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

What makes a good general practice consultation? An exploratory pilot study with people from a low socioeconomic background

BACKGROUND

While patients from low socioeconomic (SES) backgrounds are at increased risk of developing chronic health conditions, typically managed within general practice, they report fewer positive consultation experiences with GPs than patients from higher SES groups. To our knowledge, existing research does not provide an in-depth understanding of the GP conducts that contribute to positive consultations.

AIM

To identify the factors that patients from low SES backgrounds perceive as essential for creating good consultation experiences.

DESIGN & SETTING

This exploratory pilot study was performed in GP clinics in Melbourne, Australia.

METHOD

We used an appreciative inquiry approach, focused on positive consultation experiences, previously shown to be helpful for researching sensitive topics. Nine patients from low SES backgrounds, who reported positive consultation experiences, undertook a semi-structured qualitative interview while watching the video recording of their GP consultation. Four different GPs were captured in the recordings. Inductive thematic coding was performed by two researchers.

RESULTS

The following four categories were developed: 1) the doctor's demeanour and how the patient was made to feel during the consultation drove their engagement; 2) an established and collaborative therapeutic relationship was of high importance to patients; 3) a doctor's therapeutic skillset was integral to patient confidence and comfort; and 4) patients appreciated verbal and non-verbal communication techniques. In each interview, the discussion about the video-recorded consultation often triggered reflections about previous consultations with the respective GP.

CONCLUSION

For patients from low SES groups, positive consultation experiences were underpinned by perceived continuity of care with a specific GP who consistently showed good communication skills and key interpersonal characteristics. This research is a small step towards increasing our understanding of the experience of individuals from low SES backgrounds in primary care and the existing health inequities within this area.

Physician Empathy in Doctor-Patient Communication: A Systematic Review

Physician empathy is at the heart of doctor-patient communication and significantly influences patient outcomes. However, the research on how physicians express their empathy and how physician empathy affects patient outcomes and doctor-patient communication has not been well summarized in the latest literature. Thus, we conducted a systematic review to synthesize existing studies on physician empathy and its value to patient outcomes and doctor-patient communication. The systematic review consisted of studies published in English peer-reviewed journals between January 2017 and October 2021. Following the PRISMA procedure, a total of 3055 articles were retrieved, and 11 articles were retained. The thematic analysis revealed three emergent themes: physicians' empathic expressions; patient outcomes (patient functional status, patient safety, and patient satisfaction); and empathy enhancing doctor-patient communication. This study highlighted the different ways empathy may be expressed by physicians and its positive effects on patient outcomes and doctor- patient communication. This study also suggested the under-researched areas that can be expanded in the future.

Assessing the effectiveness of virtual reality to promote empathy for patients through a mixed-methods study

OBJECTIVE

To describe the implementation and outcomes of EmpathyVR, an immersive experience using virtual reality (VR) to promote empathy for patients with physical limitations due to chronic diseases.

METHODS

First-year student pharmacists participated in a learning experience that incorporated VR and stiff gloves to simulate physical limitations associated with color-blindness and arthritis, respectively. Students completed pre- and post-intervention surveys that included the Kiersma-Chen Empathy Scale and measures of immersion, user enjoyment, perceived usefulness for learning, and adverse effects of the experience. A focus group was also conducted with 6 students to obtain additional feedback on the learning experience.

RESULTS

Of the 132 students who were enrolled in the program, 131 completed the assigned tasks; 117 of these agreed to participate in the study, and their data were included in the analyses. There was a significant improvement in empathy scores in the cognitive domain from pre- to post-intervention. Post-intervention survey results also demonstrated a high degree of immersion in the experience, high levels of self-reported enjoyment, and high levels of perceived usefulness of the activity to support learning. There was a low to moderate incidence of minor self-reported adverse effects from the activity. Focus group feedback was also positive. One student stated, "… it really allowed you to think and put yourself in their shoes."

CONCLUSION

Implementation of a VR-based learning activity into the first semester of the PharmD curriculum was successful and resulted in improved student empathy scores and a positive learning experience.

Comparison of empathy profiles of medical students at the start and in the advanced clinical phase of their training

Background

The National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) cites empathy as a basic competence for medical doctors. Based on a multidimensional concept of clinical empathy, empathy profiles of medical students at the start of their training and in the 9th semester were identified and compared in order to draw conclusions for the conception of effective course offers.

Method

Using the Saarbrücker Personality Questionnaire on Empathy (SPF-IRI), self-rated empathy was recorded in a cross-sectional study of medical students (1st semester: N=192/9th semester: N=221). Two Stage Clustering was performed for data analysis.

Result

Three empathy profiles which could be meaningfully delineated by content were identified: 1. reflected, functional empathy, 2. unreflected, burdensome empathy and 3. distancing and avoidance. Students in the 9th semester mostly tended toward unreflected, burdensome empathy. Only one-third appeared capable of feeling empathy with patients while at the same time adequately regulating their own emotions and thus protecting themselves from emotional overload.

Conclusion

An adequately reflected and functional empathy among medical students can neither be assumed at the start of their training, nor do existing course offers appear to provide sufficient training for this. Empathy should thus be implemented as a competence which needs to be promoted over the entire course of study. Emotion regulation plays a key role.

Better outcomes through patient - Provider therapeutic connections? An exploratory study of proposed mediating variables

BACKGROUND

Patient-provider therapeutic connections (TCs) have been theorized to enhance patient outcomes as well as care provider job satisfaction and to reduce burnout. High-quality TCs may result in better matching of health care to patient needs, and thus, better care quality and patient outcomes. For care providers, work environments that enable high-quality TCs may make the work more motivating and facilitate resilience.

METHOD

We surveyed patients (n = 346) and care providers (n = 341) about their experiences of TCs, and how TCs related to outcomes. We tested parallel mediation models to examine relations.

RESULTS

TCs predicted better patient health status, mental health status, and satisfaction, and predicted greater care provider job satisfaction and lower burnout. TCs were theorized to operate through two sets of mechanisms (health self-efficacy and activation for patients; meaningfulness of work and psychological safety for providers). Results revealed significant indirect associations between TCs and outcomes for both groups.

CONCLUSIONS

TCs are associated with patient and provider outcomes; however, these relations appear to be explained by several mediating variables. It appears that TCs are associated with better outcomes for patients through health self-efficacy and activation, and TCs are associated with better outcomes for care providers through meaningfulness of work and psychological safety.

A Motivational Interviewing Chatbot With Generative Reflections for Increasing Readiness to Quit Smoking: Iterative Development Study

BACKGROUND

The motivational interviewing (MI) approach has been shown to help move ambivalent smokers toward the decision to quit smoking. There have been several attempts to broaden access to MI through text-based chatbots. These typically use scripted responses to client statements, but such nonspecific responses have been shown to reduce effectiveness. Recent advances in natural language processing provide a new way to create responses that are specific to a client's statements, using a generative language model.

OBJECTIVE

This study aimed to design, evolve, and measure the effectiveness of a chatbot system that can guide ambivalent people who smoke toward the decision to quit smoking with MI-style generative reflections.

METHODS

Over time, 4 different MI chatbot versions were evolved, and each version was tested with a separate group of ambivalent smokers. A total of 349 smokers were recruited through a web-based recruitment platform. The first chatbot version only asked questions without reflections on the answers. The second version asked the questions and provided reflections with an initial version of the reflection generator. The third version used an improved reflection generator, and the fourth version added extended interaction on some of the questions. Participants' readiness to quit was measured before the conversation and 1 week later using an 11-point scale that measured 3 attributes related to smoking cessation: readiness, confidence, and importance. The number of quit attempts made in the week before the conversation and the week after was surveyed; in addition, participants rated the perceived empathy of the chatbot. The main body of the conversation consists of 5 scripted questions, responses from participants, and (for 3 of the 4 versions) generated reflections. A pretrained transformer-based neural network was fine-tuned on examples of high-quality reflections to generate MI reflections.

