0.984) and was reduced by the removal of any of 10 items. High corrected item-total correlations (0.897-0.946) suggested homogeneity. Factor analysis showed a single solution with high item loadings (0.917-0.957). Construct validity was supported by a significant relationship (Spearman's rho 0.74, P < 0.001) with overall satisfaction with the consultation.

CONCLUSION

The Japanese CARE Measure appears to be valid and reliable in a primary medical care setting. Further work is required to determine its ability to discriminate between doctors.

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.

Perceptions, expectations, and attitudes about communication with physicians among Chinese American and non-Hispanic white women with early stage breast cancer

PURPOSE

Asian Americans have consistently reported poorer communication with physicians compared with non-Hispanic Whites (NHW). This qualitative study sought to elucidate the similarities and differences in communication with physicians between Chinese and NHW breast cancer survivors.

METHODS

Forty-four Chinese and 28 NHW women with early stage breast cancer (stage 0-IIa) from the Greater Bay Area Cancer Registry participated in focus group discussions or individual interviews. We oversampled Chinese women because little is known about their cancer care experiences. In both interview formats, questions explored patients' experiences and feelings when communicating with physicians about their diagnosis, treatment, and follow-up care.

RESULTS

Physician empathy at the time of diagnosis was important to both ethnic groups; however, during treatment and follow-up care, physicians' ability to treat cancer and alleviate physical symptoms was a higher priority. NHW and US-born Chinese survivors were more likely to assert their needs, whereas Chinese immigrants accepted physician advice even when it did not alleviate physical problems (e.g., pain). Patients viewed all physicians as the primary source for information about cancer care. Many Chinese immigrants sought additional information from primary care physicians and stressed optimal communication over language concordance.

CONCLUSIONS

Physician empathy and precise information were important for cancer patients. Cultural differences such as the Western emphasis on individual autonomy vs. Chinese emphasis on respect and hierarchy can be the basis for the varied approaches to physician communication we observed. Interventions based on cultural understanding can foster more effective communication between immigrant patients and physicians ultimately improving patient outcomes.

Communicating good care: a qualitative study of what people with urological cancer value in interactions with health care providers

PURPOSE

Communication with health care providers is important to help meet cancer patients' information and support needs. It can significantly affect the extent to which patients feel cared for, respected and involved, and it can influence a range of cancer care processes and outcomes. This paper presents findings from a study which explored urological cancer patients' experiences of care, focussing on insights into what they appeared to value in their interactions with health care providers and why.

METHOD

In-depth interviews were undertaken with 20 men and 6 women with different types of urological cancer at a range of times since diagnosis. Interviews were audio-recorded, transcribed and thematically analysed using an established interpretive approach.

RESULTS

Patients valued being treated as someone who mattered and was worthy of care; being recognised and responded to as an individual; and experiencing support for autonomy/agency. Reasons for their valuations related to the implications of communicative interactions for the ways patients thought health professionals related to them 'as persons'. Our findings highlight the value of relational aspects of communication for: indicating to patients what clinicians think of their worth; facilitating individualised care; and enabling patients to contribute to their own care.

CONCLUSIONS

Efforts to improve health care provider-patient communication should attend not only to the transfer of information about the condition and its management but to the range of features of interactions that can signal to people how health care providers relate to them as persons.

Patterns in clinicians' responses to patient emotion in cancer care

OBJECTIVE

To investigate how patient, clinician and relationship characteristics may predict how oncologists and nurses respond to patients' emotional expressions.

METHODS

Observational study of audiotapes of 196 consultations in cancer care. The consultations were coded according to Verona Coding Definitions of Emotional Sequences (VR-CoDES). Associations were tested in multi-level analyzes.

RESULTS

There were 471 cues and 109 concerns with a mean number of 3.0 (SD=3.2) cues and concerns per consultation. Nurses in admittance interviews were five times more likely to provide space for further disclosure of cues and concerns (according to VR-CoDES definitions) than oncologists in out-patient follow-up consultations. Oncologists gave more room for disclosure to the first cue or concern in the consultation, to more explicit and doctor initiated cues/concerns and when the doctor and/or patient was female. Nurses gave room for further disclosure to explicit and nurse initiated cues/concerns, but the effects were smaller than for oncologists.

