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

On the proliferation of the empathy concept in healthcare and medical education research

OBJECTIVE

To offer a critique of empathy concept usage in healthcare and medical education research.

METHODS

Analysis of current usage and suggestions for authors and researchers.

RESULTS

Empathy is often undefined or inconsistently defined, and "empathy" as represented in research covers an unmanageably wide and varied range of intentions, attitudes, emotions, and behaviors. The ubiquitous use of "empathy" as a vague and often undefined umbrella term hinders comprehension and, therefore, scientific progress. Patients are rarely asked directly about empathy; instead, measures of so-called perceived empathy contain descriptive items that could as well be called quality of care, patient-centeredness, or patient satisfaction.

CONCLUSIONS

Although "empathy" in medical care is widely valued by researchers, educators, and practitioners, the empathy concept as used in the published literature is overused and unclear, and potentially damaging to scholarship, medical education, and ultimately healthcare. The vague term empathy should be replaced as much as possible with concrete descriptions of what is actually measured, experimentally manipulated, or taught.

PRACTICE IMPLICATIONS

Identifying patients' own empathy definitions will improve medical education and medical care through clarifying what clinical behaviors will best fulfill patients' needs and desires. This approach allows for greater specificity and personalized care delivery.

Validity and reliability of the Spanish version of the consultation and relational empathy measure in dental students (Sp-Dent-CARE): A cross-sectional study

INTRODUCTION

An evaluation was made of the psychometric properties of a Spanish version of the Consultation and Relational Empathy Measure (CARE) to assess relational empathy in undergraduate dental students. In addition, the influence of demographic, socio-economic and consultation-related factors upon the degree of perceived empathy and overall satisfaction was studied.

MATERIALS AND METHODS

A cross-sectional study was carried out in patients seen in the Oral Surgery Unit by fourth year dental students. Dentists, specialized translators and psychologists developed the translation of the questionnaire. After a pilot test, a convenience sample of patients was included. Construct validity was tested by factor analysis using principal component analysis with varimax rotation and Kaiser standardization, and internal consistency was assessed by Cronbach's α.

RESULTS

Two pilot tests were carried out with a panel of experts until the final version of the questionnaire was established. In the validation stage, 191 patients participated (92 men and 99 women), with a mean age of 52.5 ± 17 years. The mean score of the CARE measure was 47.2 ± 4.4, and 57.6% of the patients (n = 110) reported the maximum score on the questionnaire. The final version showed a 1-factor solution explaining 68.6% of the total variance, with excellent final internal consistency (α = 93.4%).

CONCLUSION

The Spanish version of the CARE measure affords high reliability and validity in assessing relational empathy in dental students. Perceived empathy is related to overall satisfaction. Patient demographics and the number of visits do not influence perceived empathy.

Chain mediation model of consultation empathy, resilience and resignation coping on depression: a cross-sectional study among patients with COVID-19 in China

OBJECTIVES

This study aimed to explore the mediating role of resilience and resignation coping in the relationship between consultation empathy and depression in patients with COVID-19.

DESIGN

Cross-sectional study.

SETTING

Participants were recruited from a tertiary hospital in Guangzhou, Guangdong province.

PARTICIPANTS

A total of 215 patients were recruited for this study.

OUTCOME MEASURES

A total of 215 patients completed the Consultation and Relational Empathy Measure, Connor-Davidson Resilience Scale, Medical Coping Modes Questionnaire and Hospital Anxiety and Depression Scale. PROCESS 4.1 model 6 was used to analyse the moderated mediating effects.

RESULTS

Consultation empathy had a positive correlation with resilience (r=0.34, p<0.001), and a negative correlation with resignation (r=-0.288, p<0.001) and depression (r=-0.379, p<0.001). Resilience had a negative correlation with resignation (r=-0.463, p<0.001) and depression (r=-0.605, p<0.001). Resignation had a positive correlation (r=0.547, p<0.001) with depression. In the moderated mediating model, consultation empathy had significant indirect predictive effects on depression through resilience (95% CI -0.093 to -0.030) or resignation (95% CI -0.043 to -0.005). Consultation empathy had significant indirect predictive effects on depression through both resilience and resignation (95% CI -0.030 to -0.008).

CONCLUSIONS

Consultation empathy not only predicted depression directly, but also indirectly predicted depression through the chain mediating effects of resilience and resignation coping.

Development of the Italian version of the Consultation and Relational Empathy (CARE) measure: translation, internal reliability, and construct validity in patients undergoing rehabilitation after total hip and knee arthroplasty

PURPOSE

To translate and cross-culturally adapt the Consultation and Relational Empathy (CARE) measure into Italian, examine its internal reliability, and construct validity in a rehabilitation setting.

MATERIALS AND METHODS

The translation process consisted of two forward translations, a pre-final version, a back-translation, and a final version, in accordance with available guidelines. We administered the Italian version of the CARE measure to 101 patients hospitalised for rehabilitation after total hip or total knee arthroplasty (THA and TKA). We assessed face validity, internal reliability, and construct validity.

RESULTS

Face validity was high. Patients answered all questions and the "does not apply" option was never selected. Internal reliability (Cronbach's α = 0.962) resulted in line with the original version. The exploratory factor analysis confirmed the unidimensional structure of the CARE measure with 74.82% of variance explained by the first factor.

CONCLUSIONS

The Italian version of the CARE measure showed high face validity. Internal reliability and construct validity were in line with the original version in patients undergoing rehabilitation after THA and TKA.IMPLICATIONS FOR REHABILITATIONInternal reliability and construct validity of the Italian version of the CARE measure are in line with those of the original version of the CARE measure.The Italian CARE measure can be used to assess patient's perceived therapist's empathy in patients undergoing physical therapy after THA and TKA.Physiotherapists should use the CARE measure with more caution in other rehabilitative contexts.