RESULTS

The increase in average confidence using the nongenerative version was 1.0 (SD 2.0; P=.001), whereas for the 3 generative versions, the increases ranged from 1.2 to 1.3 (SD 2.0-2.3; P<.001). The extended conversation with improved generative reflections was the only version associated with a significant increase in average importance (0.7, SD 2.0; P<.001) and readiness (0.4, SD 1.7; P=.01). The enhanced reflection and extended conversations exhibited significantly better perceived empathy than the nongenerative conversation (P=.02 and P=.004, respectively). The number of quit attempts did not significantly change between the week before the conversation and the week after across all 4 conversations.

CONCLUSIONS

The results suggest that generative reflections increase the impact of a conversation on readiness to quit smoking 1 week later, although a significant portion of the impact seen so far can be achieved by only asking questions without the reflections. These results support further evolution of the chatbot conversation and can serve as a basis for comparison against more advanced versions.

Activities to promote empathy for patients among pharmacy learners: A scoping review

BACKGROUND

Provider empathy has been shown to be directly linked to improved patient outcomes. The objective of this scoping review of the literature was to identify and describe learning activities that promote empathy for patients among pharmacy learners.

METHODS

This scoping review was conducted using the following inclusion criteria: publication in English, activities conducted in any academic pharmacy training program (professional degree program, experiential, residency, or fellowship), description of the learning activity(ies) provided, and focus on the experience of empathy/caring/compassion for patients, either human or animal. Articles were excluded if they focused only on skills such as empathic responding or if they did not describe the learning experience. All study designs other than reviews were included.

RESULTS

The scoping review revealed 89 full-text articles that met the inclusion criteria. Included studies demonstrated a wide variety of approaches to the design of learning experiences as well as methods of measurement of empathy. Various types of learning modalities have been used to develop empathy in pharmacy learners, with reflection being the most common. A large proportion of studies that assessed empathy development used quasi-experimental or qualitative designs and did not report tests of statistical significance, which would make it difficult to compare the effectiveness of the different learning activities.

IMPLICATIONS

A variety of approaches have been used among pharmacy learners to develop empathy for patients. Due to the high level of variability in approaches, more rigorous studies are needed to assess the effectiveness of these learning activities.

The relationship of perceived empathy with levels of pain intensity and incapability among patients visiting a musculoskeletal specialist

BACKGROUND

People that have more intense symptoms and greater incapability might have less rapport with the clinicians that care for them.

OBJECTIVE

This study tested the hypothesis that perceived clinician empathy is related to pain intensity and magnitude of incapability among people seeing a musculoskeletal specialist.

PATIENT INVOLVEMENT

After a consult with a musculoskeletal specialist, 211 adult patients completed a survey recording demographics, and measures of pain intensity, incapability, and perceived clinician empathy.

RESULTS

Higher perceived empathy was associated with being in a committed relationship and, to a modest degree (r = -0.16) lower pain intensity in bivariate and multivariable analyses.

DISCUSSION

People experiencing greater pain may be slightly less likely to perceive the clinician as empathetic.

PRACTICAL VALUE

Study of the relationship between the patient's experience of care and patient and clinician personal factors can inform efforts to improve patient experience. Advances may depend on experience measures with more normal distributions and less ceiling effect.

The impact of artificial intelligence on the person-centred, doctor-patient relationship: some problems and solutions

Artificial intelligence (AI) is often cited as a possible solution to current issues faced by healthcare systems. This includes the freeing up of time for doctors and facilitating person-centred doctor-patient relationships. However, given the novelty of artificial intelligence tools, there is very little concrete evidence on their impact on the doctor-patient relationship or on how to ensure that they are implemented in a way which is beneficial for person-centred care.Given the importance of empathy and compassion in the practice of person-centred care, we conducted a literature review to explore how AI impacts these two values. Besides empathy and compassion, shared decision-making, and trust relationships emerged as key values in the reviewed papers. We identified two concrete ways which can help ensure that the use of AI tools have a positive impact on person-centred doctor-patient relationships. These are (1) using AI tools in an assistive role and (2) adapting medical education. The study suggests that we need to take intentional steps in order to ensure that the deployment of AI tools in healthcare has a positive impact on person-centred doctor-patient relationships. We argue that the proposed solutions are contingent upon clarifying the values underlying future healthcare systems.

Patient perceptions of empathy in primary care telephone consultations: A mixed methods study

OBJECTIVE

Clinical empathy can enhance patient outcomes. This study examined patients' perceptions of empathy in primary care consultations delivered by telephone.

METHODS

A mixed methods study was nested in a larger feasibility study conducted May-October 2020. Adults reporting a UK primary care consultation in the previous 2 weeks completed an online survey. A sample of survey respondents participated in a semi-structured qualitative interview. Interviews were analysed thematically.

RESULTS

Survey respondents (n = 359) rated practitioners as between 'good' and 'very good' at established patient-reported indicators of clinical empathy. Telephone consultations were rated slightly lower than face-to-face or other consultations. 30 survey respondents were interviewed. Three qualitative themes identified how telephone consultations can shape clinical empathy: setting for an empathic encounter; feeling connected; being acknowledged.

CONCLUSION

Primary care patients typically perceive good levels of clinical empathy in telephone consultations; specific features of telephone consultations may facilitate and/or hinder clinical empathy.

PRACTICE IMPLICATIONS

To ensure patients feel listened to, acknowledged and understood, practitioners may need to increase their empathic verbalisations in telephone consultations. By using verbal responses to demonstrate active listening and by clearly describing and/or implementing next steps in management, practitioners may be able to enhance clinical empathy in telephone consultations.

Measurement of person-centred consultation skills among healthcare practitioners: a systematic review of reviews of validation studies

BACKGROUND

Person-centred care is integral to high-quality health service provision, though concepts vary and the literature is complex. Validated instruments that measure person-centred practitioner skills, and behaviours within consultations, are needed for many reasons, including in training programmes. We aimed to provide a high-level synthesis of what was expected to be a large and diverse literature through a systematic review of existing reviews of validation studies a of instruments that measure person-centred practitioner skills and behaviours in consultations. The objectives were to undertake a critical appraisal of these reviews, and to summarise the available validated instruments and the evidence underpinning them.

METHODS

A systematic search of Medline, EMBASE, PsycINFO and CINAHL was conducted in September 2020. Systematic reviews of validation studies of instruments measuring individual practitioner person-centred consultation skills or behaviours which report measurement properties were included. Review quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Details of the reviews, the included validation studies, and the instruments themselves are tabulated, including psychometric data, and a narrative overview of the reviews is provided.

RESULTS

Four reviews were eligible for inclusion. These used different conceptualisations of person-centredness and targeted distinct, sometimes mutually exclusive, practitioners and settings. The four reviews included 68 unique validation studies examining 42 instruments, but with very few overlaps. The critical appraisal shows there is a need for improvements in the design of reviews in this area. The instruments included within these reviews have not been subject to extensive validation study.

DISCUSSION

There are many instruments available which measure person-centred skills in healthcare practitioners and this study offers a guide to what is available to researchers and research users. The most relevant and promising instruments that have already been developed, or items within them, should be further studied rigorously. Validation study of existing material is needed, not the development of new measures.

Eleven years of data on the Jefferson Scale of Empathy - medical student version: Japanese norm data and tentative cutoff scores

BACKGROUND

More and more studies investigate medical students' empathy using the Jefferson Scale of Empathy (JSE). However, no norm data or cutoff scores of the JSE for Japanese medical students are available. This study therefore explored Japanese norm data and tentative cutoff scores for the Japanese translation of the JSE-medical student version (JSE-S) using 11 years of data obtained from matriculants from a medical school in Japan.

METHODS

Participants were 1,216 students (836 men and 380 women) who matriculated at a medical school in Japan from 2011 to 2021. The JSE-S questionnaire was administered to participants prior to the start of the program. Data were summarized using descriptive statistics and statistical tests were performed to show the norm data and tentative cutoff scores for male and female students separately.

RESULTS

The score distributions of the JSE-S were moderately skewed and leptokurtic for the entire sample, with indices -0.75 and 4.78, respectively. The mean score (standard deviation) for all participants was 110.8 (11.8). Women had a significantly higher mean score (112.6) than men (110.0; p < 0.01). The effect size estimate of gender difference was 0.22, indicating a small effect size. The low and high cutoff scores for men were ≤ 91 and ≥ 126, respectively, and the corresponding scores for women were ≤ 97 and ≥ 128, respectively.