CONCLUSION

Responses of clinicians which provide room for further disclosure do not occur at random and are systematically dependent on the source, explicitness and timing of the cue or concern.

PRACTICE IMPLICATIONS

Knowledge on which factors influence responses to cues and concerns may be useful in communication skills training.

The psychological experience of living with head and neck cancer: a systematic review and meta-synthesis

OBJECTIVE

To summarise patients' experiences of head and neck cancer (HNC) by examining the findings of existing qualitative studies

METHODS

We undertook a systematic review and meta-synthesis of qualitative studies in 29 published articles using Noblit and Hare's 'meta-ethnography' approach to synthesise findings. The inclusion criteria were primary qualitative studies, focusing on HNC patients' experience and an English abstract. Seven databases were systematically searched.

RESULTS

The articles focused on the experience of having HNC, the experience of treatments and the role of information. Our synthesis identified six core concepts-uncertainty and waiting, disruption to daily life, the diminished self, making sense of the experience, sharing the burden and finding a path. People experienced significant disruption to normal daily activities, because of the physical and emotional effects of HNC and its treatment. Day-to-day challenges were compounded by social and existential changes and a palpable loss of the individual's sense of self and future. In order to find a way through the considerable uncertainty and daily challenge of living with and beyond HNC, patients made continual efforts to make sense of their experience. Supportive relationships with their social network, HNC peers and healthcare professionals were particularly important, but support following treatment completion was sometimes limited. Perceptions of the future were affected by whether they saw life as diminished, merely changed or even enhanced by the experience of cancer.

CONCLUSIONS

This review supports further specific research into these emerging themes and provides a context for future work, informing interventions to improve patients' experiences.

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.

Changes of empathy in medical college and medical school students: 1-year follow up study

BACKGROUND

This study aims to determine the correlation between medical education systems, medical college (MC) and medical school (MS), and empathy by investigating the changes in empathy among students with each additional year of medical education.

METHODS

The subjects were MC and MS students who had participated in the same study the previous year. All participants completed the same self-report instruments: a questionnaire on sociodemographic characteristics, and the Korean edition of the Student Version of the Jefferson Scale of Empathy (JSE-S-K), Among 334 students, the final analysis was conducted on the data provided by 113 MC and 120 MS students, excluding 101 with incomplete data.

RESULTS

The age and sex did not affect the changes in empathy. Though the JSE-S-K score of MS was significantly higher than that of MC in initial investigation, this study found no difference of empathy between MC and MS.

CONCLUSION

Empathy increased significantly after one year of medical education. The difference between two education systems, MC and MS, did not affect the changes in empathy.

Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation

BACKGROUND

Most patients with depression are managed in general practice. In deprived areas, depression is more common and poorer outcomes have been reported.

AIM

To compare general practice consultations and early outcomes for patients with depression living in areas of high or low socioeconomic deprivation.

DESIGN AND SETTING

Secondary data analysis of a prospective observational study involving 25 GPs and 356 consultations in deprived areas, and 20 GPs and 303 consultations in more affluent areas, with follow-up at 1 month.

METHOD

Validated measures were used to (a) objectively assess the patient centredness of consultations, and (b) record patient perceptions of GP empathy.

RESULTS

PHQ-9 scores >10 (suggestive of caseness for moderate to severe depression) were significantly more common in deprived than in affluent areas (30.1% versus 18.5%, P<0.001). Patients with depression in deprived areas had more multimorbidity (65.4% versus 48.2%, P<0.05). Perceived GP empathy and observer-rated patient-centred communication were significantly lower in consultations in deprived areas. Outcomes at 1 month were significantly worse (persistent caseness 71.4% deprived, 43.2% affluent, P = 0.01). After multilevel multiregression modelling, observer-rated patient centredness in the consultation was predictive of improvement in PHQ-9 score in both affluent and deprived areas.

CONCLUSION

In deprived areas, patients with depression are more common and early outcomes are poorer compared with affluent areas. Patient-centred consulting appears to improve early outcome but may be difficult to achieve in deprived areas because of the inverse care law and the burden of multimorbidity.

