Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 2013;63:e76-e84. [PMID: 23336477 DOI: 10.3399/bjgp13x660814]

Perceived Physician Empathy in Pediatric Orthopedics: A Cross-Sectional Study

Empathy is the cornerstone of the patient–physician relationship and is consistently ranked by patients as one of the most important factors in the quality of their care. In this paper we examine the degree to which perceived physician empathy is associated with the characteristics of the caregiver (parent or legal guardian) and physician in pediatric orthopedic surgery. This was a cross-sectional survey study of 200 English-speaking caregivers of pediatric patients at a large children's hospital. The Consultation and Relational Empathy (CARE) Measure was used to measure perceived physician empathy. Only if the caregiver felt carefully listened to by the physician (p-value < 0.001), and if the physician showed respect for what the caregiver had to say (p-value = 0.007) were statistically significant and positively associated with perceived physician empathy. The most significant determinant of perceived physician empathy is whether the caregiver felt listened to during the encounter. Other factors such as caregiver demographics, health literacy, self-rated mental health, wait time, and time spent with the physician do not significantly affect perceived physician empathy.

Clinician views on optimism and empathy in primary care consultations

Background

Practitioner expressions of optimism and empathy may improve treatment engagement, adherence, and patient satisfaction but are not delivered consistently amid the challenges of everyday clinical practice.

Aim

To explore primary care practitioner (PCP) views about optimistic and empathic communication in consultations; and to identify behavioural, attitudinal, and/or contextual issues likely to encourage or deter PCPs from practising such communication.

Design & setting

Qualitative interview study with 20 PCPs (GPs, practice nurses, and primary care physiotherapists).

Method

Semi-structured telephone interviews with 20 PCPs. Data were analysed thematically.

Results

A conceptual mismatch between optimism and patient expectations became apparent; when asked how PCPs communicate about the likely effects of a treatment, answers were focussed around managing patient expectations. When prompted, it became clear PCPs were open to communicating optimistically with patients, but emphasised the need for realism. Concerns arose that patients may not be receptive to optimistic messages, especially when holding negative expectations. PCPs felt that expressing empathy is fundamental to all clinical consultations, noting that it can be challenging. Some PCPs worried that increasing expressions of empathy might increase their risk of clinician burnout and felt guilty about (appropriately) communicating empathy while maintaining some emotional distance.

Conclusion

PCPs agreed expressing realistic optimism during consultations could aid communication and would constitute a novel change to practice. PCPs strive for clinical empathy but can struggle to manage emotional self-protection. Specific training to help PCPs express realistic optimism and empathy, and better utilise efficient non-verbal skills could help these issues.

The perceptions and experiences of medical students in a pediatric buddy program: a qualitative study

BACKGROUND

Partnership programs between medical students and patients provide students with non-clinical experiences that enhance medical learning, especially with respect to humanistic care. We explored the perceptions and experiences of medical students in a pediatric oncology buddy program.

METHODS

Using a basic interpretive qualitative approach, we conducted interviews with 15 medical students at three time points: before meeting his/her buddy (pre-interview), four months into the partnership (4-month interview), and at the end of the partnership (post interview). We then conducted a thematic analysis of the interview data.

RESULTS

All students in the program who met the study criteria (N = 15/16) participated. The medical students highlighted that: (a) providing support to buddies and their families is important; (b) providing care to children with serious illnesses is emotionally difficult; (c) developing deep connections with buddies and their families is rewarding; and (d) gaining empathy and personal fulfillment from buddies and their families is inevitable.

CONCLUSIONS

This study provides an understanding of medical students' perceptions and experiences in a pediatric oncology, non-clinical buddy program. Tailored one-on-one partnerships between medical students and pediatric oncology patients play an important role in medical education and contributes to the teaching of humanistic care.

The development of empathy in the healthcare setting: a qualitative approach

BACKGROUND

Healthcare professionals' empathetic behaviors have been known to lead to higher satisfaction levels and produce better health outcomes for patients. However, empathy could decrease over time especially during training and clinical practice. This study explored factors that contributed to the development of empathy in the healthcare setting. Findings could be used to improve the effectiveness and sustainability of empathy training.

METHOD

A qualitative approach, informed by aspects of grounded theory, was utilized to identify factors that enabled the development of empathy from the perspectives of doctors, nurses, allied healthcare workers and students. Twelve sessions of focus group discussions were conducted with 60 participants from two hospitals, a medical school, and a nursing school. Data was analyzed independently by three investigators who later corroborated to refine the codes, subthemes, and themes. Factors which influence the development of empathy were identified and categorized. This formed the basis of the creation of a tentative theory of empathy development for the healthcare setting.

RESULTS

The authors identified various personal (e.g. inherent characteristics, physiological and mental states, professional identity) and external (e.g. work environment, life experience, situational stressors) factors that affected the development of empathy. These could be further categorized into three groups based on the stability of their impact on the individuals' empathy state, contributed by high, medium, or low stability factors. Findings suggest empathy is more trait-like and stable in nature but is also susceptible to fluctuation depending on the circumstances faced by healthcare professionals. Interventions targeting medium and low stability factors could potentially promote the development of empathy in the clinical setting.

CONCLUSIONS

Understanding factors that impact the development of empathy allows us to develop measures that could be implemented during training or at the workplace leading to improve the quality of care and higher clinical work satisfaction.

Relationship between self-reported cognitive and behavioural empathy among medical students

OBJECTIVE

The aim of this study was to explore the relationship between cognitive and behavioural empathy in medical students.

METHODS

Fourteen 4th year medical students recruited on the basis of their scores on the self-reported Jefferson Scale of Empathy (JSE-S) were divided into two groups: low JSE-S scorers (n = 8) (M = 96.75, SD = 10.3) and high JSE-S scorers (n = 6) (M = 121.3, SD = 2.94). They were discreetly videotaped while taking history with an incognito standardized patient. Students' behavioural empathy was measured using the Verona Coding System (VR-CoDES-P) and rating of non-verbal behaviour.

RESULTS

Patients expressed the same number of concerns per encounter in both groups but gave more cues to high-scorers (p = 0.029). However, students of both groups demonstrated the same amount of verbal empathy (high: 16% vs low: 15% p = 1.00). High JSE-S scorers' non-verbal communication tended to be rated slightly higher than low JSE-S-scorers with a higher use of facial expression (p = 0.008).

CONCLUSION

This study did not reveal any differences of students' verbal empathy to patients' cues and concerns between low and high JSE_S scorers.

PRACTICE IMPLICATIONS

The VR-CoDES_P is a useful tool to assess medical students and physicians empathic behaviour, allowing to disentangle the different components of empathy.

Fostering empathy and self-efficacy in pharmacy students through service learning

BACKGROUND

Pharmacy student proficiency in direct patient interactions is an integral component of the doctor of pharmacy curriculum. Service-learning experiences offer pharmacy students valuable opportunities to develop self-efficacy and empathy while serving communities with unmet needs. The objective of this review is to evaluate the impact of service-learning experiences on the self-efficacy and empathy of pharmacy and other health professions students.

METHODS

A narrative literature review was conducted using PubMed, ERIC, and CINAHL databases. Articles were included if they described the relationship between any health professions student service-learning experience and changes in self-efficacy and empathy. Articles were excluded if they involved simulation experiences, standardized patients, or international experiences.