CONCLUSIONS

This study provides JSE-S norm data and tentative cutoff scores for Japanese medical school matriculants, which would be helpful in identifying those who may need further training to enhance their empathy.

Impact of Perfectionism and Resilience on Empathy in Medical Students: A Cross-Sectional Study

Empathy is a cognitive attribute that forms the cornerstone for good doctor–patient encounters. The formative period for the development of empathy toward patients begins with clinical encounters within medical school. An individual medical student's empathy levels may in part be a product of their resilience and perfectionist attitudes. A cross-sectional study with 320 medical students across all years of study was conducted to determine the correlation of perfectionism and resilience with clinical empathy in medical students. The JSE-S, CD-RISC 10, and APS-R scales were used to assess levels of empathy, resilience, and perfectionism, respectively. The study found that a positive correlation exists between resilience (r = 0.174) and academic year with empathy, and a negative correlation exists between maladaptive perfectionism and empathy (r = −0.138). The resilience score declined progressively as the year of study progressed with a statistically significant. Mean empathy scores were lowest in fifth-year students (96.8 ± 12.5) and highest in third-year students (107.8 ± 13.2). Further longitudinal studies are necessary to better understand the impact of resilience and perfectionism on empathy.

Validity and reliability of a Korean version of the Consultation and Relational Empathy (CARE) measure

BACKGROUND

No validated tool is available to assess patients' perception of physician empathy in Korea. The objective of this study was to establish a Korean version of the Consultation and Relational Empathy (CARE) measure-originally developed in English and widely used internationally-and to examine its reliability and validity.

METHODS

The CARE measure was translated into Korean and tested on 240 patients from one secondary care hospital and one tertiary care hospital in Korea. Internal consistency by Cronbach's alpha, exploratory analysis, and confirmatory factor analysis were conducted to verify the 10 items of the Korean CARE measure.

RESULTS

The Korean CARE measure demonstrated high acceptability and face validity, excellent internal reliability (Cronbach's alpha = 0.97) and moderate test-retest reliability (Pearson correlation coefficient = 0.53; Spearman correlation coefficient = 0.51). Distribution of scores showed negative skewedness. Corrected item-total correlations ranged from 0.77-0.92, indicating homogeneity. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.949, and Bartlett's test of sphericity was good (χ2 = 3157.11, P < 0.001). Factor analysis yielded a single dimensional structure of physician empathy with all factor loadings exceeding 0.80 and showing excellent goodness of fit.

CONCLUSION

This study supports the reliability and validity of the Korean CARE measure in a university hospital setting in Korea.

Evaluation of MyRelief Serious Game for Better Self-Management of Health Behaviour Strategies on Chronic Low-Back Pain

Low back pain is a leading cause of disability worldwide, putting a significant strain on individual sufferers, their families, and the economy as a whole. It has a significant economic impact on the global economy because of the costs associated with healthcare, lost productivity, activity limitation, and work absence. Self-management, education, and adopting healthy lifestyle behaviors, such as increasing physical activity, are all widely recommended treatments. Access to services provided by healthcare professionals who provide these treatments can be limited and costly. This evaluation study focuses on the application of the MyRelief serious game, with the goal of addressing such challenges by providing an accessible, interactive, and fun platform that incorporates self-management, behavior change strategies, and educational information consistent with recommendations for managing low-back pain, based on self-assessment models implemented through ontology-based mechanics. Functional disability measured using the Oswestry Disability Questionnaire showed the statistically significant (p < 0.001) improvement in subjects’ self-evaluation of their health status. System Usability Scale (SUS) test score of 77.6 also suggests that the MyRelief serious game can potentially influence patient enablement.

Understanding factors affecting 30-day unplanned readmissions for patients undergoing total knee arthroplasty (TKA): the ACT Transition from Hospital to Home Orthopaedics Survey

OBJECTIVES

The aim of this study was to investigate factors associated with unplanned 30-day readmissions following a total knee arthroplasty (TKA), including association with post-hospital syndrome, patient enablement and transition from hospital to home.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional written survey of public and private patients attending a 6-week follow-up appointment after TKA at one of four clinical services in the Australian Capital Territory (ACT) between 1 February 2018 and 31 January 2019. Multiple logistic regression analyses were used to measure associations between patient, hospital and transitional care factors with unplanned 30-day readmissions, while controlling for known confounders.

RESULTS

Of the 380 participants who completed the survey (n=380, 54% of TKAs undertaken over the study period), 3.4% (n=13; 95% CI: 1.8 to 5.8) were subsequently readmitted within 30 days of discharge after a primary hospitalisation. Public patients were significantly more likely to be readmitted within 30 days compared with private patients (adjusted OR=6.31, 95% CI: 1.59 to 25.14, p=0.009), and patients who attended rehabilitation were significantly less likely to be readmitted within 30 days of discharge than those who did not (adjusted OR=0.16, 95% CI: 0.04 to 0.57, p=0.005). There were no associations between post-hospital syndrome or patient enablement and 30-day readmissions in this study.

CONCLUSION

Reasons underlying the difference in unplanned readmission rates for public versus private patients need to be explored, including differences in surgical waiting times and the consequences for impairment and disease complexity. Strategies to foster increased participation post-surgical rehabilitation programmes need to be developed as an avenue to mitigate the burden of unplanned 30-day readmissions on individuals and health systems.

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.

Adapting the depression component of WHO Mental Health Gap Intervention Guide (mhGAP-IG.v2) for primary care in Shenzhen, China: a DELPHI study

Background

Primary care doctors in Shenzhen, China are increasingly expected to identify and prevent depressive disorder; however, they have received limited mental health training and community healthcare centres (CHC) do not provide standardised protocols for the diagnosis and care of depressive disorder. The World Health Organization’s mental health gap intervention guide, version 2 (mhGAP-IG.v2) is a decision support tool for non-specialists for the assessment, management and follow-up of mental, neurological and substance use disorders (including depressive disorder). Given that mhGAP-IG.v2 is a generic tool, it requires adaptation to take account of cultural differences in depression presentation and unique characteristics of China’s emergent mental health system.

Methods

A two-round, web-based, Delphi survey was conducted. A panel of primary care doctors from Shenzhen, were invited to score their level of agreement with 199 statements (arranged across 10 domains) proposing changes to the content and structure of mhGAP-IG.v2 for use in Shenzhen. Consensus was predefined as 80% panelists providing a rating of either “somewhat agree/definitely agree”, or “definitely disagree/somewhat disagree” on a five-point scale for agreement.

Results

79% of statements received consensus with a mean score of 4.26 (i.e. “somewhat agree”). Agreed adaptations for mhGAP-IG.v2 included:- an assessment approach which considers a broader spectrum of depression symptoms and reflects the life course of disease; incorporating guidance for screening tool usage; clarifying physicians’ roles and including referral pathways for intersectorial care with strong family involvement; aligning drug treatment with national formularies; stronger emphasis of suicide prevention throughout all sections of the guide; contextualizing health education; reflecting a person-centred approach to care. Panelists chose to maintain diagnostic and treatment advice for bipolar patients experiencing a depressive episode as in the current guide.

Conclusions

An adapted mhGAP-IG.v2 for depression recognises China’s cultural and contextual needs for assessment guidance; unique primary healthcare system organization, priorities and treatment availability; and diverse psychosocial educational needs. An adapted mhGAP-IG.v2 could both inform the future training programs for primary care in Shenzhen and also offer an additional mental health resource for non-specialists in other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00523-0.

Patient-provider therapeutic connections to improve health care: Conceptual development and systematic review of patient measures

BACKGROUND

The Triple Aim (improved population health, improved patient experiences, and lower costs) has influenced U.S. health care since it was introduced in 2008. With it, value-based purchasing has brought unprecedented focus on patient experience measurement. Despite having devoted extensive resources toward improving patient experiences, inconsistent improvements suggest there are some dimensions not yet being widely measured or addressed. Furthermore, a renewed focus on health disparities calls for stronger patient-provider connections in order to reduce health care inequities.