Reliability and validity of the Arabic version of the Consultation and Relational Empathy (CARE) measure

PURPOSE

Empathy is the ability to communicate an understanding of an individual's subjective experience. It plays a vital role in the physician-patient relationship and improves clinical outcomes. This increases the importance of measuring and studying empathy in the clinical setting. The Consultation and Relational Empathy (CARE) is a 10-item questionnaire that measures patient assessment of physician's empathy in primary care. To our knowledge, there are no validated measures of empathy in the clinical setting in Arabic. This study aims at validating the CARE in Arabic.

METHODS

Data collection took place between October 2019 and February 2020. A total of 220 patients completed the questionnaire which consisted of the 10 CARE items, participants' opinions regarding the importance of each item, demographic information, and information about the consultation. The reliability and validity of the Arabic CARE were measured using Cronbach alpha, item-total correlations, and factor analysis. Construct validity was measured based on the overall patient satisfaction, and their satisfaction with the length of the consultation.

RESULTS

High Cronbach alpha and item-total correlation reveal the internal consistency and homogeneity of the Arabic version. Our findings showed significant positive correlations between CARE score and each of the characteristics: overall satisfaction with the consultation, duration of the consultation, patients' satisfaction with consultation duration and whether they would recommend the doctor to others.

CONCLUSION

The Arabic version of the CARE measure appears to be valid and reliable. It is available for use in research, education, and assessment of physicians' empathy.

A 2-item version of the Japanese Consultation and Relational Empathy measure: a pilot study using secondary analysis of a cross-sectional survey in primary care

BACKGROUND

The Consultation and Relational Empathy (CARE) measure is a patient-reported measure of physician empathy which is widely used internationally. The Japanese version of the CARE measure has very high internal reliability, suggesting that a shorter version may have adequate validity and reliability.

OBJECTIVE

To investigate a valid shorter version of the Japanese CARE measure.

METHODS

We conducted a pilot study using secondary analysis of previous data obtained from 9 general practitioners and 252 patients and used to develop the Japanese CARE measure. All 1,023 possible combinations of the Japanese CARE items (n = 1-10) were candidates for the short measure. The internal consistency (Cronbach's alpha) and the correlations between candidate short questionnaires and the original questionnaire were calculated. After selecting the most valid short questionnaire, inter-rater reliability was determined using generalizability theory, and construct validity (Spearman's rho) was determined using patient satisfaction.

RESULTS

Two items were selected for a pilot shorter version: item 6 "Showing care and compassion" and item 9 "Helping you to take control." These showed high internal consistency and correlations with the 10-item measure (Cronbach's alpha = 0.920, correlation = 0.979). Forty-five questionnaires per doctor allowed us to reliably differentiate between practitioners. The construct validity for the pilot short measure was high (Spearman's rho 0.706, P < 0.001).

CONCLUSION

We generated a pilot 2-item version of the Japanese CARE measure. This pilot 2-item version provides a basis for future validation studies of short CARE measures in other languages.

Trends in the psychosocial and mental health of HIV-positive women in China from 2015 to 2020: Results from two cross-sectional surveys

Background

The human immunodeficiency virus (HIV) continues to be one of the major public health challenges in the world. Despite the advancement in medication and changes in views towards HIV in Chinese society, little is known about the changes in the psychosocial and mental health of HIV‐positive women in recent years.

Objectives

The present study examined the change in depression, anxiety, stigma, relationship with the child, intimacy with a partner, and social support from family, friends, and health professionals, for HIV‐positive women in China from 2015 to 2020.

Methods

Two cross‐sectional surveys were conducted in 2015 and 2020, and 429 and 382 HIV‐positive women were recruited from the Women's Health Department in Yunnan and Guangxi, China between November 2015 to May 2016, and November 2019 to January 2020, respectively.

Results

After controlling for significant sociodemographic variables, participants recruited in 2019–2020 had significantly lower levels of depression and anxiety and higher scores on emotional and tangible support from friends. On the other hand, they had lower scores in intimacy with partners and emotional and tangible support from family. No significant changes were found in stigma, relationship with the child, and support from health professionals.

Conclusion

Results provide important information on the changes in psychosocial and mental health, which offer insights into the design of interventions to promote psychosocial and mental health among HIV‐positive women in China.

Patient or Public Contribution

HIV‐positive women contributed to the data of this study. Health care professionals were involved in the discussion of the methods and results.

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.

The Relationship Between the Physician-Patient Relationship, Physician Empathy, and Patient Trust

BACKGROUND

A trusting physician-patient relationship is an essential component of high-quality care.

OBJECTIVE

To explore the relationship between the physician-patient relationship, physician empathy, and patient trust.

DESIGN

Cross-sectional survey.

PARTICIPANTS

A total of 3289 patients (response rate 68.6%) from 103 hospitals in eastern, central, and western China completed surveys.

MAIN MEASURE

Physician empathy, patient trust, and physician-patient relationship were measured by the Chinese version of Consultation and Relational Empathy Scale, Wake Forest Physician Trust Scale, and Patient-Doctor Relationship Questionnaire, respectively. Bootstrapped mediation analysis was performed.

KEY RESULTS

There were moderate to strong correlations between physician empathy, patient overall trust, and patient trust in physician's benevolence and competence, and the physician-patient relationship (r = 0.49-0.75, P < 0.01 for all). Patients' evaluation of physician-patient relationship was predicted by their perception of physician empathy, patient overall trust, and trust in the physician's benevolence. Mediation analysis showed that the indirect effect of physician empathy on physician-patient relationship through patient overall trust was significant (β = 0.18, 95% CI: 0.15-0.21) and that the mediation effect of patient trust in physician's benevolence was significant (β = 0.24, 95% CI: 0.20-0.28), though the mediation effect of patient trust in physician's competence was not (β = 0.01, 95% CI: -0.02 to 0.02).

CONCLUSIONS

Patients' perception of physician empathy influences their evaluation of the physician-patient relationship both directly and indirectly via patient trust in the physician's benevolence. These findings underline the importance of patient belief in physician benevolence and empathy in building trustful and harmonious relationships between physicians and patients.