RESULTS

A total of 11 relevant articles were identified, seven examined changes in student self-efficacy and six assessed student empathy. Articles included students representing seven health professions, with one eligible article in pharmacy. All articles investigating self-efficacy reported a positive impact of service learning on student confidence. Most articles focusing on empathy found that service learning had a positive impact on student empathy, and only one article noted a negative trend. Students with limited prior direct patient care experience had the greatest improvement in clinical confidence and empathy.

IMPLICATIONS

This review adds a new perspective to the literature by evaluating evidence-based service-learning models in pharmacy education. Offering additional structured service-learning opportunities for pharmacy students fosters self-efficacy and empathy while supporting communities with unmet needs. Future studies evaluating innovative service-learning models and methods of continuous assessment within the pharmacy curriculum are warranted.

Improving Health Equity: The Role of the Oncology Advanced Practitioner in Managing Implicit Bias

Implicit bias (IB) is the involuntary activation of thoughts, feelings, attitudes, or stereotypes that exist outside of conscious awareness. Implicit bias develops early in life and research documents the existence of IB across health-care settings. Negative IB impacts patient-provider interactions, produces inferior patient outcomes, and contributes to health-care disparities. Oncology APs are subject to IB and should be aware of its potential impact on professional practice. This manuscript explores the concept of IB and reviews evidence examining the clinical impact of IB in the oncology setting. Strategies for identifying and mitigating IB are explored. Highlights include the use of the Implicit Association Test and emotional intelligence. Advanced practice implications are discussed and range from self-improvement to organizational transformation.

Survey of Medical Student Empathy at a Canadian Medical School: A Cross-Sectional Quantitative Survey

INTRODUCTION

Within a medical context, empathy is defined as "an appropriate understanding and communication of a patient's experience." While it has been established that empathy is an important quality to have as a doctor, studies have shown that empathy in medical students declines during their clinical years. However, there are no studies to date that evaluate medical student empathy in Canada. Therefore, we aimed to evaluate medical student empathy at McGill University Medical School using the Jefferson Scale of Empathy (JSE).

METHODS

We used a cross-sectional study design and invited medical students across all 4 years, in October 2019, to complete the JSE. The JSE is a validated psychometric tool that measures empathy at one point in time. The survey was distributed via email and on social media.

RESULTS

A total of 133 students from all 4 years responded, proportionate across each year; 119 responses were included in analysis. Differences in mean questionnaire were not statistically significant for gender, age or specialty interest. The analysis of variance for differences in year of medical school was significant (P=.0104). Between groups analysis revealed a statistically significant decrease between Med-2 empathy scores (average score 117.6) and Med-3 (107.5), P<.01. Multivariable analysis demonstrated the decrease in empathy remained statistically significant (P<.05).

DISCUSSION

Our statistical analysis determined that medical students' empathy declines between the second and third year of medical school in a Canadian context, consistent with global results. This information can help target changes in the medical curriculum to preserve empathy in students, and prevent this decline, which could then be applied to other medical schools internationally.

Anxiety and depression in patients with breast cancer undergoing radiotherapy: the role of intelligence, life history, and social support-preliminary results from a monocentric analysis

Purpose

It is known that the diagnosis of breast cancer often causes anxiety and depression. Radiotherapy of the breast as an obligatory part of a breast-conserving treatment concept can markedly increase these psychological symptoms in many, but not all patients. In this clinical observational study, we aimed at identifying cognitive, health-related and social factors that may either enhance or reduce the emergence of anxiety and depression.

Methods

Using a longitudinal study design with 25 women (mean age: 52.9 years; SD = 10.6; age range 29–70 years) with a first diagnosis of nonmetastatic breast cancer, measures of anxiety, depression, situational emotional states, intelligence, and aspects of social frameworks were assessed before, during, and after radiotherapy of the breast. At 4 time-points, standard and self-constructed questionnaires were used to assess the course of anxiety and depressive symptoms across the radiotherapy intervention.

Results

We found that anxiety is highest immediately before the start of radiation therapy, while the anxiety level was lowest on the day that therapy was completed. Anxiety and depression were enhanced in women with a lifetime history of chronic diseases at all time points of measurement. Moreover, women with high intelligence and low social support had stronger symptoms of depression than women with low intelligence and a stable family background at some time points of measurement. The degree of anxiety was neither related to intelligence nor to social support.

Conclusion

For the first time, we demonstrate empirical pilot data on cognitive and social modulators of anxiety and depression in women with breast cancer over the course of radiotherapy. Our results may help to optimize clinical procedures and thereby reduce symptoms of anxiety and depression in these patients.

Supplementary Information

The online version of this article (10.1007/s00066-022-01904-7) contains supplementary material, which is available to authorized users.

Exploring women's experiences of treatment for binge eating disorder: Methylphenidate vs. cognitive behavioural therapy

OBJECTIVE

The current qualitative study explored the personal experiences of a sample of women with binge eating disorder (BED). The women were previously enrolled in a 12-week randomized controlled trial comparing pharmacotherapy (methylphenidate [MP]) and cognitive behavioural therapy (CBT).

METHODS

Semi-structured interviews were conducted with 15 women who completed the trial (8 MP, 7 CBT) to obtain their narrative accounts. Key themes were then identified from transcribed tape recordings, using thematic analysis.

RESULTS

Participants described self-awareness as bringing greater attention to their binge eating, and to their thoughts and emotions. Furthermore, both groups valued the interpersonal relationships with the clinicians and their ability to create a safe and comforting environment. In the MP group, many participants described the medication as reducing their preoccupation with food, and hence, binge frequency. In CBT, there was a focus on psychoeducation and obtaining a "toolbox" of long-term binge-management skills that could also be used following treatment. In both groups, stress was described as a primary trigger for a binge and/or a cause of relapse.

DISCUSSION

Although patients reported having a positive experience in the therapies, it is suggested that broader stress regulation skills training would be useful to evaluate further, to bolster relapse prevention skills. These qualitative findings add a much-needed lived-experience perspective on clinical treatments for binge eating. This is especially significant considering that a psychostimulant similar to MP is the only approved pharmacotherapy for BED, and to date, little is known about the patient's subjective experiences when taking this medication.

What constitutes a good healthcare experience for unintended pregnancy? A qualitative study among young people in California

Little is known about young people's experiences accessing healthcare for unintended pregnancy in the USA. To address this gap, we conducted in-depth interviews with 25 young people in California who had experienced at least one unintended pregnancy at or before 25 years of age. Participants were asked about their interactions with healthcare providers during the pregnancy, their thoughts on the determinants of their perceived quality of care, and the ways in which their healthcare experience could have been improved. Thematic analysis was used to organise information within and across interview transcripts. Two important determinants of participants' satisfaction with their healthcare experience were identified during analysis: (1) receiving comprehensive information about their pregnancy options and what to expect from each, and (2) having an empathetic, non-judgemental provider. Regarding abortion, participants described an unmet need for accurate information and frequent stigmatising experiences with dismissive and judgemental care providers. These findings highlight the importance of providing comprehensive, non-judgemental pregnancy options counselling to all pregnant people, regardless of age and desired pregnancy outcome; and reinforce the need for providers to consider ways in which their own bias may influence the quality of care they provide.