PURPOSE

The aim of this study was to articulate the concept of therapeutic connections (TCs) in health care and examine existing survey measures, from the patient perspective, to learn whether they capture the TC construct.

METHOD

We interviewed subject matter experts (n = 24) and patients (n = 22) about measuring TCs and then conducted a systematic review of quantitative measures from three databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria.

RESULTS

Of 31 unique measures, none captured all of the theorized TC dimensions. Most were measures of collaboration and shared decision-making or caring.

DISCUSSION

Focusing on the nature of patient-provider connections is vital because they are the backbone of most delivery models seeking to achieve the Triple Aim. Further development of the TC concept and measures is warranted to facilitate organizational and financing policies that meaningfully support widespread improvement.

PRACTICE IMPLICATIONS

A focus on barriers and facilitators of TCs is needed. Without advancing our understanding of the role TCs play in care, policymakers and practitioners will be limited in their ability to make impactful changes.

Perceptions of Hospital-at-Home Among Stakeholders: a Meta-synthesis

BACKGROUND

Hospital-at-home (HaH) provides acute healthcare in patients' homes as an alternative to traditional hospital inpatient care. HaH has been shown to improve clinical outcomes, increase patient satisfaction, and reduce hospitalization costs. Despite its effectiveness, the uptake of HaH remains slow and little is known about factors that impact the quality and transferability of HaH. This review aimed to qualitatively synthesize existing literature to examine the perspectives of stakeholders to identify areas of improvement in this model of care.

METHODOLOGY

Six electronic databases (Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase, PsychINFO, Scopus, and Mednar) were searched from inception date until 3 February 2021. The included studies were assessed for quality using the Critical Appraisal Skills Program tool. This review was registered on the International Prospective Register of Systematic Reviews. The meta-synthesis was completed according to Sandelowski and Barroso's guidelines.

RESULTS

Sixteen articles met the inclusion criteria. The overarching synthesized theme was "the intricacies of developing HaH," and the four main themes were (1) factors influencing patient selection, (2) advantages of HaH, (3) challenges of HaH, and (4) enablers for HaH development.

CONCLUSION

Overall, high levels of satisfaction were expressed by various stakeholders. Continuity of care remains an important factor for patient-centeredness in HaH. Caregivers should be involved in the decision-making process and supported throughout the HaH duration to prevent caregiver burnout. Collaboration and coordination among healthcare professionals are vital and can be strengthened through training and technological advancements of remote patient monitoring. Institutional and organizational support for stakeholders may make HaH a viable solution to modern healthcare challenges.

An Ethical Case for Medical Scribes

This article addresses ethical concerns with the use of electronic health records (EHRs) by physicians in clinical practice. It presents arguments for two claims. First, requiring physicians to maintain patient EHRs for medically unnecessary tasks is likely contributing to increased burnout, decreased quality of care, and potential risks to patient safety. Second, medical institutions have ethical reasons to employ medical scribes to maintain patient EHRs. Finally, this article reviews central objections to employing medical scribes and provides responses to each.

Meaning in life as a mediator of dark triad with confidence in treatment and subjective evaluation of treatment outcome among male drug abstainers

BACKGROUND

Although the roles of personality in predicting substance abuse have been widely documented, few studies have investigated the relationships the dark triad (DT) personalities had with confidence in treatment (CIT) and subjective evaluation of treatment outcome (SETO) in drug abstainers.

OBJECTIVE

This study examined the relationship between DT and treatment-relevant variables, and the potential effect of meaning in life (MIL) in these links.

METHODS

Participants were male inpatients who started substance abuse treatment between June and December 2018 in Henan Province, China. The inclusion criteria were the diagnosis of substance use disorders. The exclusion criteria were illiteracy, comorbidity with psychopathology disorders, intellectual disability, and refusal of consent. A total of 236 men (aged 21-62 years, M = 45.30, SD = 7.72) were randomly selected and reported their DT, MIL, CIT, and SETO.

RESULTS

Results showed that DT was negatively correlated with MIL, CIT, and SETO. MIL was positively correlated with CIT and SETO. The dark triad is associated with CIT both directly and indirectly via MIL. DT is indirectly correlated with SETO via MIL. Higher levels of DT in drug abstainers can reduce CIT and SETO by decreasing individual's MIL.

CONCLUSION

This study provides insights into the links between the DT and treatment-relevant variables, which can potentially impact the effectiveness of current substance abuse treatment programs.

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.

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.

The direct and indirect effects of clinical empathy on well-being among pre-medical students: a structural equation model approach

BACKGROUND

Empathy is a well-established facet of clinical competency that research suggests is associated with enhanced medical student well-being. Since little is known about empathy and well-being before students enter medical school-during pre-medical education-the main goal of this study is to test a conceptual model of how clinical empathy is related to two indicators of well-being, depression, and burnout among pre-medical students. The theoretical model hypothesizes that three dimensions of clinical empathy-Perspective-Taking, Compassionate Care, and Standing in Patients' Shoes- will be directly and negatively related to depression, as well as indirectly through its inverse relationship with three facets of burnout, Emotional Exhaustion, Poor Academic Efficacy, and Cynicism.

METHODS

Using survey data from a sample of 132 pre-medical students at an American Midwestern university, this study employs structural equation modeling (SEM) to test the theoretical model of the relationships between empathy, burnout, and depression among pre-medical students. We identify the direct effects of the three dimensions of the Jefferson Scale of Physician Empathy (JSE-S) on depression (CES-D), as well as the indirect effects of clinical empathy on depression through the three dimensions of the Maslach Burnout Inventory (MBI-S).

RESULTS

SEM analyses show that while none of the three dimensions of the JSE-S are directly related to depression, clinical empathy does significantly affect depression indirectly through burnout. Specifically, as predicted, we find that Perspective-Taking decreases Emotional Exhaustion, but, contrary to expectations, Compassionate Care increases it. And, the positive relationship between Compassionate Care and Emotional Exhaustion is particularly strong. In turn, Perspective-Taking and Compassionate Care are associated with depression in opposite directions and to different degrees.

CONCLUSIONS

Findings suggest that clinical empathy as measured by the JSE-S produces both positive and negative effects on personal well-being. We conclude that further conceptual clarity of clinical empathy is needed to better discern how the different dimensions impact different indicators of well-being. Given that pre-medical education is a crucial time for emotional socialization, the challenge for medical education will be fostering the positive, cognitive aspects of clinical empathy while simultaneously mitigating the adverse effects of affective empathy on medical student well-being.

Perceptions and experiences of a manual therapy trial: a qualitative study of people with moderate to severe COPD

Background

Chronic obstructive pulmonary disease (COPD) presents with physical, emotional and social difficulties that affect quality of life. Multimodal management includes both pharmacological and non-pharmacological strategies, and pulmonary rehabilitation (PR) plays an important role. Recent research has suggested that manual therapies may improve perceptions of dyspnea for people with COPD.

Methods

Focus group interviews were conducted as part of a mixed methods study to assess the feasibility of implementing a manual therapy technique—muscle energy technique (MET)—as an adjunct to PR for people with moderate to severe COPD. Focus group interviews were conducted to examine trial participants views of the intervention and the trial design. A thematic analysis was undertaken to explore the data.

Results

Twelve participants with moderate to severe COPD participated in three focus groups. Participants were motivated to participate in the trial to be proactive about their health. They perceived MET to be a gentle, comfortable form of stretching that allowed them to ‘breathe easier’ and prepared them for PR. A small number of participants reported mild muscular discomfort during MET, but this was short-lasting and was not bothersome. Participants enjoyed the one-on-one contact with researchers and learned more about their breathing while performing spirometric testing. Most participants wanted longer and more frequent MET sessions, and some requested ‘homework’ stretching exercises.

Conclusions

The findings of this study show that a manual therapy intervention was received well by participants in a clinical trial setting. A small number of participants reported mild musculoskeletal discomfort in relation to the MET treatment. Participant preferences for additional and longer treatment sessions should be carefully considered against available resources in future clinical trials.

Trial registration

ANZCTR, ACTRN12618000801213. Registered 11 May 2018 - Retrospectively registered. http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374643&isReview=true

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00387-0.