Arabic Validity of the (CARE) Measure for Improving Medical and Mental Health Services

Results

The majority of the item's responses showed high level of satisfaction. The coronach alpha of our study that examines the Arabic version of the CARE measurement tool 10 items was 0.96 showing an excellent internal consistency. The Kaiser-Meyer-Olkin measure was 0.96 indicating the adequacy of the data for factor analysis and the Bartlett test of sphericity shows (x2(45) = 8743.126, p < 0.001) indicating the adequacy of the correlation matrix for analysis.

Conclusion

The Arabic version of CARE Measure seems to be consistent and reliable in the primary health care setting.

Exploration of the psychometric properties of the Person-Centred Primary Care Measure (PCPCM) in a Chinese primary care population in Hong Kong: a cross-sectional validation study

OBJECTIVES

To evaluate the validity and psychometric properties of the Chinese Person-Centred Primary Care Measure (PCPCM) in a Chinese-speaking population.

DESIGN

A cross-sectional study.

SETTING

A primary care clinic in Hong Kong.

PARTICIPANTS

300 Chinese adult patients (150 males and 150 females) were recruited from a primary care clinic to complete a questionnaire containing the PCPCM, Consultation and Relational Empathy (CARE), Patient Enablement Index (PEI) and Adult (short version) Primary Care Assessment Tool (PCAT). The Chinese PCPCM was readministered to 118 participants after 14 days for test-retest reliability.

OUTCOME MEASURES

The construct validity, reliability and sensitivity of the Chinese PCPCM.

RESULTS

The Chinese PCPCM was identified to have a one-factor construct, with good item fit and unidimensionality on Rasch analysis. Internal reliability was high (Cronbach's alpha >0.8) with moderate test-retest reliability (intraclass correlation coefficient=0.622, p<0.001). Significant correlations (0.58, 0.42, 0.48) between the PCPCM and CARE, PEI and Adult (short version) PCAT scores supported good convergent construct validity. PCPCM scores were higher among patients who had known their doctors for a longer period or who were more likely to be able to see the same doctor at every visit, and among those who self-reported to have 'better health' rather than 'worse health'.

CONCLUSION

The Chinese PCPCM appears to be a valid, reliable and sensitive instrument for evaluating the quality of person-centred care among primary care patients in Hong Kong. Further studies are needed to confirm the utility of this instrument in other Chinese-speaking populations around the world.

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.

Associations between the severity of medical and surgical complications and perception of surgeon empathy in esophageal and gastric cancer patients

OBJECTIVE

To assess the impact of global physician empathy and its three subdimensions (establishing rapport, emotional and cognitive processes) on the severity of postoperative complications in a sample of cancer patients.

METHODS

We retrospectively analyzed data on 256 patients with esogastric cancer from the French national FREGAT database. Empathy and its subdimensions were assessed using the patient-reported CARE scale and the severity of medical and surgical complications was reported with the Clavien-Dindo classification system. The usual covariates were included in multinomial logistic regression analyses.

RESULTS

Physician empathy predicted the odds of reporting major complications. When patients perceived high empathy, they were less likely to report major complications compared to no complications (OR = .95, 95% CI = [.91-.99], p = .029). Among the three dimensions, only "establishing rapport" (OR = .84, 95% CI = [.73-.98], p = .019) and the "emotional process" (OR = .85, 95% CI = [.74-.98], p = .022) predicted major complications.

CONCLUSIONS

Physician empathy is essential before surgery. Further research is needed to understand the mechanisms associating empathy with health outcomes in cancer. Physicians should be trained to establish good rapport with patients, especially in the preoperative period.

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.

Direct and Indirect Associations Between Interpersonal Resources and Posttraumatic Growth Through Resilience Among Women Living with HIV in China

This study aims to test the associations between interpersonal resources and posttraumatic growth (PTG) and their indirect associations through resilience among women living with HIV (WLWH). A cross-sectional study interviewed 546 WLWH from eight clinics of Yunnan and Guangxi provinces in China. PTG, resilience and doctors' empathy were assessed by the validated scales. Family support, friend support, and partner intimacy were assessed by the self-constructed scales. Significant background factors of PTG included duration of residence in the area, monthly family income, number of years since HIV diagnosis, self-reported presence of AIDS-related symptoms, and current pregnancy. Family social support, partner intimacy, doctors' empathy, and resilience were positively associated with PTG; friend support was negatively associated with PTG (p < .05). Furthermore, resilience partially mediated the relationships between family support/partner intimacy and PTG, explaining 13.6-14.2% of the variance. Structural equation modeling showed that family support was significantly and indirectly associated with PTG through resilience when controlling for other interpersonal resource indicators. Implications and potential interventions to promote PTG are discussed.

How clinician examiners compare with simulated patients in assessing medical student empathy in a clinical exam setting

Background: Empathy is an important clinical attribute to be assessed during clinical examinations. While simulated patients (SPs) are well positioned to assess empathy in such settings, clinician-examiners are objective observers who are also experts in assessment. In this study, the assessments of student empathy from both examiners and SPs in clinical examinations were compared.Methods: The 10-item CARE measure were used for the assessment of empathy in 158 medical students in the Family Medicine specialty clerkship clinical competency test. The ratings from examiners and SPs were analyzed together with genders of students, examiners and patients, and the examination results.Results: SPs empathy ratings were higher than those from examiners across all ten items of CARE. A weak positive correlation was found between both ratings. Female SPs were more likely to give higher ratings, and examiners were more likely to give higher ratings to female students. SPs rating was moderately correlated with student examination score, while the correlation with examiners rating was strong.Conclusion: Although the inter-rater reliability was weak between the empathy rating from simulated patients and examiners, the evaluation of empathy from the patient's perspective was seen to be more authentic as they are in interaction with the students.

