[When is a doctor a good doctor? An analysis of the contents of statements by representatives of the medical profession ]

Characteristics of Exceptionally Good Doctors: A Protocol for a Cross-Sectional Survey of Adults

Background

Doctors constitute a significant proportion of a very large number of medical interactions. They are known to vary in the quality of their work, with some having an exceptionally beneficial effect on patients’ physical health. In a qualitative study, we interviewed medical doctors on their opinions and experiences of exceptionally good doctors. Their responses and the results from previous research are used as a basis for this proposed cross-sectional survey directed to members of the public on their encounters with exceptionally good doctors. The primary aim of this cross-sectional study is to describe the characteristics of exceptional doctors as reported by a large representative sample of adult patients.

Methods and Analysis

A mixed qualitative and quantitative anonymous cross-sectional survey of 500 Amazon Mechanical Turk (MTurk) respondents, who have met one or more exceptionally good doctors in their life, will be conducted. Information requested will include reasons for nominating a particular doctor; experience of how that doctor differs from other and average doctors; and 34 5-point Likert scale questions on the characteristics of that doctor and the same Likert questions for the average doctor. An opportunity to report their experience in free-text form will be provided. Sample size will be sufficient to obtain a margin of error of 4%. The authors will provide descriptive statistics, including graphs of the Likert scale question responses; conduct factor analysis for internal validity; investigate satisficing and logical inconsistencies; and explore whether there are multiple types of exceptionally good doctors.

Discussion

Previous surveys of patients’ perceptions of doctors exist though none have focused on exceptionally good doctors. The expected results will include a list of characteristics that are important to patients in determining exceptionally good doctors.

Qualitative Study of Medical Doctors on Their Experiences and Opinions of the Characteristics of Exceptionally Good Doctors

BACKGROUND

It is generally accepted that there is a therapist effect in psychotherapy, with master therapists being studied using qualitative methods. There are surgeons with exceptionally positive patients' physical health outcomes, and qualitative research on what makes good doctors. However, characteristics of exceptionally good doctors are less studied and understood.

OBJECTIVE

To qualitatively study the opinions of physicians on exceptionally good doctors.

METHODS

Thirteen semi-structured interviews of English-speaking medical doctors of any specialty were conducted. Recruitment was achieved through the authors' network; contacting authors of relevant research papers; and Bond University's General Practitioner recruitment program. Their opinion was sought on what makes an exceptionally good doctor, whether they have met such a person, what was their experience of that person, and whether they consider themselves as exceptionally good doctors.

ANALYSIS

A six-phase thematic analysis in an experiential framework, as per Braun and Clarke, was implemented to identify themes and their details in an inductive approach with a realist epistemological position, ie, assuming truthful knowledge on what makes exceptionally good doctors can be obtained.

RESULTS

Each interviewee had met and been inspired by exceptionally good doctors. Descriptions covered six themes: character traits; other characteristics; patient relationships; peer and health care system relations; education; and treatment examples. Exceptionally good doctors were found to have up-to-date extensive medical knowledge and skills, relate well with patients, and have excellent diagnostic abilities. They tend to be humble, approachable, inspiring, and are long-remembered role models. However, they may not always be appreciated by their peers and their health care system because of their exceptional abilities.

DISCUSSION AND CONCLUSION

Exceptional doctors are beneficial for their peers, their patients, and their health care system. Identifying, acknowledging, and making such doctors more accessible to medical students and junior doctors could have a positive impact on medical practice.

Complications After Inpatient Laparoscopic Cholecystectomy: Effect of Surgeon Experience, Procedure Volume, and Other Surgeon-Based Characteristics

BACKGROUND

Previous studies have examined how factors such as gender, education, type of training (MD or DO), and experience of the treating surgeon affect patient outcomes. We investigated patient complications after elective laparoscopic cholecystectomy based on surgeon characteristics.