Students' and Examiners' Experiences of Their First Virtual Pharmacy Objective Structured Clinical Examination (OSCE) in Australia during the COVID-19 Pandemic

Objective Structured Clinical Examinations (OSCEs) are routinely used in healthcare education programs. Traditionally, students undertake OSCEs as face-to-face interactions to assess competency in soft skills. Due to physical distancing restrictions during COVID-19, alternative methods were required. This study utilized a mixed-method design (online survey and interviews) to evaluate second-year pharmacy students' and examiners' experiences of their first virtual OSCEs in Australia. A total of 196 students completed their first virtual OSCE in June 2020 of which 190 students completed the online survey. However, out of the 190 students, only 88% (n = 167) consented to the use of the data from their online survey. A further 10 students and 12 examiners were interviewed. Fifty-five students (33%) who participated in the online survey strongly agreed or agreed that they preferred the virtual experience to face-to-face OSCEs while 44% (n = 73) neither agreed nor disagreed. Only 20% (n = 33) felt more anxious with the virtual OSCEs. Additionally, thematic analysis found non-verbal communication as a barrier during the OSCE. Positive aspects about virtual OSCEs included flexibility, decreased levels of anxiety and relevance with emerging telehealth practice. The need for remote online delivery of assessments saw innovative ways of undertaking OSCEs and an opportunity to mimic telehealth. While students and examiners embraced the virtual OSCE process, face-to-face OSCEs were still considered important and irreplaceable. Future opportunities for OSCEs to be delivered both face-to-face and virtually should be considered.

The Intricate Relationship Between Client Perceptions of Physician Empathy and Physician Self-Assessment: Lessons for Reforming Clinical Practice

Objectives: Clinical empathy is an important predictor of patient outcomes. Several factors affect physician’s empathy and client perceptions. We aimed to assess the association between physician and client perception of clinical empathy, accounting for client, physician, and health system factors. Methods: We conducted a hospital-based cross-sectional study in 3 departments (family medicine, internal medicine, and surgery) of King Saud Medical City in Riyadh, Saudi Arabia. We interviewed 30 physicians and 390 clients from 3 departments. Physicians completed the Jefferson Scale of Empathy (JSE) and the clients responded to the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). We used a hierarchical multilevel generalized structural equation approach to model factors associated with JSE and JSPPPE and their inter-relationship. Results: Mean (SD) score of client-rated physician empathy was 26.6 (6) and that of physician self-rated was 111 (12.8). We found no association between the 2 (b  =  0.06; 95% confidence intervals CI: −0.1, 0.21), even after adjusting for client, physician, and health system factors. Physician's nationality (0.49; 0.12, 0.85), adequate consultation time (1.05; 0.72, 1.38), and trust (1.33; 0.9, 1.75) were positively associated whereas chronic disease (−0.32; −0.56, −0.07) and higher waiting times (−0.26; −0.47, −0.05) were negatively associated. Conclusion: A physician's self-assessed empathy does not correlate with clients’ perception. We recommend training and monitoring to enhance clinical empathy.

Quality of Life During Treatment for Cervicofacial Non-melanoma Skin Cancer

Non-melanoma skin cancer (NMSC), despite its low mortality, can impose a significant psychological burden on patients. The aim of the present study is to examine the evolution of the quality of life (QOL) in patients with cervicofacial NMSC during treatment. This prospective cohort study was conducted to a group of patients with cervicofacial NMSC, confirmed by skin biopsy. These patients completed the Skin Cancer Index questionnaire at the time of diagnosis and at 1 week, 1 month and 6 months after treatment began. Data for these patients' demographic characteristics and variables related to the type of tumour, the treatment received and the evolution of the condition were recorded. The study group was composed of 220 patients. At the time of diagnosis, the overall mean score for QOL was 54.1 (SD 21.9); for the social appearance component, it was 76.7 (SD 26.2), and for the emotional component, it was 23 (SD 25.1). Six months after treatment began, the overall mean score was 61 (SD19.1), that for social appearance, 85 (SD 20.6), and that for the emotional component, 27.4 (SD 26.6). All the differences were statistically significant (p < 0.05). The results obtained show that during the treatment period, it is at the time of diagnosis when patients with cervicofacial NMSC undergo the greatest deterioration in their QOL. In comparison with the findings obtained in previous studies, our population obtained lower overall scores in the questionnaires and less improvement during follow-up.

Medical Students' Perspectives on the Factors Affecting Empathy Development During Their Undergraduate Training

INTRODUCTION

This study investigated the perspectives of medical students on the factors influencing empathy development during their undergraduate training.

METHODOLOGY

A descriptive phenomenological approach was used to generate illustrations of empathy development and decline that had educational significance and applicability. Individual online semi-structured interviews were conducted to elicit experiential details from twelve final-year medical students. The interview recordings were transcribed verbatim, and data were analysed employing Braun and Clarke's thematic analysis method.

RESULTS

The self-reported empathic behavior of medical students seemed to have improved with time in medical school. Students attributed their empathy development to real patient encounters, positive role-modelling by teachers, and attainment of confidence and personal maturity. They identified exams, academic overload, time constraints, personal stresses, negative role models, unconducive learning environments, and lack of formal empathy training as barriers to empathy development.

CONCLUSION

Medical institutes should identify and address the barriers to empathy development and encourage the holistic development of medical students. Furthermore, medical educators should model their behavior accurately for their increasing roles and responsibilities and support the students in their empathic expressions with patients.

Understanding moral empathy: A verbatim-theatre supported phenomenological exploration of the empathy imperative

OBJECTIVES

Several studies have measured a decline in empathy during medical training, speculating that factors within the formal, informal and hidden curricula are responsible for this phenomenon. Although the medical education literature describes the moral domain of empathy as most fundamental to the empathic response, most research into the decline has examined the cognitive, affective and behavioural domains. This study distinguishes itself by focusing on how moral empathy is affected through training.

METHODS

Ten medical residents from core education specialties at McMaster University participated in lightly structured interviews concerning their training experiences. Interview transcripts were analysed by way of a descriptive phenomenological approach. Analyses afforded descriptions of the way medical training influences moral empathy. These descriptions were then used to generate a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers and scholars. Following the play, audience participants completed a survey to member-check the descriptions and to glean other reflective experiences in resident training that impact moral empathy. The survey results informed revisions to the codebook that was subsequently used to re-analyse the interview transcripts. This resulted in a final, refined version of the influence of training on learner moral empathy.

RESULTS

The findings suggest that a resident's sense of moral empathy relies upon the notion of an innate capacity for empathy, and is influenced by their clinical and classroom education, and specific experiences with patients during training. Importantly, these factors are rarely experienced as having a direct deleterious impact on residents' moral empathy but rather are experienced as challenges to their ability to act on their moral empathy.

CONCLUSIONS

The study promotes reflection of what it means to experience empathy in the moral domain. The description offers a new perspective from which to view empathic declines that have been previously reported, while also highlighting a moral-behavioural tension that has implications for competency-based assessment and the way empathy is conceptualised in medical education.