Important Roles of Health Professionals in Maternal HIV Disclosure Among HIV-Infected Women in China

Maternal HIV disclosure to children is beneficial for both mothers and children. A cross-sectional survey was conducted to investigate the prevalence of maternal HIV disclosure to at least one living child aged > 5 years among 292 HIV-infected mothers in Guangxi Province, China. Among all participants, 45.2% had self-disclosed their HIV positive sero-status to at least one living child aged > 5 years. After adjusting for the significant background variables, participants self-reported health professionals in governmental antenatal care clinics had discussed with them about maternal HIV disclosure (adjusted odds ratios, aOR: 5.85), had received counseling services (aOR: 7.84) or support (aOR: 8.75) from these health professionals when making decision on maternal HIV, and perceived higher empathy of these health professionals (aOR: 1.09) were more likely to have reported maternal HIV disclosure. Instrumental and affective interactions between health professionals and HIV-infected mothers were important facilitators of maternal HIV disclosure.

Measurement of Perceived Physician Empathy in Orthopedic Patients

Background

Empathy is a key component of a therapeutic relationship. Perceived empathy and compassion are associated with patient satisfaction, reduced symptoms, and adherence to treatment.

Objective

To assess the advantages and disadvantages of the validated Jefferson Scale of Patient's Perception of Physician Empathy (JSPPPE) and the Consultation and Relational Empathy (CARE) tools.

Methods

Eighty-four patients completed the JSPPPE and the CARE measure. With Pearson's correlation and exploratory factor analysis, we measured the underlying construct. Flooring and ceiling effects were measured. Multivariable models were created to assess factors associated with both measures.

Results

The high interquestionnaire correlation (rho = 0.70) and factor loading (0.77) confirm that the JSPPPE and CARE measure the same construct. The CARE (55%) had a higher ceiling effect than JSPPPE (18%). Both JSPPPE (partial R ² = 0.53, 95% confidence interval [CI]: 0.38-0.64) and CARE (partial R ² = 0.60, 95% CI: 0.46-0.69) accounted for similar amounts of variation in satisfaction with the orthopedic surgeon.

Conclusion

Perceived empathy accounts for a substantial amount of the variation in satisfaction. The JSPPPE measures the same construct as CARE with a lower ceiling effect. Because both questionnaires have considerable ceiling effects, a new questionnaire might help to study factors associated with a more empathetic experience.

Translation, Cross-cultural Adaptation to Brazilian Portuguese, and Analysis of Measurement Properties of the Consultation and Relational Empathy Measure

Objective

The purpose of this study was to translate, cross-culturally adapt to Brazilian Portuguese, and analyze the measurement properties of the Consultation and Relational Empathy (CARE) Measure and investigate whether empathy can be a predictor of clinical improvement.

Methods

This psychometric study was divided into 2 stages: the cross-cultural adaptation process included 30 patients, and the evaluation of the measurement properties included 106 patients with chronic musculoskeletal pain. After the third therapy session with the same physical therapist, the following questionnaires were applied to assess internal consistency, construct validity, and ceiling and floor effects: Pain Numerical Rating Scale, Brazilian Portuguese version of the CARE Measure (CARE-Br), MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care, and Global Perceived Effect Scale. To assess reliability and measurement error, the CARE-Br was answered 48 hours later. For prediction analysis of the CARE-Br in relation to clinical improvement, the participants answered the Pain Numerical Rating Scale and Global Perceived Effect Scale 2 months after baseline.

Results

The internal consistency was adequate (Cronbach's ɑ = 0.88), reliability was substantial (intraclass correlation coefficient = 0.77), measurement error was good (standard error of the measurement = 5.16%), and a moderate correlation was found with the MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (r = 0.50). A ceiling effect was also found (39.6% of participants). Empathy was not considered a predictor of clinical improvement.

Conclusion

The Brazilian Portuguese version of the CARE Measure is reliable, adequate, and applicable in clinical settings and research in Brazil. However, it is not capable of predicting clinical improvement in patients with chronic musculoskeletal pain.

Empathy in vaccination counselling: a survey on the impact of a three-day residential course

BACKGROUND

In an era of hesitance to use vaccines, the importance of effective communication for increasing vaccine acceptance is well known. This study aimed to assess the impact of a three-day residential course concerning empathy and counselling abilities on patients' ratings of the level of empathy of physicians and nurses working in vaccination centers.

METHODS

The empathy of healthcare providers was evaluated using the Adapted Consultation and Relational Empathy (CARE) Measure. The survey involved 20 healthcare workers, doctors, and nurses in three immunization services of a Local Health Unit in South Italy. Before and after attending the course, all of them administered the questionnaire to 50 consecutive parents of vaccinated children. Statistical tests were used to assess the homogeneity of pre- and post -course samples, to measure the level of empathy perceived by parents in doctors and nurses in pre- and post-course evaluations, and to compare the average CARE Measure scores among groups.

RESULTS

Analysis of the questionnaires showed an increase of "excellent" scores and statistically significant differences between the pre- and post -course median values. Statistically significant differences between doctors and nurses were shown in almost all questions pre-course and in only four questions post-course.

CONCLUSIONS

This study demonstrated that a residential course is effective at improving patient-rated empathy of doctors and nurses working in vaccination centers and could result in an increase of parents' adherence to vaccination programs.

How many patients are required to provide a high level of reliability in the Japanese version of the CARE Measure? A secondary analysis

Background

Empathy is widely regarded as being key to effective consultation in general practice. The Consultation and Relational Empathy (CARE) Measure is a widely used and well-validated patient-rated measure in English. A Japanese version of the CARE Measure has undergone preliminary validation, but its ability to differentiate between individual doctors has not been established. The current study sought to investigate the reliability of the Japanese version of the CARE Measure in terms of discrimination between doctors.

Methods

We conducted secondary analysis of a dataset involving 252 patients assessed by nine attending General Practitioners. The intra-cluster correlation coefficient was evaluated as an index of the reliability of the Japanese version of the CARE Measure for discriminating between doctors. With a criterion of intra-cluster correlation coefficient = 0.8, we conducted a decision (D) study using generalizability theory to determine the required number of patients for reliable CARE Measure estimates.