Students meeting with caregivers of cancer patient: results of an experience-based learning project

The communication between medical students and cancer caregivers, and the problems they have experienced as well as the outcomes for their professional development before starting clinical practice was assessed in the context of a student research project. Data were collected by questionnaires or by 20 to 40-min long interviews with cancer caregivers. Their communications with physicians, hearing the bad news, and health service satisfaction were questioned. Therefore, the caregivers trusted the professional approach of their physician. However, they expected more empathic communication in the process of diagnosis and therapy. Development of empathy and trust-based communication between patients and physicians and enhancement of the quality of devoted time to cancer patients and caregivers may have an effect on the course of disease. Interviewer students mentioned that they developed communication skills about difficult clinical tasks and in delivering bad news face to face to cancer caregivers before starting their clinical education.

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.

Conveying empathy to hospice family caregivers: team responses to caregiver empathic communication

OBJECTIVE

The goal of this study was to explore empathic communication opportunities presented by family caregivers and responses from interdisciplinary hospice team members.

METHODS

Empathic opportunities and hospice team responses were analyzed from bi-weekly web-based videoconferences between family caregivers and hospice teams. The authors coded the data using the Empathic Communication Coding System (ECCS) and identified themes within and among the coded data.

RESULTS

Data analysis identified 270 empathic opportunity-team response sequences. Caregivers expressed statements of emotion and decline most frequently. Two-thirds of the hospice team responses were implicit acknowledgements of caregiver statements and only one-third of the team responses were explicit recognitions of caregiver empathic opportunities.

CONCLUSION

Although hospice team members frequently express emotional concerns with family caregivers during one-on-one visits, there is a need for more empathic communication during team meetings that involve caregivers.

PRACTICE IMPLICATIONS

Hospice clinicians should devote more time to discussing emotional issues with patients and their families to enhance patient-centered hospice care. Further consideration should be given to training clinicians to empathize with patients and family caregivers.

"I am worried, Doctor!" Emotions in the doctor-patient relationship

OBJECTIVE

To review research on emotional communication in medical interviews regarding predictors, physiological correlates and effects of clinicians' responses to patients' cues and concerns and individual differences among patients.

METHODS

A selective review of research literature on emotional communication in medical interviews was conducted.

RESULTS

Four questions regarding emotional communication were explored: What factors predict how clinicians respond to emotional cues and concerns? What happens in the brain and the body of both patients and clinicians during emotional talk? Are there individual differences in patients' responses to emotional talk in medical interviews? Do clinicians' responses to emotion affect health outcome?

CONCLUSION

Building on evidence reviewed, research on predictors of clinician responses, physiological correlates of behavior, individual differences and effects on outcome should be further pursued.

PRACTICE IMPLICATIONS

In communication skills training programs, better understanding of the phenomena described could have implications for training clinicians to handle emotions in clinical interviews.

Providing support to patients in emotional encounters: a new perspective on missed empathic opportunities

OBJECTIVE

Studies have repeatedly found that providers miss 70-90% of opportunities to express empathy. Our study sought to characterize provider responses to patients' emotions, with the overall goal of better understanding reasons for lack of empathic response.

METHODS

We analyzed 47 visits between patients and their providers. We defined empathic opportunities as instances where patients expressed a strong negative emotion. We then developed thematic categories to describe provider response.

RESULTS

We found a total of 29 empathic opportunities within 21 visits. Provider responses were categorized as ignore, dismiss, elicit information, problem-solve, or empathize. An empathic statement occurred at some point in the response sequence in 13/29 opportunities (45%). When problem-solving was the initial response, empathic statements rarely occurred in subsequent dialogue. Among the 16 instances with no empathic statements, providers engaged in problem-solving in 8 (50%).

CONCLUSION

Similar to other studies, we found providers missed most opportunities to respond empathically to patient emotion. Yet contrary to common understanding, providers often addressed the problem underlying the emotion, especially when the problem involved logistical or biomedical issues, as opposed to grief.

PRACTICE IMPLICATIONS

With enhanced awareness, providers may better recognize situations where they can offer empathy in addition to problem-solving.

Patients feeling severely affected by multiple sclerosis: how do patients want to communicate about end-of-life issues?

OBJECTIVE

Investigate multiple sclerosis patients' desire to communicate with their physicians about their disease progression and end-of-life issues.