Reliability and validity of the Spanish (Spain) version of the consultation and relational empathy measure in primary care

BACKGROUND

Empathy is an essential competence in the medical field. There are no validated patient-rated empathy measures in Spanish (Spain). The Consultation and Relational Empathy (CARE) measure is a widely used patient-rated measure of physician empathy.

OBJECTIVE

To analyse the reliability and validity of the Spanish (Spain) version of the CARE measure in primary care.

METHODS

After translation, back translation and pilot testing, a convenient sample of 369 patients recruited through 21 primary care physicians in five primary care centres in Pamplona (Navarre, Spain) completed the Spanish (Spain) CARE (Sp-CARE) measure. The number of 'does not apply' or blank responses was calculated to assess acceptability. We analysed internal reliability by means of Cronbach's alpha and ordinal alpha and homogeneity with corrected item-total correlations. The construct validity was examined by confirmatory factor analysis (CFA) and concurrent validity by Spearman's correlation.

RESULTS

We observed high acceptability; only 37 (1%) responses were marked 'does not apply' and only 3 (0.08%) were left blank. Cronbach's alpha and ordinal alpha for the Sp-CARE measure were 0.953 and 0.970, respectively, and all corrected item-total correlations exceeded the accepted cut of 0.30, demonstrating high internal reliability and homogeneity. CFA corroborated the one-factor structure proposed in the original version. The Sp-CARE measure total score was significantly correlated with overall patient satisfaction (Spearman's rho 0.45, P < 0.001).

CONCLUSION

The results support the reliability and validity of the Sp-CARE measure as a patient-rated empathy measure in the primary care setting.

Treatment satisfaction mediates the association between perceived physician empathy and psychological distress in a community sample of individuals with chronic pain

OBJECTIVE

While the benefits of patient-centered care have been consistently demonstrated in the health literature, there exists a dearth of pathway research within health outcome research, especially within the chronic pain context. This study examined the relationship between perceived physician empathy and patient psychological distress and its underlying mechanism.

METHODS

A community sample of 259 adults with chronic pain completed online questionnaires measuring patient-perceived physician empathy, treatment satisfaction, depressive and anxiety symptoms. Analyses were conducted using correlational and mediation analyses.

RESULTS

Results revealed perceived empathy to be positively and strongly correlated with treatment satisfaction (r = .72, p < .001). A significant negative correlation was also demonstrated between perceived empathy and depressive symptoms (r = -.13, p < .05), but not between perceived empathy and anxious symptoms (r = .03, p = .65). Results revealed significant mediation models between perceived empathy and patient depressive symptoms (indirect effect: B = -.19, SE =.06, 95 % CI [-.31, -.09]) and anxious symptoms (indirect effect: B = -.24, SE = .06, 95 % CI [-.35, -.14]), via treatment satisfaction as mediator and including covariates.

CONCLUSION

Chronic pain patients who perceive greater levels of physician empathy experience fewer depressive and anxious symptoms, as mediated by treatment satisfaction.

PRACTICE IMPLICATIONS

Clinical training and practice should promote empathetic components of health communication within chronic pain treatment.

Application of the Spanish-Language Consultation and Relational Empathy (CARE) Measure to Assess Patient-Centered Care Among Latino Populations

INTRODUCTION

Reliable and valid measures are needed to assess the patient-centeredness of clinical care among Latino populations.

METHODS

We translated the Consultation and Relational Empathy (CARE) measure from English to Spanish and assessed its psychometric properties using data from 349 Latino parents/guardians visiting a pediatric clinic. Using confirmatory factor analysis, we examined the psychometric properties of the Spanish CARE measure.

RESULTS

Internal reliability of the Spanish CARE measure was high (Omega coefficient = 0.95). Similar to the English-language CARE measure, factor analysis of the Spanish CARE measure yielded a single domain of patient-centeredness with high item loadings (factor loadings range from 0.79 to 0.96).

CONCLUSION

This preliminary analysis supports the reliability and validity of the Spanish version of the CARE measure among Latinos in pediatric care settings. With further testing, the Spanish CARE measure may be a useful tool for tracking and improving the health care delivered to Latino populations.

General practitioners' training and their attitudes towards young people who self-harm: A cross-sectional survey

AIM

Self-harm is common among adolescents and young adults and carries increased risk of suicide and other negative outcomes, yet only a small proportion will seek professional help. General practitioners (GPs) are a potentially valuable source of help as most young people visit their GP regularly for other reasons. The primary aim of this research was to explore GPs' empathy and attitudes towards young people who self-harm and how these are related to GP specialist training.

METHOD

GPs completed questionnaires regarding their training, levels of empathy, perceived knowledge and attitudes towards young people who self-harm. The cross-sectional design included a random sample of 178 GPs and 47 GPs-in-training in the Republic of Ireland. Bootstrapped mediation analysis using structural equation modelling (SEM) was applied to explore the pattern of relationships among GP-training, empathy, perceived knowledge of self-harm and attitudes towards youth who self-harm.

RESULTS

The SEM results revealed that the model had a very good fit to the data. Empathy was the strongest predictor of attitudes towards self-harm even if GPs had received youth mental health training and fully mediated the effect of youth mental health training on perceived knowledge of self-harm. Specialized training in self-harm was a stronger predictor of perceived knowledge than empathy but had no association with negative attitudes.

CONCLUSIONS

The findings emphasize positive outcomes associated with GP training and highlight potential differences in the effects associated with specific vs general training in youth mental health. These differences may be used to inform the design and implementation of continuing professional development.

Do GPs use motivational interviewing skills in routine consultations with patients living with mental-physical multimorbidity? An observational study of primary care in Scotland

OBJECTIVES

To examine whether motivational interviewing is used by GPs in consultations with patients living with mental-physical multimorbidity.

METHODS

Secondary analysis of selected videos from an existing database of routine general practice consultations with adult patients in Glasgow, Scotland. Consultations involving patients with mental-physical multimorbidity were selected and coded using the Motivational Interviewing Treatment Integrity (MITI) coding system.

RESULTS

Sixty consultations were coded involving 32 GPs across 16 practices. Mean consultation length was 9.9 min. On average GPs asked 1.7 questions per minute and offered 1.2 pieces of information per minute. Using the MITI, five GPs met beginner proficiency for the relational global qualities of partnership and empathy; however, none of the GPs met beginner proficiency for the technical global rating of efforts made to encourage patients to discuss behaviour change. Simple reflections were observed in 67% of consultations and complex reflections in 28% of consultations. Confrontation, a technique inconsistent with motivational interviewing, was observed in 18% of consultations.

DISCUSSION

MI was not evident in these consultations with patients living with mental-physical multimorbidity. This study provides information about the baseline motivational interviewing-consistent skills of GPs working with multimorbid patients and may be helpful in informing motivational interviewing training efforts and future research.

Communication Experiences in Primary Healthcare with Refugees and Asylum Seekers: A Literature Review and Narrative Synthesis

Refugee and asylum seeker population numbers are rising in Western countries. Understanding the communication experiences, within healthcare encounters, for this population is important for providing better care and health outcomes. This review summarizes the literature on health consultation communication experiences of refugees and asylum seekers living in Western countries. Seven electronic databases were searched from inception to 31 March 2019. Studies were included if they aimed to improve, assess or report on communication/interaction in the primary health care consultation setting with refugees or asylum seekers, and were conducted in Western countries. A narrative synthesis of the literature was undertaken. Thematic analysis of the 21 included articles, showed that refugees and asylum seekers experience a range of communication challenges and obstacles in primary care consultations. This included practical and relational challenges of organizing and using informal and formal interpreters and cultural understanding of illness and healthcare. Non-verbal and compassionate care aspects of communication emerged as an important factor in helping improve comfort and trust between healthcare providers (HCP) and refugees and asylum seekers during a healthcare encounter. Improvements at the systems level are needed to provide better access to professional interpreters, but also support compassionate and humanistic care by creating time for HCPs to build relationships and trust with patients.