Results

The ability of the CARE Measure to discriminate between doctors increased with the number of patients assessed per doctor. A sample size of 38 or more patients provided an average intra-cluster correlation coefficient of 0.8.

Conclusions

The Japanese CARE Measure appears to reliably discriminate between doctors with a feasible number of patient-ratings per doctor. Further studies involving larger numbers of doctors with a multicenter analysis are required to confirm the results of the current study, which was conducted at a single institution.

Measuring empathy in pediatrics: validation of the Visual CARE measure

Background

Empathy is a key element of “Patient and Family Centered Care”, a clinical approach recommended by the American Academy of Pediatrics. However, there is a lack of validated tools to evaluate paediatrician empathy. This study aimed to validate the Visual CARE Measure, a patient rated questionnaire measuring physician empathy, in the setting of a Pediatric Emergency Department (ED).

Methods

The empathy of physicians working in the Pediatric ED of the University Hospital of Udine, Italy, was assessed using an Italian translation of the Visual Care Measure. This test has three versions suited to different age groups: the 5Q questionnaire was administered to children aged 7–11, the 10Q version to those older than 11, and the 10Q–Parent questionnaire to parents of children younger than 7.

The internal reliability, homogeneity and construct validity of the 5Q and 10Q/10Q–Parent versions of the Visual Care Measure, were separately assessed. The influence of family background on the rating of physician empathy and satisfaction with the clinical encounter was also evaluated.

Results

Seven physicians and 416 children and their parents were included in the study. Internal consistency measured by Cronbach’s alpha was 0.95 for the 10Q/10Q–Parent versions and 0.88 for the 5Q version. The item-total correlation was > 0.75 for each item. An exploratory factor analysis showed that all the items load onto the first factor.

Physicians’ empathy scores correlated with patients’ satisfaction for both the 10Q and 10Q–Parent questionnaires (Spearman’s rho = 0.7189; p < 0.001) and for the 5Q questionnaire (Spearman’s rho = 0.5968; p < 0,001). Trust in the consulting physician was lower among immigrant parents (OR 0.43. 95% CI 0.20–0.93).

Conclusions

The Visual Care Measure is a reliable second-person test of physician empathy in the setting of a Pediatric Emergency Room. More studies are needed to evaluate the reliability of this instrument in other pediatric settings distinct from the Emergency Room and to further evaluate its utility in measuring the impact of communication and empathy training programmes for healthcare professionals working in pediatrics.

Assessing the Consultation and Relational Empathy (CARE) Measure in sexual health nurses' consultations

Background

Increasingly healthcare policies emphasise the importance of person-centred, empathic care. Consequently, healthcare professionals are expected to demonstrate the ‘human’ aspects of care in training and in practice. The Consultation and Relational Empathy (CARE) Measure is a patient-rated measure of the interpersonal skills of healthcare practitioners. It has been widely validated for use by healthcare professionals in both primary and secondary care. This paper reports on the validity and reliability of the CARE Measure with sexual health nurses.

Methods

Patient questionnaires were collected for 943 consultations with 20 sexual health nurses. Participating patients self-completed the questionnaire immediately after the encounter with the nurse. The questionnaire included the ten item CARE Measure, the Patient Enablement Index, and overall satisfaction instruments. Construct validity was assessed through Spearman’s correlation and principal component analysis. Internal consistence was assessed through Cronbach’s alpha and the inter-rater reliability through Generalisability Theory. Data were collected in 2013 in Scotland.

Results

Female patients completed 68% of the questionnaires. The mean patient age was 28.8 years (standard deviation 9.8 years). Two of the 20 participating nurses withdrew from the study. Most patients (71.7%) regarded the CARE Measure items as very important to their consultation and the number of ‘not applicable’ and missing responses’ were low (2.6% and 0.1% respectively). The participating nurses had high CARE Measure scores; out of a maximum possible score of 50, the overall mean CARE measure score was 47.8 (standard deviation 4.4). The scores were moderately correlated with patient enablement (rho = 0.232, p = 0.001) and overall satisfaction (rho = 0.377, p = 0.001. Cronbach’s alpha showed the measure’s high internal consistency (Cronbach’s alpha coefficient = 0.95), but the inter-rater reliability could not be calculated due to the high achieved CARE Measure scores that varied little between nurses.

Conclusions

Within this clinical context the CARE Measure has high perceived relevance and face validity. The findings support construct validity and some evidence of reliability. The high CARE Measure scores may have been due to sample bias. A future study which ensures a representative sample of patients on a larger group of nurses is required to determine whether the measure can discriminate between nurses.

A Swedish version of the Consultation and Relational Empathy (CARE) measure

OBJECTIVE

A validated measure to gather patient feedback on physicians' empathy is not available in Swedish. The objective for this study was to examine the psychometric characteristics of a Swedish version of the Consultation and Relational Empathy (CARE) measure (widely used in English).

DESIGN, SETTING AND PATIENTS

The CARE measure was translated into Swedish and tested on 554 unselected patients visiting physicians in two primary care clinics in northwestern Stockholm, Sweden.

MAIN OUTCOME MEASURES

Adequate translation, as well as reliability and validity of the Swedish CARE measure.

RESULTS

The Swedish CARE measure seemed to demonstrate high acceptability and face validity when consulting a physician. The mean CARE score 41.5 (SD 8.9) over all 10 item was not significantly influenced by seasonality, age or gender. Scores were somewhat negatively distributed, but corrected item-total correlations were high (0.86-0.91) suggesting homogeneity. Internal reliability was very high (Cronbach's alpha 0.975). Factor analysis implied a one-dimensional structure with factor loadings between 0.89 and 0.93.

CONCLUSIONS

The Swedish CARE measure appears to be psychometrically valid and reliable enough in physicians.