The Effects of Physicians' Communication and Empathy Ability on Physician-Patient Relationship from Physicians' and Patients' Perspectives

Physician communication (PC) is central to influencing physician–patient relationship (PPR), and physician empathy (PE) is central to PC. A comprehensive and objective assessment of the mechanisms underlying PPR from the two-way perspective of physicians and patients are important for social development. However, the relationship between these three variables under the two-way perspective is not clear. To examine the effectiveness of PC in predicting PPR from a two-way perspective of physicians and patients and the underlying mechanisms that influence PPR. We selected 2665 physicians and 2983 patients in China and examined the effect of physician empathy on PPR and the mediating role of PC between PE and PPR using structural equation modeling. The results of the physician self-assessment showed that the link between PC and PPR was not significant, while the results of the patient other assessment showed that physician communication was not only effective in predicting the doctor–patient relationship but also mediated the relationship between physician empathy and PPR; further analysis of the underlying mechanisms affecting PPR revealed that the results of the physician self-assessment showed that PC mediated the relationship between perspective-taking and PPR; however, the results of the patient other assessment showed that physician However, patient ratings showed that PC mediated the relationship between perspective-taking and PPR, as well as between empathic concern and PPR. However, patient ratings indicate that PC mediates the relationship between perspective-taking and PPR and between empathic concern and the PPR.

My Life, My Story: Integrating a Life Story Narrative Component Into Medical Student Curricula

INTRODUCTION

Medical students experience burnout, depersonalization, and decreases in empathy throughout medical training. My Life, My Story (MLMS) is a narrative medicine project that aims to combat these adverse outcomes by teaching students to interview patients about their life story, with the goal of improving patient-centered care competencies, such as empathy.

METHODS

The MLMS project was started in the Veterans Affairs (VA) system and has since spread to dozens of VA sites. We adapted and integrated this project into the Warren Alpert Medical School of Brown University curriculum. As part of the required curriculum, first- and third-year medical students participated in a life story interview with a community-based volunteer or a patient in the inpatient hospital setting, transcribed the story, and reviewed the written story with the patient. We assessed student perceptions of the project, changes in empathy, and changes in burnout symptoms.

RESULTS

A total of 240 students participated in this project. Students spent an average of 70.7 minutes interviewing patients. A majority of the students believed MLMS was a good use of time (77%), fostered connection with patients (79%), and was effective in recognizing patients' thoughts and feelings (69%).

DISCUSSION

To our knowledge, this is one of the first life story interview interventions to be implemented into a required medical school curriculum and outside the VA setting. MLMS may assist students in improving clinical empathy skills and create a structure for medical trainees to better understand their patients.

How does overall hospital satisfaction relate to patient experience with nursing care? a cross-sectional study in China

OBJECTIVE

To determine how patient experience with nursing care influence patient satisfaction with overall hospital services.

DESIGN

This was a cross-sectional study.

SETTING

Inpatients were consecutively recruited at the national hospital (with 2000 beds) in Shanghai, China.

PARTICIPANTS

The inclusion criteria were as follows: (1) hospitalised for 2 days or more; (2) able to read and understand Chinese; and (3) aged 18 years old or above. Patients with mental health problems were excluded. 756 patient surveys distributed among 36 wards were analysed. The mean age of participants in the study was 57.7 (SD=14.5) and ranged from 18 to 80 years. Most participants were men (61.5%) and ever married (94.6%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient experience with nursing care, meaning the sum of all interactions between patients and nurses, was measured using the self-designed questionnaire, which was developed by patient interviews, literature analysis and expert consultation. The overall patient satisfaction question was measured with a 10-point response option ranging from 1 to 10.

RESULTS

A linear relationship between the patient experience with nursing care and overall patient satisfaction was observed. The patient experience with nursing care was significantly associated with overall satisfaction in the crude model and in the adjusted models. Even after adjusting for six sociodemographic and three disease-related factors, the patient experience with nursing care explained 34.9% of the variation in overall patient satisfaction.

CONCLUSIONS

This study showed that patient experience with nursing care was an important predictor for overall patient satisfaction.

Bereavement Care Practices Following Stillbirths: Health-Care Provider's Perspective

Background:

Addressing stillbirth is a difficult task and becomes more challenging with a huge burden and skewed doctorpatient ratio. There is a lack of data regarding the knowledge about the bereavement care practices following pregnancy loss and practices being followed by the health-care providers in the Indian context. The objective of this study is to describe the experience, views, and practices of health-care professionals while managing women with stillbirths.

Design:

Internet-based Monkey Survey.

Methodology:

An on-line self completion questionnaire was shared with various health care providers via emails and whats app groups.

Results:

A total of 281 responses of health-care providers were analyzed, and the majority of them were obstetricians. Almost 90% had managed women with stillbirth, but just a third (38.1%) had provided bereavement care. The majority of them felt the lack of a uniform and comprehensive training model for providing bereavement care to such women. Out of 281 participants, 258 (91.8%) believed that health-care providers should have a bereavement care training and support system, whereas only 23 (8.2%) rejected this idea.

Conclusion:

There is no defined protocol or standards for providing bereavement care to women following stillbirth. Most health-care professionals feel an urgent need for professional training to bridge the gap between the expectations of patients and the care provided.

Providing a Second Opinion to Dr. Google with the WWW Framework

While clinicians are often aware that their patients seek second opinions, they are rarely taught specific skills for how to effectively communicate with patients when they are the ones providing that second opinion. The nuances of these skills are amplified when the second opinion being provided is to the ubiquitous (and often anonymous) Dr. Google. In this perspective, the authors share an approach for discussing a patient's pre-visit health-related internet findings. After emphasizing the importance of setting the stage, they describe the WWW Framework which proposes "waiting" before responding with data, getting to the "what" of the patient's search, and "working together" to negotiate a plan. This stepwise approach is designed to provide psychological safety, build a therapeutic alliance, and empower collaborative treatment planning.

A Pilot Study of Perspective Taking and Emotional Contagion in Mental Health Professionals: Glass Brain View of Empathy

BACKGROUND

Empathy plays a fundamental role in the context of psychotherapy. Mental health professionals (MHP) are required to express empathy on a daily basis. "Perspective taking" (cognitive empathy) and "emotional contagion" (affective empathy) are elements of empathy that are both innate and acquired. This study aimed to explore the underlying neural correlates of empathy using functional magnetic resonance imaging (fMRI).

METHOD

A total of six healthy subjects from MHP and other professionals (OP) were recruited in a single-assessment study design. Subjects were screened using the Mini-International Neuropsychiatric Interview and the Standard Progressive Matrices. Behavioral measures such as cognitive and affective empathy, interpersonal reactivity, and emotional and social quotient were assessed. Perspective taking was examined with the fMRI face recognition task and the reading mind through eyes task. Emotional contagion was examined by the negative, positive, and pain emotions task. The fMRI was conducted in a 3T Siemens Magnetom Skyra scanner, using a block design paradigm.

RESULTS

Activation was noted in the following areas: cingulate and thalamus for positive and negative emotions, precuneus for negative emotion and pain, inferior parietal lobe for reading mind task and negative emotion, declive for reading mind and pain, and precuneus and frontal gyrus for reading mind task and facial recognition.

CONCLUSIONS

There was no significant difference between MHP and OP groups on the behavioral measures. However, there were variations in cerebral and cerebellar activation in the functional imaging parameters.