Effect of PARACT (PARAmedical Interventions on Patient ACTivation) on the Cancer Care Pathway: Protocol for Implementation of the Patient Activation Measure-13 Item (PAM-13) Version

BACKGROUND

The increase in the number of cancer cases and the evolution of cancer care management have become a significant problem for the French health care system, thereby making patient empowerment as a long sought-after goal in chronic pathologies. The implementation of an activation measure via the Patient Activation Measure-13 item (PAM-13) in the course of cancer care can potentially highlight the patient's needs, with nursing care adapting accordingly.

OBJECTIVE

The objectives of this PARACT (PARAmedical Interventions on Patient ACTivation) multicentric study were as follows: (1) evaluate the implementation of PAM-13 in oncology nursing practices in 5 comprehensive cancer centers, (2) identify the obstacles and facilitators to the implementation of PAM-13, and (3) produce recommendations for the dissemination of such interventions in other comprehensive cancer centers.

METHODS

This study will follow the "Reach, Effectiveness, Adoption, Implementation, and Maintenance" framework and will consist of 3 stages. First, a robust preimplementation analysis will be conducted using the Theoretical Domains Framework (TDF) linked to the "Capability, Opportunity, Motivation, and Behavior" model to identify the obstacles and facilitators to implementing new nursing practices in each context. Then, using the Behavior Change Wheel, we will personalize a strategy for implementing the PAM-13, depending on the specificities of each context, to encourage acceptability by the nursing staff involved in the project. This analysis will be performed via a qualitative study through semistructured interviews. Second, the patient will be included in the study for 12 months, during which the patient care pathway will be studied, particularly to collect all relevant contacts of oncology nurses and other health professionals involved in the pathway. The axes of nursing care will also be collected. The primary goal is to implement PAM-13. Secondary factors to be measured are the patient's anxiety level, quality of life, and health literacy level. The oncology nurses will be responsible for completing the questionnaires when the patient is at the hospital for his/her intravenous chemotherapy/immunotherapy treatment. The questionnaires will be completed thrice in a year: (1) at the time of the patient's enrollment, (2) at 6 months, and (3) at 12 months. Third, a postimplementation analysis will be performed through semistructured interviews using the TDF to investigate the implementation problems at each site.

RESULTS

This study was supported by a grant from the French Ministry of Health (PHRIP PARACT 2016-0405) and the Lucien Neuwirth Institute of Cancerology of Saint-Etienne, France. Data collection for this study is ongoing.

CONCLUSIONS

This study would improve the implemented targeted nursing interventions in cancer centers so that a patient is offered a personalized cancer care pathway. Furthermore, measuring the level of activation and the implementation of measures intended to increase such activation could constitute a significant advantage in reducing social health inequalities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03240341; https://clinicaltrials.gov/ct2/show/NCT03240341.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17485.

Empathy, well-being and stressful experiences in the clinical learning environment

OBJECTIVE

This study examines whether students in the clinical phase show reduced well-being and lower empathy scores compared to preclinical students. Furthermore, it explores students' most stressful experiences.

METHODS

A cross-sectional mixed-methods study was conducted among medical students of the revised patient- and student-centred curriculum at Witten/Herdecke University (Germany). An online survey included questions regarding empathy (JSPE-S), well-being (WHO-5), distressing factors in the learning and clinical environments, mistreatment and thoughts of dropping out.

RESULTS

176 (34 %) of 517 medical students completed the questionnaire, 73 being preclinical and 103 clinical students. Despite lower well-being, clinical student did not demonstrate lower empathy levels. Main stressors during the clinical phase were negative physician role models and financially focussed care rather than challenging patient encounters. Compared to preclinical students, clinical students showed more mistreatment experiences and higher ratings towards thoughts of dropping out.

CONCLUSION

Our results illustrate contemporary challenges to establishing a learner-centred clinical environment that nurtures well-being and empathy of medical students. The sustainment of empathy despite more stressful experiences and lower well-being may be due to protective factors.

PRACTICE IMPLICATIONS

The paper suggests activities to support clinical students to find ways to adapt the clinical learning environment to students' needs.

The validity and reliability of the patient enablement instrument (PEI) after GP appointments in Finnish health care centres

BACKGROUND

The aim of this study was to assess the validity and reliability of the Patient Enablement Instrument (PEI) in Finnish health care centre patients. A pilot study was conducted to assess the content validity of the PEI. A questionnaire study in three health care centres in Western Finland was performed in order to assess acceptability, construct validity, internal consistency, and measurement error of the instrument. A telephone interview 2 weeks after the appointment was performed to evaluate reproducibility.

RESULTS

The pilot study with 17 participants indicated good content validity of the PEI. In the questionnaire study, altogether 483 with a completed PEI score were included in the analyses. Factor analysis and item-scale correlations suggested high structural validity. The internal consistency of the instrument was high (Cronbach's α = 0.93). The PEI score diminished strongly over the two-week period.

CONCLUSIONS

The PEI has good content validity and acceptability, good construct validity, high internal consistency but low reproducibility. Thus, the PEI seems to be an applicable tool to measure patient enablement in Finnish primary health care.

Are clinicians' self-reported empathic concern and perspective-taking traits associated with their response to patient emotions?: Communication Studies

OBJECTIVE

To understand whether clinicians' empathic concern and perspective-taking traits are associated with their response to patient emotions.

METHODS

We audio-recorded 41 HIV clinician interactions with 342 patients at two academic medical centers. We assessed clinicians' self-reported empathic concern and perspective-taking traits using the Interpersonal Reactivity Index and coded emotional communication using the Verona Coding Definitions of Emotional Sequences. We used random effects models to assess associations between clinician traits and clinician responses to patients' negative emotions, accounting for clustering of emotions within encounters and patients within clinicians.

RESULTS

Clinicians with more self-reported empathic concern received fewer emotional expressions from their patients (β -0.06; 95% CI -0.10, -0.01) and had greater odds of responding to emotions by giving information/advice (OR 1.10; 95% CI 1.01, 1.20). There were no associations between empathic concern or perspective-taking and any other clinician responses.

CONCLUSION

Clinicians with higher levels of empathic concern respond to patient emotions by giving information and advice, a response traditionally thought of as a missed empathic opportunity, not by exploring emotions or providing empathy. Whether this is helpful to patients is unknown.

PRACTICE IMPLICATIONS

Clinicians should be aware of their tendency to give information to patients with emotional distress, and consider whether this response is helpful to patients.

Does GP empathy influence patient enablement and success in lifestyle change among high risk patients?

Background

Chronic lifestyle-related-diseases can be prevented by healthy lifestyle. Patients at high risk of disease may benefit from targeted health checks in general practice. However, general-practice-based-studies have shown that patient outcome, enablement, and well-being may be influenced by general practitioner (GP) empathy. The aim of this study is to investigate 1) how high risk patients evaluate their GPs’ empathy during a health check consultation, 2) whether the perceived GP empathy is associated with the patient’s enablement in immediate continuation of the health check consultation and 3) the patient’s subsequent lifestyle changes.

Methods

This study is part of a population based non-randomized feasibility study testing a complex intervention that systematically identifies citizens at high risk of lifestyle-related disease and with health-risk behavior and offers targeted preventive services in the Danish primary care sector. The ultimate aim of the intervention is to improve lifestyle and thereby reduce the risk of lifestyle-related disease. In the feasibility study a random sample of patients aged 30 to 59 years were invited to participate, and to fill in a questionnaire on lifestyle-risk factors. Participants deemed to be at high risk of disease were offered a focused clinical examination and a subsequent health check consultation at the GP. Following each health check consultation GP empathy and patient enablement were assessed using The Care Measure (CARE) and Patient Enablement Instrument (PEI). Patient’s perceived healthy-lifestyle change (y/n) was assessed after three months. The study has been approved by the Danish Data Protection Agency (J.nr 2015–57-0008) and registered at ClinicalTrial. Gov on June 13, 2016.

Results

Twenty-six GP’s participated in the study. Among 93 patients receiving a health check consultation 60 rated the GPs empathy. The median CARE-score was 40. The PEI median was 5.5 and 44.9% achieved a healthier lifestyle. No association was observed between GP empathy and patient enablement or a perceived healthier lifestyle.

Conclusion

No statistical significant association between the CARE-score and patient enablement or a perceived healthier lifestyle was observed. Our results contrast previous findings and may to some extent be explained by a small sample size and the selected high-risk group.