METHODS

A Medicare database was used to identify surgeon-specific data. The main outcome measure was the adjusted complication rates (ACR) for individual surgeons as reported by the ProPublica Surgeon Scorecard. Surgeon gender, type of training, medical school rank, years since graduation, procedure volume, and teaching status of the primary hospital affiliation were assessed for any association with increased ACR using logistic regression analysis. We explored the associations among procedure volume, years of experience, and ACR using Spearman correlation.

RESULTS

1107 predominantly male (94.6%) surgeons were included. 94.4% were MDs and 34.5% were affiliated with teaching hospitals. Mean length of practice was 24 ± 9 years, and median surgeon procedure volume was 28 (IQR = 23, 37). Overall median ACR was 4.3%. Multivariate analysis demonstrated that surgeon gender (P = .71), medical school rank, type of training (P = .68), or hospital affiliation (P = .77) did not have a significant impact on ACR. Increased surgeons' years in practice (r = -.028, P = .35) and increased surgeon procedure volume (r = -.021, P = .49) were negatively associated with increased ACR.

CONCLUSION

Surgeon gender, type of training, medical school rank, or hospital affiliation had no impact on complications after laparoscopic cholecystectomy. Surgeon experience and procedure volume may have clinical implications for patient outcomes. Further studies to elucidate factors associated with surgeon quality and patient outcomes are necessary.

Protocol for a Qualitative Study on Doctors' Opinions on and Experiences of Exceptionally Good Doctors

OBJECTIVE

Doctors have a varying effect on patients' physical health. This means that there are doctors that are more effective than others. Even though the doctor is a part of very many medical interactions, it is not known in which way exceptionally good doctors differ from their peers. After authoring two systematic and one methodological review on identifying exceptional doctors, the authors in this qualitative interview-based study take a bottom-up, inductive approach to answer the question of what makes an exceptionally good doctor.

METHODS

About 10-15 semi-structured interviews of medical doctors of any specialty who speak English will be conducted. Recruitment will be through the authors' network and their referrals. Questions will be whether they have an opinion on what makes an exceptionally good doctor, whether they have met such a person and how did this doctor differ from other doctors. The interviews will be done by a 62-year old PhD student who is not a clinician but has extensive experience in having personal conversations as a financial adviser. This could be helpful as the interviewer is only aware that there are exceptionally good doctors but has no notion how exceptionally good doctors differ from their colleagues.

ANALYSIS

A six-phase thematic analysis in an experiential framework as per Braun and Clarke will be implemented with the aim to find out what the doctors think and have experienced. This is an inductive approach using a realist epistemological position under the assumption that it is possible to acquire truthful knowledge on what makes exceptionally good doctors.

DISCUSSION

Previous qualitative research on exceptionally good doctors consisted of interviewing author-selected exceptionally good doctors. This study takes a step back from this approach by asking the peers of exceptionally good doctors how they define being exceptionally good and how they experience such doctors.

Association of professional pre-qualifications, study success in medical school and the eligibility for becoming a physician: A scoping review

BACKGROUND

Literature, individual experiences and common considerations suggest that prior professional qualification can be an advantage for later career development. For instance, in Germany, professional pre-qualification has been honored by medical faculties in selection procedures for several years. However, a systematic evaluation of this relationship lacks. This scoping review summarizes existing literature and addresses the role of prior professional pre-qualifications on objective or subjective study success and the choice of a specialization.

METHODS

The scoping review was performed oriented on the PRISMA guidelines. PsycINFO and PubMed databases were searched for relevant studies that included data of medical students with and without professional pre-qualifications. To answer the underlying research questions, this scoping review also includes studies that examine professional pre-qualifications in association with non-cognitive "soft" criteria.