A Comparison of Doctor of Physical Therapy Students’ Self-Reported Empathy With Standardized Patients Perceptions of Empathy During a Simulated Telehealth Encounter

Empathy is an important factor in developing a positive patient–provider relationship. It has been shown to lead to improved patient outcomes, well-being, and satisfaction. This study examines the relationship between first-year physical therapy students’ self-reported empathy levels and a patient's perceptions of caregiver empathy during a standardized patient interview via telehealth. Forty-five students completed a self-reported empathy survey before the standardized patient encounter using telehealth. Following the experience, standardized patients rated the perceived empathy demonstrated by the students during that patient–provider encounter using 2 validated measures. The mean student self-reported empathy using the Jefferson Scale of Empathy-Health Care Provider Student (JSE-HPS) version was 123.93 (range 95-135 SD 7.328). The standardized Jefferson Scale of Patient Perception of Provider Empathy (JSPPPE) scores showed a mean of 23.8 (range 11-32 SD 3.951) and a mean of 3.16 (range 1-5 SD.85) on the Global Rating of Empathy (GRE). There was no significant correlation found between the JSE-HPS and the JSPPPE, r = −.47, P = .760, or the GRE r = −.166, P = .276. The artificial nature of a standardized patient interaction using the telehealth format for this encounter may have contributed to the students’ inability to communicate empathy to the patient and may explain this discrepancy.

The Relationships Between Patient Experience with Nursing Care, Patient Satisfaction and Patient Loyalty: A Structural Equation Modeling

PURPOSE

When creating and managing patient loyalty, medical institutes always focus on medical technicians, overall healthcare quality, and hospital brands, and the role of nursing seems to be underappreciated. Empirical evidence about the relationship between patient experience with nursing care and patient loyalty is limited, especially in the Chinese healthcare system. This study aimed to explore to what extent patient experience with nursing care influences patient loyalty to the hospital and the impact routes.

PATIENTS AND METHODS

This study is a multicenter cross-sectional survey. The STROBE was selected as the checklist in this study. Patient experience with nursing care, patient satisfaction and patient loyalty were collected from 1469 inpatients in three hospitals in China through a paper-based survey. Data were analyzed using SPSS and AMOS software; a structural equation model was established to explore the effect of patient experience with nursing care and satisfaction on patient loyalty using the PROCESS macro.

RESULTS

There were significant direct and indirect effects between patient experience with nursing care and patient loyalty, explaining 32.0% of patient loyalty variance. Patient experience with nursing care had a direct and positive impact on patient loyalty (β=0.298, P<0.01), and better patient experience with nursing care was directly associated with better patient loyalty. In addition, the results also revealed the effect of patient experience with nursing care on patient loyalty was partially mediated by patient satisfaction with nursing care and overall hospital services (β=0.162, P<0.01).

CONCLUSION

This study confirmed the importance of nursing care in creating patient loyalty; improving the patient experience with nursing care would be beneficial to patient loyalty. When creating patient loyalty, hospital administrators and nursing managers should make efforts to develop positive patient experience of nursing care in daily clinical practice through organizational changes, culture shaping and staff education.

Multi-institutional intervention to improve patient perception of physician empathy in emergency care

BACKGROUND

Physician empathy has been linked to increased patient satisfaction, improved patient outcomes and reduced provider burnout. Our objective was to test the effectiveness of an educational intervention to improve physician empathy and trust in the ED setting.

METHODS

Physician participants from six emergency medicine residencies in the US were studied from 2018 to 2019 using a pre-post, quasi-experimental non-equivalent control group design with randomisation at the site level. Intervention participants at three hospitals received an educational intervention, guided by acognitivemap (the 'empathy circle'). This intervention was further emphasised by the use of motivational texts delivered to participants throughout the course of the study. The primary outcome was change in E patient perception of resident empathy (Jefferson scale of patient perception of physician empathy (JSPPPE) and Trust in Physicians Scale (Tips)) before (T1) and 3-6 months later (T2).

RESULTS

Data were collected for 221 residents (postgraduate year 1-4.) In controls, the mean (SD) JSPPPE scores at T1 and T2 were 29 (3.8) and 29 (4.0), respectively (mean difference 0.8, 95% CI: -0.7 to 2.4, p=0.20, paired t-test). In the intervention group, the JSPPPE scores at T1 and T2 were 28 (4.4) and 30 (4.0), respectively (mean difference 1.4, 95% CI: 0.0 to 2.8, p=0.08). In controls, the TIPS at T1 was 65 (6.3) and T2 was 66 (5.8) (mean difference -0.1, 95% CI: -3.8 to 3.6, p=0.35). In the intervention group, the TIPS at T1 was 63 (6.9) and T2 was 66 (6.3) (mean difference 2.4, 95% CI: 0.2 to 4.5, p=0.007). Hierarchical regression revealed no effect of time×group interaction for JSPPPE (p=0.71) nor TIPS (p=0.16).

CONCLUSION

An educational intervention with the addition of text reminders designed to increase empathic behaviour was not associated with a change in patient-perceived empathy, but was associated with a modest improvement in trust in physicians.

Improving the Quality of Patient Care and Healthcare Staff Well-Being through an Empathy Immersion Educational Programme in New Zealand: Protocol of a Feasibility and Pilot Study

Empathy is positively related to healthcare workers and patients’ wellbeing. There is, however, limited research on the effects of empathy education delivered in acute clinical settings and its impact on healthcare consumers. This research tests the feasibility and the potential efficacy outcomes of an immersive education programme developed by the research team in collaboration with clinical partners and a multidisciplinary advisory group. Healthcare worker participants in the intervention ward will receive an 8-week immersive empathy education. The primary outcome (feasibility) will be assessed by evaluating the acceptability of the intervention and the estimated resources. The secondary outcome (efficacy) will be assessed using a quasi-experimental study design. Non-parametric tests will be used to test healthcare worker participants’ empathy, burnout, and organisational satisfaction (within-group and across groups), and healthcare consumer participants’ satisfaction (between-group) over time. Despite growing interest in the importance of empathy in professional relationships, to our knowledge, the present pilot study is the first to explore the feasibility and efficacy of an immersive empathy education in New Zealand. Our findings will provide critical evidence to support the development of a randomised cluster trial and potentially provide preliminary evidence for the effectiveness of this type of empathy education.

Study protocol for the ETMED-L project: longitudinal study of mental health and interpersonal competence of medical students in a Swiss university using a comprehensive framework of empathy

INTRODUCTION

Physician interpersonal competence is crucial for patient care. How interpersonal competence develops during undergraduate medical education is thus a key issue. Literature on the topic consists predominantly of studies on empathy showing a trend of decline over the course of medical school. However, most existing studies have focused on narrow measures of empathy. The first aim of this project is to study medical students' interpersonal competence with a comprehensive framework of empathy that includes self-reported cognitive and affective empathy, performance-based assessments of emotion recognition accuracy, and a behavioural dimension of empathy. The second aim of the present project is to investigate the evolution of mental health during medical school and its putative link to the studied components of interpersonal competence. Indeed, studies documented a high prevalence of mental health issues among medical students that could potentially impact their interpersonal competence. Finally, this project will enable to test the impact of mental health and interpersonal competence on clinical skills as evaluated by experts and simulated patients.

METHODS AND ANALYSIS

This project consists of an observational longitudinal study with an open cohort design. Each year during the four consecutive years of the project, every medical student (curriculum years 1-6) of the University of Lausanne in Switzerland will be asked to complete an online questionnaire including several interpersonal competence and mental health measures. Clinical skills assessments from examinations and training courses with simulated patients will also be included. Linear mixed models will be used to explore the longitudinal evolutions of the studied components of interpersonal competence and mental health as well as their reciprocal relationship and their link to clinical skills.

ETHICS AND DISSEMINATION

The project has received ethical approval from the competent authorities. Findings will be disseminated through internal, regional, national and international conferences, news and peer-reviewed journals.