Reliability and validity of the Dutch version of the Consultation and Relational Empathy Measure in primary care

BACKGROUND

Empathy is an essential skill in doctor-patient communication with positive effects on compliance, patient satisfaction and symptom duration. There are no validated patient-rated empathy measures available in Dutch.

OBJECTIVE

To investigate the validity and reliability of a Dutch version of the Consultation and Relational Empathy (CARE) Measure, a widely used 10-item patient-rated questionnaire of physician empathy.

METHODS

After translation and back translation, the Dutch CARE Measure was distributed among patients from 19 general practitioners in 5 primary care centers. Tests of internal reliability and validity included Cronbach's alpha, item total correlations and factor analysis. Seven items of the QUality Of care Through the patient's Eyes (QUOTE) questionnaire assessing 'affective performance' of the physician were included in factor analysis and used to investigate convergent validity.

RESULTS

Of the 800 distributed questionnaires, 655 (82%) were returned. Acceptability and face validity were supported by a low number of 'does not apply' responses (range 0.2%-11.9%). Internal reliability was high (Cronbach's alpha 0.974). Corrected item total correlations were at a minimum of 0.837. Factor analysis on the 10 items of the CARE Measure and 7 QUOTE items resulted in two factors (Eigenvalue > 1), the first containing the CARE Measure items and the second containing the QUOTE items. Convergent construct validity between the CARE Measure and QUOTE was confirmed with a modest positive correlation (r = 0.34, n = 654, P < 0.001).

CONCLUSION

The findings support the preliminary validity and reliability of the Dutch CARE Measure. Future research is required to investigate divergent validity and discriminant ability between doctors.

Impact of Perceived Weight Stigma among Underserved Women on Doctor-Patient Relationships

Objective

The aim of this study was to evaluate how perception of weight stigma among underserved women with obesity impacts doctor–patient relationships.

Methods

This study consisted of an interviewer‐administered survey of 149 women with obesity (body mass index (BMI) > 30 kg m⁻²) immediately after their physician visit at four Federally Qualified Health Centers. Perceptions of weight stigma and physician empathy were measured using the Stigma Situations in Health Care instrument and Consultation and Relational Empathy (CARE) measure, respectively. Associations of CARE and Stigma scores with BMI and patient characteristics were analysed using Mantel–Haenszel chi‐squared test and ordinal logistic regression.

Results

The mean CARE score was 42.1 (standard deviation 8.4; range 11.0–50.0), and mean stigma score was 4.6 (standard deviation 7.6; range 0–43.0). Each increase in BMI category was associated with almost twofold increased odds of higher perception of stigma (odds ratio, 1.90, 95% confidence interval 1.30–2.78, P = 0.001). BMI was not associated with CARE. However, for each increase in stigma category, the odds of lower CARE score doubled (odds ratio, 0.52, 95% confidence interval 0.36–0.75, P = 0.0005).

Conclusions

While BMI was not associated with perception of physician empathy, higher frequency of weight stigmatizing situations was negatively associated with perception of physician empathy. Reducing weight stigma in primary care could improve doctor–patient relationships and quality of care in patients with obesity.

Patient Perceptions of Expression of Empathy From Chinese Medicine Clinicians in a Chinese Population: A Cross-Sectional Study

This study aims to examine the level of empathy perceived by patients receiving care from herbalists, acupuncturists and massage therapists and to investigate the factors that influence levels of perceived empathy.Participants who were 18 years or above; able to provide written informed consent; and able to read and write in Chinese without assistance were included. A total of 514 participants sampled from charity and semipublic Chinese medicine (CM) clinics in Hong Kong were recruited to assess levels of empathy perceived during various length of consultations (1-20 minutes) by the Chinese Consultation and Relational Empathy Measure (Chinese CARE). Multiple linear regressions were conducted to evaluate the associations between perceived levels of empathy and the type of CM practitioner consulted and participants' demographic and health characteristics.The average Chinese CARE total score for participants consulting CM practitioners was 34.3 of a maximum of 50. After adjusting for participants' health and demographic characteristics, acupuncturists received the highest ratings (P < 0.001), whereas massage therapists (P < 0.001) scored the lowest of the 3 modalities. Participants receiving social benefits (P = 0.013), those with longer waiting times (P = 0.002), and those with shorter consultation durations (P = 0.020) scored significantly lower on the Chinese CARE.The level of empathy perceived by participants using CM was similar to results found for those in conventional care, in contrast to findings in other geographical settings, where a high level of perceived empathy was a major motivator for participants to choose complementary medicine.

The Association of Types of Training and Practice Settings with Doctors' Empathy and Patient Enablement among Patients with Chronic Illness in Hong Kong

BACKGROUND

The increase in non-communicable disease (NCD) is becoming a global health problem and there is an increasing need for primary care doctors to look after these patients although whether family doctors are adequately trained and prepared is unknown.

OBJECTIVE

This study aimed to determine if doctors with family medicine (FM) training are associated with enhanced empathy in consultation and enablement for patients with chronic illness as compared to doctors with internal medicine training or without any postgraduate training in different clinic settings.

METHODS

This was a cross-sectional questionnaire survey using the validated Chinese version of the Consultation and Relational Empathy (CARE) Measure as well as Patient Enablement Instrument (PEI) for evaluation of quality and outcome of care. 14 doctors from hospital specialist clinics (7 with family medicine training, and 7 with internal medicine training) and 13 doctors from primary care clinics (7 with family medicine training, and 6 without specialist training) were recruited. In total, they consulted 823 patients with chronic illness. The CARE Measure and PEI scores were compared amongst doctors in these clinics with different training background: family medicine training, internal medicine training and those without specialist training. Generalized estimation equation (GEE) was used to account for cluster effects of patients nested with doctors.