Trial registration number

NCT02797392.

Effect of Anxiety on Empathy: An Observational Study Among Nurses

Empathy, defined as an emotional ability to put oneself in the place of others, read their state of mind, and think how they are feeling, is an essential pillar of nursing care. On the other hand, anxiety is a frequent emotion that can be generated in stressful work environments, like nurses developing their activity. The aim of the present study is to explore the value of empathy and anxiety personal traits in staff nurses. The sample was comprised of 197 staff nurses from tertiary level hospitals from Madrid, Spain, where 79.2% were women and 20.8% were men in the present study. The instrument used for analysis was the Spanish adaptation of the 16PF5 questionnaire. The results showed the following measurements to warmth (5.58), lively (5.25), socially bold (5.6), privacy (5.82), open to change (5.62), self-reliance (6.12), and anxiety (6.38). Furthermore, anxiety affects positively to warmth (t: 2.66; p > 0.0001) and lively (t = 2.36; p < 0.05), but in a negative way to social bold (t = −3.17; p < 0.001) or open to change (t = −5.81; p < 0.0001). However, it was not seen to have any effect over privacy (t = 1.96; p = 0.052) and self-reliance (t = 1.19; p = 0.234). Finally, it is recommended that healthcare professionals reinforce their personal competencies to strengthen their skills to manage anxiety and improve their empathy competencies.

Research on the formation of humanistic care ability in nursing students: A structural equation approach

OBJECTIVE

To construct and test a hypothetical model linking the caring ability of nursing students with empathy ability, emotional intelligence, and communication ability.

METHOD

Participants were 851 students from three undergraduate colleges and one junior college in China, Gansu Province. Participating students had to fulfill the following requirements: different levels of nursing majors (undergraduates or junior college students), understand the study purpose, and be willing to participate in this study. Exclusion: secondary college students. Variables were measured by the Caring Ability Inventory, Emotional Intelligence Scale, Supportive Communicative Scale, and Interpersonal Reactivity Index. Data were analyzed with structural equation modeling to explore the path relationships and mutual effects between structural elements.

RESULTS

Empathy (β = 0.25, P<0.001), emotional intelligence (β = 0.36, P<0.001), and communication ability (β = 0.28, P<0.001) were significantly associated with the caring ability of nursing students. Empathy was the strongest factor associated with caring ability and emotional intelligence was a partial mediator of the relationship between empathy and communication skills.

CONCLUSIONS

The nurse's humanistic care ability requires continuous learning and school education. To enhance the humanistic care ability of nursing students, nursing educators should develop target strategies to improve the 'sympathetic ability,' 'emotional intelligence' and 'communication ability' of nursing students.

Care Is the Doctor's Best Prescription: The Impact of Doctor-Patient Empathy on the Physical and Mental Health of Asthmatic Patients in China

Background

To explore the impact of empathy between Chinese doctors and patients on anxiety, self-efficacy, sleep and IL-6 levels in hospitalized asthmatic patients.

Methods

This study included 195 asthmatic patients and 30 respirologists in China. The Jefferson Empathy Scale (JSE) was used to measure the empathy level of doctors, and the consultation and relational empathy (CARE) scale was used to measure patients' perception of empathy between themselves and their doctors. Doctors were divided into three groups, according to JSE scores. Data about anxiety, self-efficacy, sleep and IL-6 were collected and compared between patients in different JSE groups at admission (T1) and 3 months later (T2). The correlation between JSE scores and CARE scores was analyzed. Pearson correlation analysis along with a structural equation model was applied to explore the relevance among anxiety, self-efficacy, sleep, inflammatory factors (IL-6) and patients' perception of empathy shown by their doctors.

Results

There was no statistical difference between the indices of patients in three groups at admission. For all patients, the changes of indicators were statistically different from T1 to T2. Three months later, patients in high empathy scoring group showed lower anxiety and IL-6, and higher self-efficacy and sleep quality. There was a positive correlation between JSE and CARE scores. Patients' perception of doctor-patient empathy was negatively correlated to anxiety levels and IL-6, and positively correlated to self-efficacy and sleep quality. Anxiety, self-efficacy and sleep quality were mediators in the relationship between patients' perception of empathy and IL-6.

Conclusion

In the Chinese sample, anxiety, self-efficacy, sleep, empathy between doctors and patients and IL-6 are closely correlated. Anxiety, self-efficacy and sleep may play additional roles in the influence of patients' perception of empathy between doctors and patients on IL-6 in asthmatic patients.

Challenges in promoting clinical empathy skills in medical students: A content analysis study

Background: Empathy is a key clinical skill in the medical profession, and many studies have reported a decline in it among medical students during their years of education; especially, in the clinical stage, and this affective decline persists in the physician-hood. This study aimed to explore the participants' perceptions about challenges for promoting clinical empathy in training stages. Methods: A qualitative design using content analysis was applied. Semi-structured interviews were applied to obtain data. Individual interviews were conducted with 14 interns and six clinical professors. The data were analyzed through conventional content analysis and the credibility, trustworthiness, and conformability of the data were confirmed. Results: Data analysis led to the extraction of two main categories, including overt and covert challenges, and also four categories and nine sub-categories. Conclusion: Resolving clinical empathy challenges in medical students requires financial and human resources, and training on the principles of effective doctor-patient interactions. Furthermore, professionalism should be strengthened in professors, and both official and hidden curricula should be revised accordingly.

Association Between Primary Care Practitioner Empathy and Risk of Cardiovascular Events and All-Cause Mortality Among Patients With Type 2 Diabetes: A Population-Based Prospective Cohort Study

PURPOSE

To examine the association between primary care practitioner (physician and nurse) empathy and incidence of cardiovascular disease (CVD) events and all-cause mortality among patients with type 2 diabetes.

METHODS

This was a population-based prospective cohort study of 49 general practices in East Anglia (United Kingdom). The study population included 867 individuals with screen-detected type 2 diabetes who were followed up for an average of 10 years until December 31, 2014 in the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen Detected Diabetes in Primary Care (ADDITION)-Cambridge trial. Twelve months after diagnosis, patients assessed practitioner empathy and their experiences of diabetes care during the preceding year using the consultation and relational empathy (CARE) measure questionnaire. CARE scores were grouped into tertiles. The main outcome measures were first recorded CVD event (a composite of myocardial infarction, revascularization, nontraumatic amputation, stroke, and fatal CVD event) and all-cause mortality, obtained from electronic searches of the general practitioner record, national registries, and hospital records. Hazard ratios (HRs) were estimated using Cox models adjusted for relevant confounders. The ADDITION-Cambridge trial is registered as ISRCTN86769081.

RESULTS

Of the 628 participants with a completed CARE score, 120 (19%) experienced a CVD event, and 132 (21%) died during follow up. In the multivariable model, compared with the lowest tertile, higher empathy scores were associated with a lower risk of CVD events (although this did not achieve statistical significance) and a lower risk of all-cause mortality (HRs for the middle and highest tertiles, respectively: 0.49; 95% CI, 0.27-0.88, P = .01 and 0.60; 95% CI, 0.35-1.04, P = .05).

CONCLUSIONS

Positive patient experiences of practitioner empathy in the year after diagnosis of type 2 diabetes may be associated with beneficial long-term clinical outcomes. Further work is needed to understand which aspects of patient perceptions of empathy might influence health outcomes and how to incorporate this understanding into the education and training of practitioners.

A Learning Loop Model of Collaborative Decision-Making in Chronic Illness

Shared decision-making is a core attribute of quality health care that has proved challenging to implement and assess in pediatric practice. Current models of shared decision-making are limited, including their capacity to incorporate multiple stakeholders; to integrate downstream effects of subacute or minor decisions; and to account for the context(s) in which such decisions are being made and enacted. Based on a review of literature from organizational psychology, cognitive sciences, business, and medicine, we propose an iterative decision-making model of care planning and identify targets at several levels of influence warranting measurement in future studies. Our learning loop model posits the relationship between pediatric patients, their parents, and their clinicians as central to the collaborative decision-making process in the setting of chronic illness. The model incorporates the evolution of both context and developmental capacity over time. It suggests that "meta-learning" from the experience of and outcomes from iterative decision is a key factor that may influence relationships and thus continued engagement in collaboration by patients, their parents, and their clinicians. We consider the model in light of the needs of children with special health care needs, for whom understanding the ongoing iterative effects of decision making and clinician-parent-child dynamics are likely to be particularly important in influencing outcomes.