Stability and Differences in Empathy Between Men and Women Medical Students: a Panel Design Study

PHENOMENON

Empathy is central to the physician-patient relationship, and affects clinical outcomes. There is uncertainty about the stability of empathy in medical students over the course of medical school, as well as differences in empathy between men and women.

APPROACH

A panel study design was used to follow first year through fourth year medical students (MS1-4) during the 2018-2019 school year. Empathy was measured using the interpersonal reactivity index (IRI), a self-report scale that separates empathy into a cognitive perspective taking (PT) and affective empathic concern (EC) component.

FINDINGS

A total of 631 (359 women and 272 men) from 970 students (65% response rate) responded to a baseline survey, and a total of 536 students (300 women and 236 men) from 970 students (55% response rate) responded to surveys throughout the year. At baseline, women had significantly higher EC scores than men (p < 0.0001), with no significant PT difference between men and women (p > 0.05). These differences were stable for all MS cohorts.

INSIGHTS

Women had self-reported higher affective empathy (EC component) than men, while there were no differences in cognitive empathy (PT component). We discuss these data in the context of defining gender vs. sex, socialized gender stereotypes, and implications for future research.

Empathy in patient care: from 'Clinical Empathy' to 'Empathic Concern'

As empathy gains importance within academia, we propose this review as an attempt to bring clarity upon the diverse and widely debated definitions and conceptions of empathy within the medical field. In this paper, we first evaluate the limits of the Western mainstream medical culture and discuss the origins of phenomena such as dehumanization and detached concern as well as their impacts on patient care. We then pass on to a structured overview of the debate surrounding the notion of clinical empathy and its taxonomy in the medical setting. In particular, we present the dichotomous conception of clinical empathy that is articulated in the debate around cognitive empathy and affective empathy. We thus consider the negative impacts that this categorization brings about. Finally, we advocate for a more encompassing, holistic conception of clinical empathy; one that gives value to a genuine interest in welcoming, acknowledging and responding to the emotions of those suffering. Following this line of reasoning, we advance the notion of 'empathic concern', a re-conceptualization of clinical empathy that finds its source in Halpern in Med Health Care Philos (2014) 17:301-311 engaged curiosity. We ultimately advance Narrative Medicine as an approach to introduce, teach and promote such an attitude among medical trainees and practitioners.

The impact of patient narratives on medical students' perceptions of shared decision making: A randomized controlled trial

Successful shared decision making (SDM) in clinical practice requires that future clinicians learn to appreciate the value of patient participation as early as they can in their medical training. Narratives, such as patient testimonials, have been successfully used to support patients' decision-making process. Previous research suggests that narratives may also be used for increasing clinicians' empathy and responsiveness in medical consultations. However, so far, no studies have investigated the benefits of narratives for conveying the relevance of SDM to medical students. In this randomized controlled experiment, N = 167 medical students were put into a scenario where they prepared for medical consultation with a patient having Parkinson disease. After receiving general information, participants read either a narrative testimonial of a Parkinson patient or a fact-based information text. We measured their perceptions of SDM, their control preferences (i.e., their priorities as to who should make the decision), and the time they intended to spend for the consultation. Participants in the narrative patient testimonial condition referred more strongly to the patient as the one who should make decisions than participants who read the information text. Participants who read the patient narrative also considered SDM in situations with several equivalent treatment options to be more important than participants in the information text condition. There were no group differences regarding their control preferences. Participants who read the patient testimonial indicated that they would schedule more time for the consultation. These findings show that narratives can potentially be useful for imparting the relevance of SDM and patient-centered values to medical students. We discuss possible causes of this effect and implications for training and future research. Trial registration: The study was pre-registered on the pre-registration platform AsPredicted (aspredicted.org) before data collection began (registration number: #29,342). Date of registration: 17 October 2019.

The impact of a tailored mindfulness-based program for resident physicians on distress and the quality of care: A randomised controlled trial

BACKGROUND

Many resident physicians suffer from distress, which endangers their individual health and the quality of care.

OBJECTIVE

To examine the impact of a tailored mindfulness-based program (MBP) for resident physicians on distress and the quality of care.

METHODS

A single-centre, two-armed, longitudinal randomised controlled trial. The intervention group took part in an 8-week, tailored MBP that included a coursebook. The MBP was followed by a 4-month maintenance phase. The active control group received the coursebook for self-study. Assessments were at baseline (t0, 0 months), after the intervention (t1, 2 months), after the maintenance phase (t2, 6 months), and at follow-up (t3, 12 months). The primary outcome was a change in burnout at t2. Secondary outcomes included perceived stress, mental distress, perceived job strain, depression, anxiety, hair cortisol secretion, self-reported medical errors and third-party ratings by patients, supervisors and colleagues.

RESULTS

Seventy-six participants were randomised to the intervention and 71 to the control group. The intervention group showed greater improvements in the primary outcome (burnout at t2, d = 0.32, p = 0.046), in perceived stress (d = 0.31, p = 0.046) and perceived job strain (d = 0.33, p = 0.026) at t1, and in supervisor rated empathy (d = 0.71, p = 0.037) and colleague rated attentiveness (d = 0.85, p = .006) at t2. There was no difference between groups in the other outcomes.

CONCLUSION

A tailored MBP for resident physicians improved burnout and might have improved other aspects of distress and the quality of care.

Empathy and boundary turbulence in cancer communication

OBJECTIVES

To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent.

METHODS

Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations.

RESULTS

We identified patient-centered physician response categories--empathy, affirmation, and acknowledgement; and physician-centered categories-transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered.

CONCLUSIONS

Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication "boundary turbulence." Patients may benefit from physicians' improved use of empathy and boundary management.

Clinical empathy in GP-training: Experiences and needs among Dutch GP-trainees. "Empathy as an element of personal growth"

OBJECTIVE

Clinical empathy has been described as a key component of effective person-centeredness in patient-physician communication. Yet little is known about general practitioner (GP) trainees' experiences and opinions regarding clinical empathy, empathy-education and the development of empathic skills. This study aimed to explore trainees' experiences with clinical empathy during GP training.

METHODS

This study used focus group interviews. GP trainees at two Dutch universities were approached by e-mail. Focus groups were conducted between April and November 2018. Six focus groups were conducted: two with starting trainees, two with trainees at the end of their first year and two with trainees at the end of their 3 years' training. Two experienced qualitative researchers analyzed the focus groups. During the thematic analysis the differences and similarities between the various stages of education were taken into account and a framework for the identified themes and subthemes was developed.

RESULTS

Thirty-five GP trainees took part. Four main themes could be identified. Starting trainees experienced frictions regarding the influence of personal affective reactions on their medical competencies. Trainees at the end of their first year indicated that they reached a balance between empathic involvement and their responsibility to carry out relevant medical tasks, such as following GP guidelines. Trainees at the end of their three years' training recognized the mutual relationship between the development of the behavioral part of clinical empathy and personal growth. All trainees stated that their needs concerning education changed during their GP training and proposed changes to the curriculum.

CONCLUSIONS

GP trainees face various obstacles in developing empathic skills and behavior. Particularly they mention handling personal affective reactions. Trainees express a clear wish for clinical empathy, in its theoretical as well as its skill and emotional aspects, to play a central role in the curriculum.

PRACTICE IMPLICATIONS

More explicit attention to be paid to empathy by embedding theoretical education, explicit attention to skill training and assessment of empathic behavior by patients and supervisors.