METHODS

Persons meeting the inclusion criteria of feeling severely affected by MS were invited via the German MS society to complete a needs questionnaire. Replies to questions on physician empathy and wishes about communication regarding disease progression and death and dying were quantitatively analyzed. Endpoints (point 1+2/4+5) of 5-point-likert scales are summarized under results.

RESULTS

573 of 867 questionnaires meeting our criteria were analyzed. In response to a general question 64% (n = 358) indicated a wish for disease progression and death and dying to be addressed by their doctor. A majority (76%, n = 427) considered it important that progression of their disease be discussed, while 44% (n = 246) regard addressing death and dying as unimportant. No objective disease criteria could be identified to explain the wish for communicating end-of-life issues. Doctors who were retrospectively viewed as avoiding raising critical aspects of the illness were perceived as less empathetic (p < 0.001).

CONCLUSION

People with MS have a desire to talk about progression of their disease with their doctors.

PRACTICE IMPLICATIONS

Physicians should be empathetic in raising critical aspects of the patients' illness individually.

A systematic evaluation of content, structure, and efficacy of interventions to improve patients' self-management of cancer pain

CONTEXT

Cancer pain continues to be extensively undertreated, despite established guidelines. Although the efficacy of interventions that support patients' self-management of cancer pain has been demonstrated in several studies, the most effective components of these interventions remain unknown.

OBJECTIVES

The purpose of this review of experimental and quasi-experimental studies was to systematically describe the structure and content components, as well as the efficacy of various components, of interventions designed to improve patients' self-management of cancer pain.

METHODS

A systematic review of the literature was done that supplemented the 2009 meta-analysis of Bennett et al. Intervention components were categorized using content analysis. The intervention components were compared based on their calculated largest effect sizes (ESs) within each study (i.e., Hedges G(u) for between-group differences in pain intensity scores).

RESULTS

Based on 34 publications (i.e., 24 interventions), seven structure and 16 content components were identified. In 11 studies with statistically significant ESs, the largest ES within each study ranged from -1.87 to -0.44, which represented clinically meaningful effects. No single component was found to have a discernable influence on ES.

CONCLUSION

This analysis provides researchers and clinicians with a detailed overview of the various structural and content components, as well as various combinations that were tested in intervention studies to improve cancer pain management. However, because of a variety of limitations, the most efficacious intervention components or combination of components remain to be determined in future studies.

The patient-physician relationship in patients with breast cancer: influence on changes in quality of life after rehabilitation

PURPOSE

The objective of this study was to examine whether aspects of the patient-physician relationship for breast cancer patients have an influence on the change in health-related quality of life (HRQOL) after inpatient rehabilitation.

METHODS

N = 329 breast cancer patients undergoing inpatient rehabilitation in Germany were surveyed using questionnaires at the beginning of rehabilitation, end of rehabilitation, and 6 months after rehabilitation. Multiple imputations and multilevel models of change were used in the data analyses.

RESULTS

Even after comprehensive adjustment for sociodemographic, medical, psychological variables, and center effects, aspects of the physician-patient relationship were statistically and clinically relevant predictors of HRQOL after rehabilitation. Satisfaction with physician's care appears to have a rather short-term effect, but the effect of promoting patient participation can still be partially determined 6 months after rehabilitation. Other important predictors of HRQOL improvement are optimism, higher level of education, higher income, living with a partner, and the ability to work.

CONCLUSIONS

By taking into consideration the patient's communication and participation needs, physicians can contribute to an improved HRQOL after rehabilitation. The high predictive power of socioeconomic factors shows that rehabilitation care can be more effective if it accounts for the specific situation of socially disadvantaged individuals.

Physical distress and cancer care experiences among Chinese-American and non-Hispanic White breast cancer survivors

OBJECTIVE

The number of Chinese-American breast cancer survivors (BCS) is increasing as a result of increasing incidence rates. There has been little research on Chinese BCS' follow-up cancer care. This qualitative study aims to understand how Chinese-American BCS experience and cope with physical distress relative to non-Hispanic White (NHW) survivors.