RESULTS AND FURTHER DIRECTIONS

1055 items were identified and reviewed by two independent reviewers with final 11 studies were included for this scoping review. The results of identified studies that report possible effects of prior pre-professional qualifications are inconclusive but suggest that prior professional qualifications tend not to have rather an advantage on study success. Medical school success for students with prior professional qualifications tended to be below average in the preclinical setting, and there were no differences in the clinical setting compared with students without prior professional qualifications. The influence of professional pre-qualifications has not yet been adequately studied without the moderator variable "waiting time" and "A-levels grade". The scoping review indicates insufficient number of articles stating a co-relation of prior pre-qualifications and subjective data. Again, the results found are not sufficient to state a clear relationship between professional pre-qualifications and the choice of a specific speciality preference. However, professional pre-qualifications, both in medicine and as "practical experience in rural areas", tend to be beneficial for the choice of becoming a rural physician. Large-scale cross-sectional and longitudinal studies are needed to investigate the influence of professional pre-qualifications on different study trajectory parameters.

What is a good doctor?

Changes in medical curricula have led to a shift of focus in medical education. The goal was to implement a more practical approach to teaching and thereby create better doctors. However, the question of what makes a good doctor is not easy to answer. This article gives an overview on the literature about this topic. A systematized review and narrative synthesis were conducted including 20 articles about the features of good doctors. Qualitative and quantitative studies as well as questionnaires were included. These studies reported research involving students, doctors, patients, and nurses. The resulting characteristics of good doctors fell into six categories: (1) General interpersonal qualities, (2) Communication and patient involvement, (3) Medical competence, (4) Ethics, (5) Medical management, (6) Teaching, research, and continuous education. The different stakeholders showed different ideas of the concept of a good doctor. Interestingly, patients had a stronger focus on communication skills, whereas doctors put more emphasis on medical skills. Balancing this discrepancy will be a challenge for future medical education.

[Professionalism in general practice in Germany - a qualitative approximation]

BACKGROUND

Pre- and postgraduate education is meant to be competency-based. Over the last two decades various competency frameworks have been published. One competency is professionalism, a definition of which has not yet been developed but is being discussed in the literature. The aim of this qualitative study is an approximation to professionalism among German general practitioners and general practitioner trainees.

METHODS

A qualitative study was conducted by interviewing seven pairs of GPs and their trainees. All interviews were recorded and transcribed. The analysis was performed according to Mayring supported by the software Atlas.ti.

RESULTS

Four categories of professionalism emerged: responsibility towards patients, responsibility towards other professionals, responsibility towards the society and responsibility towards oneself. Professionalism was perceived as important for general practice in Germany. In addition, barriers of professional behaviour have been identified.

CONCLUSION

The perception of professionalism among German GPs and GP trainees is in accordance with the frameworks of professionalism found in the literature. These results underline the need for conceptualising professionalism among general practice trainees in Germany.

The Relationship Between Physician Friendliness and Caring, and Patient Satisfaction: Findings from an Internet-Based Survey

BACKGROUND

This study examines patient satisfaction with physicians. Patient satisfaction is a quality measure that affects treatment outcomes. More specifically, it examines how a patient's perception of physician friendliness and caring can affect patient satisfaction.

METHODS

A cross-sectional survey study was conducted with a convenience sample of 20 901 patients who rated their recent visit to a physician via an internet-based survey. The survey included questions on aspects of overall satisfaction with physician care and office practice as well as more detailed items, including demographics, physician 'friendliness and caring' (collectively referred to as 'empathy' in this paper), time spent with the doctor, and areas that could be improved. Responses to the questions were on a scale from 0 ('not at all satisfied') to 10 ('extremely satisfied'). These scales were then used to represent patient satisfaction.

RESULTS

Of the 20 901 patients who participated in the online survey, perceived empathy was the most predominant correlate associated with patient satisfaction with their physician, with a partial correlation of 0.87 (p < 0.001) and a Pearson correlation of 0.92 (p < 0.001). Patient satisfaction with the office setting was also highly correlated with empathy scores, with a partial correlation of 0.72 (p < 0.001) and a Pearson correlation of 0.83 (p < 0.001). Other factors, such as waiting time, and problems with appointments, staff, records, parking, doctor care, and ways of obtaining information, also played a role in patients' overall satisfaction with the physician.

CONCLUSIONS

Patient satisfaction ratings are strongly correlated with patient perceptions of physician friendliness and caring.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICAL IMPLICATIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture?