Accessing community dementia care services in Ireland: Emotional barriers for caregivers

Despite the benefits of utilising community-based care services (CBS) for people with dementia and their caregiver being well established, people with dementia and caregivers use fewer services in comparison to other people in need of care. While societal, cultural and logistical factors effecting caregiver use of CBS are frequently studied, research of internal emotional barriers, mental limitations created by one's own self that prevents open communication of thoughts and feelings, and their effect on CBS use is limited. This paper explores internal emotional barriers on caregivers' use of CBS within the Irish Healthcare System. Professional Healthcare Providers were also interviewed as a preliminary indicator of their awareness of these internal emotional barriers and their impact on caregivers' use of CBS. Using interpretive description methodology, interviews with 20 caregivers and fourteen dementia professional healthcare providers were transcribed and a thematic analysis methodology applied to illuminate themes/patterns within participants' subjective perceptions of caregivers emotional barriers to using CBS. Four themes emerge: reluctance to question general practitioner (GP) authority; embarrassment during level of care requirement reviews; sense of obligation to provide all care; and fear of stigma. Caregivers interviewed were reluctant to communicate concerns with professional healthcare providers (PHPs), thereby reducing the PHP's awareness of these barriers and delaying/preventing use of CBS. As key gatekeepers within the care pathway, GPs should address the uneven power dynamic with the caregiver through user-centred models of care, which actively encourage open dialogue, and receive training to identify the indicative behaviours of internal emotional barriers and empower the caregiver to communicate their feelings/concerns directly.

Developing best practices for PPE Portraits across 25 sites: a systematic assessment of implementation and spread of adaptations using FRAME

BACKGROUND

Adaptation, a form of modification that aims to improve an intervention's acceptability and sustainability in each context, is essential to successful implementation in some settings. Due to the COVID-19 pandemic, clinicians have rapidly adapted how they deliver patient care. PPE Portraits are a form of adaptation, whereby health workers affix a postcard size portrait of themselves to the front of their personal protective equipment (PPE) to foster human connection during COVID-19.

METHODS

We used the expanded framework for reporting adaptations and modifications to evidence-based interventions (FRAME) method to better understand the reasoning behind and results of each adaptation. We hypothesized that using the FRAME in conjunction with design-thinking would lead to emerging best practices and that we would find adaptation similarities across sites. Throughout multiple implementations across 25 institutions, we piloted, tracked, and analyzed adaptations using FRAME and design thinking. For each adaptation, we assessed the stage of implementation, whether the change was planned, decision makers involved, level of delivery impacted, fidelity to original intervention, and the goal and reasoning for adaptation. We added three crucial components to the FRAME: original purpose of the adaptation, unintended consequences, and alternative adaptations.

RESULTS

When implementing PPE Portraits across settings, from a local assisted living center's memory unit to a pediatric emergency department, several requests for adaptations arose during early development stages before implementation. Adaptations primarily related to (1) provider convenience and comfort, (2) patient populations, and (3) scale. Providers preferred smaller portraits and rounded (rather than square) laminated edges that could potentially injure a patient. Affixing the portrait with a magnet was rejected given the potential choking hazard the magnetic strip presented for children. Other adaptations, related to ease of dissemination, included slowing the process down during early development and providing buttons, which could be produced easily at scale.

CONCLUSIONS

The FRAME was used to curate the reasoning for each adaptation and to inform future dissemination. We look forward to utilizing FRAME including our additions and design thinking, to build out a range of PPE Portrait best practices with accompanying costs and benefits.

Effects of a 2-Week Remote Learning Program on Empathy and Clinical and Communication Skills in Premedical Students: Mixed Methods Evaluation Study

BACKGROUND

Expressing empathy builds trust with patients, increases patient satisfaction, and is associated with better health outcomes. Research shows that expressing empathy to patients improves patient adherence to medications and decreases patient anxiety and the number of malpractice lawsuits. However, there is a dearth of research on teaching empathy to premedical students. The Clinical Science, Technology, and Medicine Summer Internship of Stanford Medicine (also called the Stanford Anesthesia Summer Institute) is a 2-week collaborative medical internship for high school and undergraduate students to inspire learners to be compassionate health care providers. The summer 2020 program was adapted to accomplish these objectives in a fully remote environment because of the COVID-19 global pandemic.

OBJECTIVE

This study aims to measure the change in empathy and competencies of participants in clinical and communication skills before and after program participation.

METHODS

A total of 41 participants completed only the core track of this program, and 39 participants completed the core + research track of this program. Participants in both tracks received instructions in selected clinical skills and interacted directly with patients to improve their interviewing skills. Research track participants received additional instructions in research methodology. All participants completed web-based pre- and postsurveys containing Knowledge and Skills Assessment (KSA) questions. Participant empathy was assessed using the validated Consultation and Relational Empathy measure. A subset of participants completed optional focus groups to discuss empathy. The pre- and post-KSA and Consultation and Relational Empathy measure scores were compared using paired 2-tailed t tests and a linear regression model. Open-ended focus group answers were then analyzed thematically.

RESULTS

Participants in both tracks demonstrated significant improvement in empathy after the 2-week remote learning course (P=.007 in core track; P<.001 in research track). These results remained significant when controlling for gender and age. A lower pretest score was associated with a greater change in empathy. Participants in both tracks demonstrated significant improvement in KSA questions related to surgical skills (P<.001 in core track; P<.001 in research track), epinephrine pen use (P<.001 in core track; P<.001 in research track), x-ray image interpretation (P<.001 in core track; P<.001 in research track), and synthesizing information to solve problems (P<.001 in core track; P=.05 in research track). The core track participants also showed significant improvements in health communication skills (P=.001). Qualitative analysis yielded 3 themes: empathy as action, empathy as a mindset, and empathy in designing health care systems.

CONCLUSIONS

Summer internships that introduce high school and undergraduate students to the field of health care through hands-on interaction and patient involvement may be an effective way to develop measurable empathy skills when combined with clinical skills training and mentorship. Notably, increases in empathy were observed in a program administered via a remote learning environment.

Impact of physician empathy on patient outcomes: a gender analysis

BACKGROUND

Empathy in primary care settings has been linked to improved health outcomes. However, the operationalisation of empathy differs between studies, and, to date, no study has concurrently compared affective, cognitive, and behavioural components of empathy regarding patient outcomes. Moreover, it is unclear how gender interacts with the studied dimensions.

AIM

To examine the relationship between several empathy dimensions and patient-reported satisfaction, consultation's quality, and patients' trust in their physicians, and to determine whether this relationship is moderated by a physician's gender.

DESIGN AND SETTING

Analysis of the empathy of 61 primary care physicians in relation to 244 patient experience questionnaires in the French-speaking region of Switzerland.

METHOD

Sixty-one physicians were video-recorded with two male and two female patients. Six different empathy measures were assessed: two self-reported measures, a facial recognition test, two external observational measures, and a Synchrony of Vocal Mean Fundamental Frequencies (SVMFF), measuring vocally coded emotional arousal. After the consultation, patients indicated their satisfaction with, trust in, and quality of the consultation.

RESULTS

Female physicians self-rated their empathic concern higher than their male counterparts did, whereas male physicians were more vocally synchronised (in terms of frequencies of speech) to their patients. SVMFF was the only significant predictor of all patient outcomes. Verbal empathy statements were linked to higher satisfaction when the physician was male.

CONCLUSION

Gender differences were observed more often in self-reported measures of empathy than in external measures, indicating a probable social desirability bias. SVMFF significantly predicted all patient outcomes, and could be used as a cost-effective proxy for relational quality.