METHODS

Seventy-one BCS (37 Chinese immigrant, 7 US-born Chinese, 27 NHW) were recruited from the Greater Bay Area Cancer Registry to participate in focus group discussions or one-on-one interviews about their survivorship experiences. All BCS were diagnosed with breast cancer at stage 0-IIA between 2006 and 2009, and had survived for 1-4 years without recurrence. Interviews were conducted in Cantonese, Mandarin, or English. Data analyses followed established qualitative methods of content analysis.

RESULTS

BCS experienced pain and side effects from radiation, surgery, and hormonal therapy. Physical distress subsequently caused emotional concerns about recurrence or metastasis. Most BCS consulted physicians about their physical distress. Chinese immigrant BCS were less likely to have their issues resolved compared to NHW and US-born Chinese who were more likely to question physicians, ask for referrals, and make repeat attempts if their problems were not resolved. Some Chinese immigrant BCS turned to Traditional Chinese Medicine for relief or accepted the idea that physical distress was part of survivorship.

CONCLUSION

Chinese immigrant BCS may be at risk for greater distress compared with US-born Chinese and NHW BCS because of cultural norms that make them less inclined to express their needs to physicians or challenge physicians when their needs are not met. Furthermore, they may express symptoms in culturally unique ways (e.g., hot-cold imbalances). Further research is needed to determine how to best improve survivorship care experiences in this understudied population, with the goal of decreasing BCS' physical distress and improving quality of life.

Physician empathy: definition, outcome-relevance and its measurement in patient care and medical education

OBJECTIVE

The present study gives a brief introduction into 1. the definition of physician empathy (PE) and 2. its influence on patients' health outcomes. Furthermore 3. we present assessment instruments to measure PE from the perspective of the patient and medical student. The latter topic will be explored in detail as we conducted a pilot study on the German versions of two self-assessment instruments of empathy, which are mostly used in medical education research, namely the "Jefferson Scale of Physician Empathy, Student Version" (JSPE-S) and the "Interpersonal Reactivity Index" (IRI).

METHODS

We first present an overview of the current empirical and theoretical literature on the definition and outcome-relevance of PE. Additionally, we conducted basic psychometric analyses of the German versions of the JSPE-S and the IRI. Data for this analyses is based on a cross-sectional pilot-survey in N=44 medical students and N=63 students of other disciplines from the University of Cologne.

RESULTS

PE includes the understanding of the patient as well as verbal and non-verbal communication, which should result in a helpful therapeutic action of the physician. Patients' health outcomes in different healthcare settings can be improved considerably from a high quality empathic encounter with their clinician. Basic psychometric results of the German JSPE-S and IRI measures show first promising results.

CONCLUSION

PE as an essential and outcome-relevant element in the patient-physician relationship requires more consideration in the education of medical students and, thus, in medical education research. The German versions of the JSPE-S and IRI measures seem to be promising means to evaluate these education aims and to conduct medical education research on empathy.

Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland

Background

Patient 'enablement' is a term closely aligned with 'empowerment' and its measurement in a general practice consultation has been operationalised in the widely used patient enablement instrument (PEI), a patient-rated measure of consultation outcome. However, there is limited knowledge regarding the factors that influence enablement, particularly the effect of socio-economic deprivation. The aim of the study is to assess the factors influencing patient enablement in GP consultations in areas of high and low deprivation.

Methods

A questionnaire study was carried out on 3,044 patients attending 26 GPs (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). Patient expectation (confidence that the doctor would be able to help) was recorded prior to the consultation. PEI, GP empathy (measured by the CARE Measure), and a range of other measures and variables were recorded after the consultation. Data analysis employed multi-level modelling and multivariate analyses with the PEI as the dependant variable.

Results

Although numerous variables showed a univariate association with patient enablement, only four factors were independently predictive after multilevel multivariate analysis; patients with multimorbidity of 3 or more long-term conditions (reflecting poor chronic general health), and those consulting about a long-standing problem had reduced enablement scores in both affluent and deprived areas. In deprived areas, emotional distress (GHQ-caseness) had an additional negative effect on enablement. Perceived GP empathy had a positive effect on enablement in both affluent and deprived areas. Maximal patient enablement was never found with low empathy.

Conclusions

Although other factors influence patient enablement, the patients' perceptions of the doctors' empathy is of key importance in patient enablement in general practice consultations in both high and low deprivation settings.