The aim of this paper was to quantify the influence of the physician's training and experience in the field of acupuncture on the outcome in patients with chronic pain. Patients visiting their physician because of chronic low back pain, headache, pain due to osteoarthritis of the knee or hip, or neck pain, were included in 4 multicenter, randomized, controlled studies. All patients received routine care; patients in the acupuncture groups received additional acupuncture treatment (on average 10 sessions). The data was pooled, and the 3-month change from baseline of the SF-36 bodily pain subscale as the main outcome defined. A total of 9,990 patients (mean age 49.6 +/- 13.6 years, 68% female) treated by 2,781 physicians (mean age 46.3 +/- 7 years, 37% female) were analyzed. The physicians had 7.3 +/- 5.2 (mean +/- sd) years of experience in acupuncture and their mean duration of formal acupuncture training had been 287 +/- 321 hours. The outcome was markedly improved in the acupuncture group. We identified only 1 physician characteristic with a significant influence on the outcome: Internists performed better (odds ratio OR = 1.49, confidence interval CI: 1.01;2.18; P = .043); orthopedists worse (OR = .79, CI: .62;1; P = .043) than the average physician. Neither the duration of training nor the duration of experience had any impact on the extent of the acupuncture effect.

PERSPECTIVE

In this analysis, physician characteristics such as training did not influence patients' outcome after acupuncture, suggesting that formal training parameters have only a limited influence on treatment effect. Other skills such as the therapeutic relationship, which are difficult to measure, may probably play a more important role and should be taken into consideration.

[Quality of life in dysphonia]

Quality of life is multidimensional and comprises physical, emotional, and social aspects. It has always been the implicit focus of medical work. However, since the 1980s it has been possible to measure it explicitly. Quality of life is impaired in dysphonic patients; this finding is supported by specific studies on self-reported physical, emotional, and social well-being. For practical application of these data, it is recommended to measure all three domains. From a therapeutic point of view, verbal intervention following the PLISSIT model (permission, limited information, special suggestions, intensive therapy) has been proven to enhance patient satisfaction. Therefore, this clinical procedure is recommended for routine application in dysphonic patients.

Analyzing the "nature" and "specific effectiveness" of clinical empathy: a theoretical overview and contribution towards a theory-based research agenda

OBJECTIVE

To establish sound empirical evidence that clinical empathy (abbreviated as CE) is a core element in the clinician-patient relationship with profound therapeutic potential, a substantial theoretical-based understanding of CE in medical care and medical education is still required. The two aims of the present paper are, therefore, (1) to give a multidisciplinary overview of the "nature" and "specific effectiveness" of CE, and (2) to use this base as a means of deriving relevant questions for a theory-based research agenda.

METHOD

We made an effort to identify current and past literature about conceptual and empirical work focusing on empathy and CE, which derives from a multiplicity of disciplines. We review the material in a structured fashion.

RESULTS

We describe the "nature" of empathy by briefly summarizing concepts and models from sociology, psychology, social psychology, education, (social-)epidemiology, and neurosciences. To explain the "specific effectiveness" of CE for patients, we develop the "Effect model of empathic communication in the clinical encounter", which demonstrates how an empathically communicating clinician can achieve improved patient outcomes. Both parts of theoretical findings are synthesized in a theory-based research agenda with the following key hypotheses: (1) CE is a determinant of quality in medical care, (2) clinicians biographical experiences influence their empathic behavior, and (3) CE is affected by situational factors.

CONCLUSION

The main conclusions of our review are twofold. First of all, CE seems to be a fundamental determinant of quality in medical care, because it enables the clinician to fulfill key medical tasks more accurately, thereby achieving enhanced patient health outcomes. Second, the integration of biographical experiences and situational factors as determinants of CE in medical care and medical education appears to be crucial to develop and promote CE and ultimately ensuring high-quality patient care.

PRACTICE IMPLICATIONS

Due to the complexity and multidimensionality of CE, evidence-based investigations of the derived hypotheses require both well-designed qualitative and quantitative studies as well as an interdisciplinary research approach.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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