Barriers to Care in Veterinary Services: Lessons Learned From Low-Income Pet Guardians' Experiences at Private Clinics and Hospitals During COVID-19

This qualitative study aimed to explore the experiences of low-income pet guardians in accessing veterinary care during COVID-19. Participants were recruited through a purposive sampling method: 12 individuals who applied to and met the low-income threshold to access support for veterinary fees from the Vancouver Humane Society (VHS) were invited for semi-structured in-depth telephone interviews. Participants indicated that they experienced pandemic-related barriers related to and compounded by their low-income status. Their experiences fit into three categories: the barriers to accessing veterinary care pre-and peri-COVID-19, the emotional impact of compounding barriers related to accessing veterinary care during COVID-19, and the human-animal bond and resilience in the context of COVID-19. Drawing on the One Health, One Welfare approach, we argue that veterinary and animal services should evaluate and improve their support services, particularly programs developed for low-income pet guardians. Based on the participants' recommendations, we propose that veterinary and animal services prepare for future disaster situations by increasing their financial capacity to support people needing assistance, undergoing training to better work with people experiencing financial and emotional stress, and providing easily accessible resources to better distribute knowledge about animal needs and available financial assistance programming. The suggestions are intended to benefit animals, their guardians, and both veterinary and animal service sector workers.

Does information structuring improve recall of discharge information? A cluster randomized clinical trial

OBJECTIVES

The impact of the quality of discharge communication between physicians and their patients is critical on patients' health outcomes. Nevertheless, low recall of information given to patients at discharge from emergency departments (EDs) is a well-documented problem. Therefore, we investigated the outcomes and related benefits of two different communication strategies: Physicians were instructed to either use empathy (E) or information structuring (S) skills hypothesizing superior recall by patients in the S group.

METHODS

For the direct comparison of two communication strategies at discharge, physicians were cluster-randomized to an E or a S skills training. Feasibility was measured by training completion rates. Outcomes were measured in patients immediately after discharge, after 7, and 30 days. Primary outcome was patients' immediate recall of discharge information. Secondary outcomes were feasibility of training implementation, patients' adherence to recommendations and satisfaction, as well as the patient-physician relationship.

RESULTS

Of 117 eligible physicians, 80 (68.4%) completed the training. Out of 256 patients randomized to one of the two training groups (E: 146 and S: 119) 196 completed the post-discharge assessment. Patients' immediate recall of discharge information was superior in patients in the S-group vs. E-group. Patients in the S-group adhered to more recommendations within 30 days (p = .002), and were more likely to recommend the physician to family and friends (p = .021). No differences were found on other assessed outcome domains.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Immediate recall and subsequent adherence to recommendations were higher in the S group. Feasibility was shown by a 69.6% completion rate of trainings. Thus, trainings of discharge information structuring are feasible and improve patients' recall, and may therefore improve quality of care in the ED.

Can You Hear Me Now? Effects of Patient-Centered Communication With Young Adults Aged 26 to 39

Patient-centered communication (PCC) is critical to the delivery of quality health care services. Although numerous health outcomes have been connected to patient–provider communication, there is limited research that has explored the processes and pathways between communication and health. Research among young adults (ages 26-39 years) is even more scarce, despite findings that health communication does vary with age. This cross-sectional study used data from the 2014 Health Interview National Trends Survey to explore the relationship between PCC, patient trust, patient satisfaction, social support, self-care skills, and emotional well-being among young adults aged 26 to 39 years. Our results showed that income, history of depression diagnosis, PCC, patient trust, social support, and patient self-efficacy (self-care skills) were all significantly related to emotional well-being. These findings suggest the need to explore the means through which communication can impact emotional well-being, specifically among young adults who are in poor health or have a history of depression. Future research should also include longitudinal studies, in order to determine causality and directionality among constructs.

Author Response to "The Therapeutic Alliance May Yet Prove Effective"

Author response to the JOSPT Letter to the Editor-in-Chief "The Therapeutic Alliance May Yet Prove Effective" J Orthop Sports Phys Ther 2021;51(10):527-528. doi:10.2519/jospt.2021.0203-R.

Resilience, Well-being, and Empathy Among Private Practice Physicians and Advanced Practice Providers in Texas: A Structural Equation Model Study

Objective

To investigate structural relationships of latent constructs such as occupational wellbeing, resilience, work meaningfulness, and psychological empowerment with affective and cognitive clinical empathy among a community of physicians and advanced practice providers.

Methods

We conducted a cross-sectional observational study. We gathered data by an anonymous self-administered multidimensional questionnaire disseminated electronically between March and May 2016. Participants were physicians and advanced practice providers belonging to the Health Texas Provider Network, a group private practice affiliated with the Baylor Scott and White Health system. We excluded allied health care staff (eg, nurses) and trainees (eg, residents, medical students). We pursued a 3-step strategy: (1) confirmatory factor analysis of a theory-driven measurement model, (2) a modified structural equation model from which pathways with nonsignificant path coefficients were deleted, and (3) multigroup analyses of the modified model.

Results

Cognitive empathy was the strongest predictor of affective empathy. We observed modest positive associations of resilience with cognitive and affective empathy and of well-being and meaning with affective but not with cognitive empathy. Resilience, meaning, and psychological empowerment were surprisingly negatively associated with well-being, suggesting diminished self-care among practitioners. Effects of psychological empowerment on empathy and well-being were mediated by resilience and meaning.

Conclusion

Cognitive empathy directly influenced affective empathy; well-being and meaningfulness exerted direct positive effects on affective but not on cognitive empathy, whereas resilience had direct positive associations with both empathy dimensions. Resilience and meaning manifested direct, negative associations with well-being, revealing clinicians’ disproportionate focus on patient care at the expense of self-care.

Effectiveness of a Mindfulness and Self-Compassion Standard Training Program versus an Abbreviated Training Program on Stress in Tutors and Resident Intern Specialists of Family and Community Medicine and Nursing in Spain

Stress is one of the most common problems among healthcare professionals, as they are exposed to potentially stressful and emotionally challenging situations in the workplace. Mindfulness-based stress reduction (MBSR) training programs have been shown to decrease stress. The objective of this study was to compare the effectiveness of an abbreviated 4-weeks MBSR training program in relation to a standard 8-weeks one on the stress levels. A controlled and randomized clinical trial was designed, in which 112 tutors and resident intern specialists in Family and Community Medicine and Nursing of six Spanish National Health System teaching units (TUs) participated. Participants included in the experimental groups (EGs) received a MBRS training program (standard or abbreviated), while control group (CG) participants did not receive any intervention. The stress levels were assessed by the Perceived Stress Questionnaire (PSQ) in three different moments during the study: before, immediately after, and 3 months after the intervention. Adjusted covariance analysis (ANCOVA), using pretest scores as the covariate, showed a significant reduction in stress (F_(2,91) = 5.165; p = 0.008; η² = 0.102) in the post-test visit, attributable to the implementation of the standard training program, but without the maintenance of its effects over time. No significant impact of the abbreviated training program on stress levels was observed in the intergroup comparison. A standard 8-weeks MBSR training program aimed at tutors and resident intern specialists in Family and Community Medicine and Nursing produces significant improvements in stress levels compared with the abbreviated intervention and no intervention. New studies about abbreviated training programs are needed to provide effective treatments which improve well-being of these professionals.