A systematic review of the associations between empathy measures and patient outcomes in cancer care

OBJECTIVE

Despite a call for empathy in medical settings, little is known about the effects of the empathy of health care professionals on patient outcomes. This review investigates the links between physicians' or nurses' empathy and patient outcomes in oncology.

METHOD

With the use of multiple databases, a systematic search was performed using a combination of terms and subject headings of empathy or perspective taking or clinician-patient communication, oncology or end-of-life setting and physicians or nurses. Among the 394 hits returned, 39 studies met the inclusion criteria of a quantitative measure of empathy or empathy-related constructs linked to patient outcomes.

RESULTS

Empathy was mainly evaluated using patient self-reports and verbal interaction coding. Investigated outcomes were mainly proximal patient satisfaction and psychological adjustment. Clinicians' empathy was related to higher patient satisfaction and lower distress in retrospective studies and when the measure was patient-reported. Coding systems yielded divergent conclusions. Empathy was not related to patient empowerment (e.g. medical knowledge, coping).

CONCLUSION

Overall, clinicians' empathy has beneficial effects according to patient perceptions. However, in order to disentangle components of the benefits of empathy and provide professionals with concrete advice, future research should apply different empathy assessment approaches simultaneously, including a perspective-taking task on patients' expectations and needs at precise moments. Indeed, clinicians' understanding of patients' perspectives is the core component of medical empathy, but it is often assessed only from the patient's point of view. Clinicians' evaluations of patients' perspectives should be studied and compared with patients' reports so that problematic gaps between the two perspectives can be addressed.

The effect of surgeon empathy and emotional intelligence on patient satisfaction

We investigated the associations of surgeons' emotional intelligence and surgeons' empathy with patient-surgeon relationships, patient perceptions of their health, and patient satisfaction before and after surgical procedures. We used multi-source approaches to survey 50 surgeons and their 549 outpatients during initial and follow-up visits. Surgeons' emotional intelligence had a positive effect (r = .45; p < .001) on patient-rated patient-surgeon relationships. Patient-surgeon relationships had a positive impact on patient satisfaction before surgery (r = .95; p < .001). Surgeon empathy did not have an effect on patient-surgeon relationships or patient satisfaction prior to surgery. But after surgery, surgeon empathy appeared to have a significantly positive and indirect effect on patient satisfaction through the mediating effect of patients' self-reported health status (r = .21; p < .001). Our study showed that long-term patient satisfaction with their surgeons is affected less by emotional intelligence than by empathy. Furthermore, empathy indirectly affects patient satisfaction through its positive effect on health outcomes, which have a direct effect on patients' satisfaction with their surgeons.

The impact of financial incentives on physician empathy: a study from the perspective of patients with private and statutory health insurance

OBJECTIVE

We hypothesized that patients' ratings of physician empathy (PE) would be higher among those with private health insurance (PHI, referring to financial incentive) than among patients with statutory health insurance (SHI).

METHODS

A postal survey was administered to 710 cancer patients. PE was assessed using the Consultation-and-Relational-Empathy measure. T-tests were conducted to analyse whether PHI and SHI-patients differ in their ratings of PE and variables relating to contact time with the physician. Structural-equation-modelling (SEM) verified mediating effects.

RESULTS

PHI-patients rated physician empathy higher. SEM revealed that PHI-status has a strong significant effect on frequency of talking with the physician, which has a strong significant effect (1) on PE and (2) has a moderate effect on patients' perception of medical staff stress, thereby also affecting patients' ratings of PE.

CONCLUSIONS

Our findings suggest that PHI-status is one necessary precondition for physicians spending more time with the patient. Spending more time with the PHI-patient has two major effects: it results in a more positive perception of PE and positively impacts PHI-patients' perception of medical staff stress, which in turn, again influences PE.

PRACTICAL IMPLICATIONS

Health policy should discuss these findings in terms of equality in receiving high-quality care.

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.