Comparison of the Patient Enablement Instrument (PEI) with two single-item measures among Finnish Health care centre patients

Background

The Patient Enablement Instrument (PEI) is an established patient-reported outcome measure (PROM) that reflects the quality of appointments with general practitioners (GPs). It is a six-item questionnaire administered to the patient immediately after a consultation. The aim of this study was to evaluate whether a single-item measure could replace the PEI when measuring patient enablement among Finnish health care centre patients.

Methods

Two single-item measures, Q1 and Q2, were chosen for comparison with the PEI. Firstly, a pilot study with questionnaire testing and brief interviews with the respondents were performed in order to assess the content validity of the PEI and the single-item measures. Secondly, a questionnaire study after a single appointment with a GP was carried out in three health care centres in Western Finland in order to evaluate the construct and criterion validity of the single-item measures. A telephone interview was performed 2 weeks after the appointment in order to assess the test-retest reliability of the single-item measures. The sensitivity, specificity, and both positive and negative predictive values of Q1 and Q2 were calculated with different PEI score cut-off points.

Results

Altogether 483 patients with a completed PEI were included in the questionnaire study analyses. Altogether 149 and 175 patients had completed Q1 and Q2, respectively, both in the questionnaire and the telephone interview. The correlations between the PEI and Q1 and Q2 were 0.48 and 0.84, respectively. Both the single-item measures had a high sensitivity and a negative predictive value in relation to patients with lower PEI scores. The reliability coefficients were 0.24 for Q1 and 0.76 for Q2. The test-retest values of Q1, Q2, and the PEI were low.

Conclusions

Q2 seems to be a valid and reliable measure of patient enablement. Q1 seems to be less correlated with the PEI, but it also has a high negative predictive value in relation to low enablement scores.

Developing Sustainable Healthcare Systems in Developing Countries: Examining the Role of Barriers, Enablers and Drivers on Knowledge Management Adoption

Knowledge management (KM) adoption is crucial to integrating sustainable development within the healthcare sector. Different barriers, enablers, and drivers affect KM adoption. Identifying these barriers, enablers, and drivers and their role in KM adoption is the core of successful KM adoption. However, there is scarcity of studies applying quantitative models and combing barriers, enablers and drivers to check their effect on KM adoption, especially form a developing country’s perspective such as Pakistan. Therefore, this study explores the role of barriers, enablers and drivers on KM adoption in Pakistan. Healthcare professionals participated in the data collection process, and results were analyzed using structural equation modeling. The findings described that: (1) organizational and strategic barriers have significant negative association with KM adoption; (2) government related enablers have significant positive association with KM adoption; (3) healthcare related drivers, and performance-based drivers have significant positive association with KM adoption. This study concludes that government intervention to promote KM adoption is necessary especially in developing countries. These findings will be helpful for the healthcare professionals and policy makers to promote KM adoption in healthcare sector. Current study contributes to the healthcare literature and body of knowledge by providing the empirical evidence of checking the quantitative effect of barriers, enablers and drivers on KM adoption.

Cross-cultural adaptation and validation of the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE) for the Portuguese population

OBJECTIVES

To translate the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) to the European Portuguese spoken language and to verify its reliability and validity.

METHODS

Cultural adaptation and linguistic translation from English to European Portuguese, revision of translations, semantics equivalence, and grammar correction of the Portuguese wording were made. Readability of the Portuguese version was verified and the analysis of internal consistency and correlation with the subscale "physician-patient relationship" of the Portuguese version of European Task Force on Patient Evaluation of General Practice Care Scale (EuroPEP) were made. Reliability was tested by intertemporal stability and internal consistency. Validity of criteria and construction was also verified.

RESULTS

The Portuguese translation was adapted to the 8th or 9th grade level, easy to understand. There was the need to change the visual appearance of the scale, answers below sentences. Interclass correlation coefficient for reliability varied between 0.737 and 1.000 and Cronbach's α between 0.806 and 0.877. Validity was verified by comparing values of socio-demographic variables for JSPPPE index and for EuroPEP with no differences. Correlation values between the total score and its five items varied from 0.806 to 0.934. Criterion validity against EuroPEP had a correlation of 0.831.

CONCLUSION

This study fulfilled the necessary steps to translate, verify the validity and the reliability of the Portuguese version of the JSPPPE, with minimum layout alteration. All five items were maintained. The authors recommend the use of the JSPPPE in research and clinical practice.

Language matters: a UK perspective

AIM

To review the existing evidence regarding the use of language in clinical encounters.

BACKGROUND

Awareness of the importance of language in clinical encounters is mostly lacking or located within broader discussions on communication.

METHODS

A scoping study was conducted to review existing research that could increase our understanding of the role language plays as well as identify gaps in knowledge and inform the development of a position statement on language in diabetes care.

RESULTS

Evidence shows that, although carefully chosen language can have a positive effect, there is a potential negative impact of language on people's experiences of diabetes care. The use of stigmatizing and discriminatory words during communication between healthcare practitioners and people with diabetes can lead to disengagement with health services as well as sub-optimal diabetes self-management. Clinical encounters can be compromised where language barriers exist or where there is limited understanding of cultural differences that may have an impact on diabetes self-management. What little empirical evidence there is shows that training can improve language and communication skills.

CONCLUSION

This review raises a number of questions that are being addressed by the NHS England Language Matters Group, which has developed a set of recommendations to support the use of appropriate language in clinical encounters.

Patient-centered care interventions to reduce the inappropriate prescription and use of benzodiazepines and z-drugs: a systematic review

Background

Benzodiazepines (BZDs) and z-drugs are effective drugs, but they are prescribed excessively worldwide. International guidelines recommend a maximum treatment duration of 4 weeks. Although these drugs are effective in the short-term, long-term BZD therapy is associated with considerable adverse effects, the development of tolerance and, finally, addiction. However, there are different interventions in terms of patient-centered care that aim to reduce the use of BZDs and z-drugs as well as assist health care professionals (HCPs) in preventing the inappropriate prescription of BZDs.

Aim

The aim of this systematic review was to identify interventions that promote patient-centered treatments for inappropriate BZD and z-drug use and to analyze their effectiveness in reducing the inappropriate use of these drugs.

Methods

To identify relevant studies, the PubMed, EMBASE, PsycINFO, Psyndex, and Cochrane Library databases were searched. Studies with controlled designs focusing on adult patients were included. Trials with chronically or mentally ill patients were excluded if long-term BZD and z-drug use was indicated. Study extraction was performed based on the Cochrane Form for study extraction. To assess the quality of the studies, we used a tool based on the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials.

Results

We identified 7,068 studies and selected 20 for systematic review. Nine interventions focused on patients, nine on HCPs, and two on both patients and HCPs. Intervention types ranged from simple to multifaceted. Patient-centered interventions that provided patient information effectively increased the appropriate use of BZDs. The educational approaches for HCPs that aimed to achieve appropriate prescription reported inconsistent results. The methods that combined informing patients and HCPs led to a significant reduction in BZD use.

Conclusions

This is the first review of studies focused on patient-centered approaches to reducing the inappropriate prescription and use of BZDs and z-drugs. The patient-centered dimension of patient information was responsible for a decrease in BZD and z-drug consumption. Further, in some studies, the patient-centered dimensions responsible for reducing the prescription and use of BZDs and z-drugs were the clinician’s essential characteristics and clinician-patient communication.

Should physicians be empathetic? Rethinking clinical empathy

The role and importance of empathy in clinical practice has been widely discussed. This paper focuses on the ideal of clinical empathy, as involving both cognitive understanding and affective resonance. I argue that this account is subject to a number of objections. Affective resonance may serve more as a liability than as a benefit in clinical settings, and utilizing this capacity is not clearly supported by the relevant empirical literature. Instead, I argue that the ideal account of empathy in medicine remains cognitive, though there is a central role for expressing empathic concern toward patients.