RESULTS

Within similar clinic settings, FM trained doctors had higher CARE score than doctors with no FM training. In hospital clinics, the difference of the mean CARE score for doctors who had family medicine training (39.2, SD = 7.04) and internal medicine training (35.5, SD = 8.92) was statistically significant after adjusting for consultation time and gender of the patient. In the community care clinics, the mean CARE score for doctors with family medicine training and those without specialist training were 32.1 (SD = 7.95) and 29.2 (SD = 7.43) respectively, but the difference was not found to be significant. For PEI, patients receiving care from doctors in the hospital clinics scored significantly higher than those in the community clinics, but there was no significant difference in PEI between patients receiving care from doctors with different training backgrounds within similar clinic setting.

CONCLUSION

Family medicine training was associated with higher patient perceived empathy for chronic illness patients in the hospital clinics. Patient enablement appeared to be associated with clinic settings but not doctors' training background. Training in family medicine and a clinic environment that enables more patient doctor time might help in enhancing doctors' empathy and enablement for chronic illness patients.

Measuring empathic, person-centred communication in primary care nurses: validity and reliability of the Consultation and Relational Empathy (CARE) Measure

Background

Empathic patient-centred care is central to high quality health encounters. The Consultation and Relational Empathy (CARE) Measure is a patient-rated experience measure of the interpersonal quality of healthcare encounters. The measure has been extensively validated and is widely used by doctors in primary care but has not been validated in nursing. This study assessed the validity and reliability of the CARE Measure in routine nurse consultations in primary care.

Methods

Seventeen nurses from nine general medical practices located in three Scottish Health Boards participated in the study. Consecutive patients (aged 16 years or older) were asked to self-complete a questionnaire containing the CARE Measure immediately after their clinical encounter with the nurse. Statistical analysis included Spearman’s correlation and principal component analysis (construct validity), Cronbach’s alpha (internal consistency), and Generalisability theory (inter-rater reliability).

Results

A total of 774 patients (327 male and 447 female) completed the questionnaire. Almost three out of four patients (73 %) felt that the CARE Measure items were very important to their current consultation. The number of ‘not applicable’ responses and missing values were low overall (5.7 and 1.6 % respectively). The mean CARE Measure score in the consultations was 45.9 and 48 % achieved the maximum possible score of 50. CARE Measure scores correlated in predicted ways with overall satisfaction and patient enablement in support of convergent and divergent validity. Factor analysis found that the CARE Measure items loaded highly onto a single factor. The measure showed high internal consistency (Cronbach’s alpha coefficient = 0.97) and acceptable inter-rater reliability (G = 0.6 with 60 patients ratings per nurse). The scores were not affected by patients’ age, gender, self-perceived overall health, living arrangements, employment status or language spoken at home.

Conclusions

The CARE Measure has high face and construct validity, and internal reliability in nurse consultations in primary care. Its ability to discriminate between nurses is sufficient for educational and quality improvement purposes.

Reliability and validity of the Croatian version of Consultation and Relational Empathy (CARE) Measure in primary care setting

Aim

To translate the Consultation and Relational Empathy (CARE) Measure into Croatian and validate the Croatian version of the questionnaire.

Methods

A cross-sectional study was conducted in July 2011 in 8 general practices (GP) in Croatia. Following two stages of translation, back-translation, and pilot testing, the Croatian version of the CARE was tested on 568 consecutive patients.

Results

Face validity was high, the number of missing values was low (9%), and the internal consistency (Cronbach’s alpha) was 0.77. A principal component analysis of 10 CARE Measure items extracted two components with eigenvalues >1. These two components explained 43.6% of the total instrument variance.

Conclusion

The Croatian version of the CARE Measure had acceptable reliability and face validity, but its intended component structure was not reproduced and further research is needed to understand its dimensionality.

Perceived empathy of service providers mediates the association between perceived discrimination and behavioral intention to take up HIV antibody testing again among men who have sex with men

HIV antibody testing is a key measure of HIV prevention for men who have sex with men (MSM). The World Health Organization recommends sexually active and at-risk MSM to take up HIV antibody testing regularly. This study aimed to investigate the prevalence of behavioral intention to take up HIV antibody testing in the next six months among Hong Kong MSM who were ever-testers. An anonymous cross-sectional survey recruited 326 MSM who had taken up HIV antibody testing from gay-friendly venues and internet in Hong Kong. Of the participants, 40.8% had had unprotected anal intercourse with regular or non-regular male sex partners in the last six months; they were at risk of HIV transmission despite experience in HIV antibody testing. Only 37.2% showed a strong intention to take up HIV antibody testing again in the next six months. Adjusted analysis showed that both perceived discrimination toward Hong Kong MSM (AOR = .60, 95% CI: .36–.98) and the CARE Measure assessing perceived empathy of service providers (AOR = 1.05, 95% CI: 1.02–1.08) were significantly associated with intention for retesting. Perceived discrimination, however, became statistically non-significant (AOR = .68, 95% CI: .41–1.14), when both CARE Measure and perceived discrimination entered into the adjusted model. It is warranted to increase HIV retesting rate by removing perceived discrimination and reducing the negative effect of perceived discrimination through enhancement of empathy of service providers.

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

BACKGROUND

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

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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

Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care

Background

There is limited evidence to support the use of facemasks in preventing infection for primary care professionals. Negative effects on communication has been suggested when the physician wears a facemask. As communication skills and doctor patient relationship are essential to primary care consultations, the effects of doctor’s facemask wearing were explored.

Method

A randomised controlled study was conducted in primary care to explore the effects of doctors wearing facemasks on patients’ perception of doctors’ empathy, patient enablement and patient satisfaction. Primary care doctors were randomized to mask wearing and non mask wearing clinical consultations in public primary care clinics in Hong Kong. Patients’ views were gathered using the Consultation and Relational Empathy (CARE) Measure, Patient Enablement Instrument (PEI) and an overall satisfaction rating scale. The effects of face mask wearing were investigated using multilevel (hierarchical) modelling.