The Chinese-version of the CARE measure reliably differentiates between doctors in primary care: a cross-sectional study in Hong Kong

BACKGROUND

The Consultation and Relational Empathy (CARE) Measure is a widely used patient-rated experience measure which has recently been translated into Chinese and has undergone preliminary qualitative and quantitative validation. The objective of this study was to determine the reliability of the Chinese-version of the CARE Measure in reliably differentiating between doctors in a primary care setting in Hong Kong

METHODS

Data were collected from 984 primary care patients attending 20 doctors with differing levels of training in family medicine in 5 public clinics in Hong Kong. The acceptability of the Chinese-CARE measure to patients was assessed. The reliability of the measure in discriminating effectively between doctors was analysed by Generalisability-theory (G-Theory)

RESULTS

The items in the Chinese-CARE measure were regarded as important by patients and there were few 'not applicable' responses. The measure showed high internal reliability (coefficient 0.95) and effectively differentiated between doctors with only 15-20 patient ratings per doctor (inter-rater reliability > 0.8). Doctors' mean CARE measure scores varied widely, ranging from 24.1 to 45.9 (maximum possible score 50) with a mean of 34.6. CARE Measure scores were positively correlated with level of training in family medicine (Spearman's rho 0.493, p < 0.05).

CONCLUSION

These data demonstrate the acceptability, feasibility and reliability of using the Chinese-CARE Measure in primary care in Hong Kong to differentiate between doctors interpersonal competencies. Training in family medicine appears to enhance these key interpersonal skills.

A longitudinal study of changes in provider-patient interaction in treatment of localized prostate cancer

PURPOSE

Whilst much is known as to the met and unmet communication needs of prostate cancer patients, few studies have been conducted on the changes in communication between provider and patient over time. Therefore, the aim of our study is to examine (a) whether there are changes over time in the quality of psychosocial care in long-term treatment of localized prostate cancer and (b) whether those changes are associated with the treatment decision.

METHODS

HAROW is a prospective, observational study designed to collect clinical data and patient reported outcomes (PROs) of different treatment options (hormonal therapy, active surveillance, radiation, operation, watchful waiting) for newly diagnosed patients with localized prostate cancer under real conditions. At 6-month intervals, general clinical data, PROs (e.g. quality of life, quality of physician-patient interaction) and individual costs are documented. We analysed data of N = 1,216 patients at the time of initial diagnosis (T1) and after 6 months (T2).

RESULTS

There is a significant decline in shared decision-making behaviour of physicians for the group of patients undergoing a prostatectomy and for the hormonal therapy group at the time of initial diagnosis and after 6 months. In terms of emotional support by physicians, there is a significant difference between the treatment groups at the time of initial diagnosis with patients undergoing a prostatectomy reporting significantly less support than the hormonal therapy group.

CONCLUSION

Future research from both, the providers' and the patients' perspective, will have to clarify if we can interpret our results as change in the communication behaviour once the treatment decision for prostatectomy or hormonal therapy is made.

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.

Measuring patients' perceptions of patient-centered care: a systematic review of tools for family medicine

PURPOSE

Patient-centered care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify and compare instruments, subscales, or items assessing patients' perceptions of patient-centered care in family medicine.

METHODS

We conducted a systematic literature review using the MEDLINE, Embase, and Cochrane databases covering 1980 through April 2009, with a specific search strategy for each database. The search strategy was supplemented with searching by hand and expert suggestions. We looked for articles meeting all of the following criteria: (1) describing self-administered instruments measuring patient perceptions of patient-centered care; (2) reporting quantitative or psychometric results of development or validation; (3) being relevant to an ambulatory family medicine context. The quality of each article retained was assessed using a modified version of the Standards for Reporting of Diagnostic Accuracy. Instrument' items were mapped to dimensions of a patient-centered care conceptual framework.

RESULTS

Of the 3,045 articles identified, 90 were examined in detail, and 26, covering 13 instruments, met our inclusion criteria. Two instruments (5 articles) were dedicated to patient-centered care: the Patient Perception of Patient-Centeredness and the Consultation Care Measure, and 11 instruments (21 articles) included relevant subscales or items.

CONCLUSIONS

The 2 instruments dedicated to patient-centered care address key dimensions but are visit-based, limiting their applicability for the study of care processes over time, such as chronic illness management. Relevant items from the 11 other instruments provide partial coverage of the concept, but these instruments were not designed to provide a specific assessment of patient-centered care.