Results

1,030 patients were randomised to doctor-mask wearing consultations (n = 514) and non mask wearing consultations (n = 516). A significant and negative effect was found in the patients’ perception of the doctors’ empathy (CARE score reduction -0.98, p-value = 0.04). In the more established doctor-patient relationship, the effect of doctors’ mask wearing was more pronounced (CARE score reduction -5.67, p-value = 0.03).

Conclusion

This study demonstrates that when doctors wearing a facemask during consultations, this has a significant negative impact on the patient’s perceived empathy and diminish the positive effects of relational continuity. Consideration should be taken in planning appropriate use of facemasks in infectious disease policy for primary care and other healthcare professionals at a national, local or practice level.

Clinical trial registration

This trial was registered on Chinese Clinical Trial Register (ChiCTR). Registration no.: ChiCTR-TTRCC-12002519. URL: http://www.chictr.org/en/proj/show.aspx?proj=3486. Due to administrative error, registration of trial did not take place until after the trial started on 1^st August 2011 and registration number was released on 21^st September 2012.

Can quality from a care ethical perspective be assessed? A review

Background:

Ethics-of-care theories contain important notions regarding the quality of care; however, until now, concrete translations of the insights into instruments are lacking. This may be a result of the completely different type of epistemology, theories and concepts used in the field of quality of care research.

Objectives:

Both the fields of ‘ethics of care’ and ‘quality of care’ aim for improvement of care; therefore; insights could possibly meet by focusing on the following question: How could ethics-of-care theories contribute to better quality in care at a measurement level? This study reviews existing instruments with the aim of bridging this gap and examines the evidence of their psychometric properties, feasibility and responsiveness.

Research design:

A systematic search of the literature was undertaken using multiple electronic databases covering January 1990 through May 2012.

Method and findings:

Of the 3427 unique references identified, 55 studies describing 40 instruments were selected. Using a conceptual framework, an attempt was made to distinguish between related concepts and to group available instruments measuring different types of concepts. A total of 13 instruments that reflect essential aspects of ethics-of-care theory were studied in greater detail, and a quality assessment was conducted.

Conclusion:

Three promising qualitative instruments were found, which follow the logic of the patient and take their specific context into account.

Doctor's attire influences perceived empathy in the patient-doctor relationship

OBJECTIVE

This study investigated whether doctors' attire influences the perception of empathy in the patient-doctor relationship during a therapeutic encounter.

METHODS

A total number of 143 patients were divided into four groups when they were consulting a Traditional Korean Medicine doctor. Depending on the group, the same doctor was wearing four different attires--Casual, Suit, Traditional dress, White coat--when having a clinical consultation with the patients.

RESULTS

The patients preferred white coat and traditional dress more than other attires, giving highest scores to white coat in competency, trustworthiness and preference of attire and to traditional dress in comfortableness and contentment with the consultation. The "Consultation and Relational Empathy (CARE)" score was significantly higher in the "White coat" and "Traditional" groups, compared to the "Casual" and "Suit" groups.

CONCLUSION

The strong association between the patients' preference of doctors' attire and the CARE score indicates that the doctor's attire plays not only an important role for establishing confidence and trustworthiness but also for the perception of empathy in the patient-doctor relationship.

PRACTICE IMPLICATIONS

The doctor's attire can function as an effective tool of non-verbal communication in order to signal confidence, trust and empathy and establish a good patient-doctor relationship.

An overview of 19 instruments assessing the doctor-patient relationship: different models or concepts are used

OBJECTIVES

The doctor-patient relationship has been linked to patient satisfaction, treatment adherence, and treatment outcome. Many different instruments have been developed to assess this relationship. The large variety makes it difficult to compare results of different studies and choose an instrument for future research. This review aims to provide an overview of the existing instruments assessing the doctor-patient relationship.

STUDY DESIGN AND SETTING

We performed a systematic search in PubMed, PsychInfo, EMBASE, and Web of Science for questionnaires measuring the doctor-patient relationship. We appraised each instrument ascertaining the questionnaires focused on the doctor-patient relationship. We compared the content and psychometric characteristics of the instruments.

RESULTS

We found 19 instruments assessing the doctor-patient relationship. The instruments assess a variety of dimensions and use diverse conceptual models for the doctor-patient relationship. The instruments found also vary in terms to which they have been psychometrically tested.

CONCLUSION

We have provided an overview of 19 instruments assessing the doctor-patient relationship. The selection of an instrument for future research should be based on the model or conceptual basis of the doctor-patient relationship that is most applicable to the study objectives and the health care field in which it will be applied.

The treatment of patients with medically unexplained physical symptoms in China: a study comparing expectations and treatment satisfaction in psychosomatic medicine, biomedicine, and traditional Chinese medicine

OBJECTIVE

Little is known about treatment for patients with medically unexplained symptoms (MUS) in China. This study investigates the treatment expectations and treatment satisfaction of patients with MUS in psychosomatic medicine, biomedicine, and Traditional Chinese Medicine (TCM).

METHOD

In a cross-sectional survey, n = 96 (10.3%) out of 931 participating patients were screened positive for multiple somatoform symptoms. These patients answered questionnaires concerning symptom duration, number of doctor visits, functional impairment, emotional distress, treatment expectations, treatment satisfaction, and empathy in the consultation. The physicians filled in a questionnaire about applied or recommended treatment.

RESULTS

Most of the patients from psychosomatic medicine wanted psychotherapy. In TCM, 55% of the patients had already received TCM treatment and most of them wanted to continue TCM treatment. Patients in biomedicine did not express clear expectations; most of them had had no previous treatment. A combination of treatment methods was most prevalent in biomedicine in comparison to psychosomatic medicine and TCM. The outcome from the patients' point of view was significantly better in TCM than in psychosomatic medicine and biomedicine. Psychosomatic medicine's strength was the empathetic physician-patient interaction.

CONCLUSIONS

From a biopsychosocial perspective, these results suggest that various treatment approaches with various emphases can be effective depending on the patient's complaints, his illness beliefs, and what the physician offers. The results will be verified in a larger multicenter longitudinal study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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