Empathy in general practice-the gap between wishes and reality: comparing the views of patients and physicians

Which clinician responses to emotion are associated with more positive patient experiences of communication?

OBJECTIVES

To identify communication strategies that may improve clinician-patient interactions, we assessed the association between clinician response to emotion and patient ratings of communication.

METHODS

From a cohort of 1817 clinician-patient encounters, we designed a retrospective case-control study by identifying 69 patients who rated their interpersonal care as low-quality and 69 patients who rated their care as high-quality. We used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to identify patient emotional expressions and clinician responses. Using mixed-effects logistic regression, we evaluated the association between clinician responses to patients' emotions and patient ratings of their interpersonal care.

RESULTS

In adjusted analyses, explicit responses that reduced space for further emotional communication were associated with high ratings of care (OR 1.94, 95% CI 1.25, 2.99); non-explicit responses providing additional space were associated with low ratings (OR 0.54, 95% CI 0.36-0.82). In terms of specific response types, neutral/passive responses were associated with low ratings (OR 0.59, 95% CI 0.39-0.90), whereas giving information/advice was associated with high ratings (OR, 95% 1.91 CI 1.17-3.1).

CONCLUSIONS

Patients may prefer responses to their expressed emotions that demonstrate clinician engagement, with or without expressions of empathy.

PRACTICE IMPLICATIONS

These findings may inform educational interventions to improve clinician-patient communication.

Empathy in family medicine postgraduate education: A mixed studies systematic review

PURPOSE

Empathy is an important construct in patient-physician relationships, particularly critical in family physicians' daily practice. We aimed to understand how empathy has been conceived and integrated into family medicine postgraduate training.

MATERIALS AND METHODS

Medline, PsyINFO, and Embase were searched in this systematic mixed studies systematic review. Two independent reviewers screened abstracts and full texts. Disagreements were solved through research team consensus-based discussion. Included studies were synthesized thematically.

RESULTS

A total of 18 studies were included. Four themes were identified. (1) Empathy definition. Included studies stressed the cognitive component of empathy, paired either with a behavioural or an affective response. (2) Empathy modifiers. Starting residency right after medical school, having a role model, having high empathy levels before residency, having children, being married, and being exposed to patient involvement in education were found to have a positive impact on empathy. (3) Empathy-burnout relationship. Whereas greater burnout was related to lower empathy levels, excess empathy seems to favour burnout through 'compassion fatigue.' (4) Educational programs for empathy development. Five programs were identified: a communication workshop, a patient-led program, a mindfulness program, a family-oriented intervention, and an arts-based program.

CONCLUSIONS

Studies mostly measured the cognitive component of empathy. The moral component of empathy was underrepresented in the conceptualization of empathy and the development of educational interventions. Conflicting evidence exists regarding the decline of empathy levels during the family medicine residency. Longitudinal designs should be privileged when exploring the evolution of empathy levels across the continuum of medical education.

Do I care for you more when you really need help? An experimental test of the effect of clinical urgency on compassion in health care

OBJECTIVES

To experimentally investigate whether more urgent patient presentations elicit greater compassion from health care professionals than less urgent, facilitating future research and thinking to address systemic barriers to compassion in health care.

DESIGN

This is a pre-registered online study with an experimental, within-subjects repeated-measure study design. Two clinical vignettes that systematically varied the urgency of patient presentation were utilized. Both vignettes depicted a patient with difficult behaviours typically associated with lower compassion.

METHODS

Health care professionals (doctors, nurses and allied health practitioners) recruited from all 20 District Health Boards across Aotearoa/New Zealand completed two vignettes in a counterbalanced order. Paired-sample t-tests were used to test the effect of the presentation urgency on indices of compassion.

RESULTS

A total of 939 participants completed the vignettes (20% doctors, 47%, nurses and 33% allied health professionals). As expected, participants reported greater care and motivation to help the more urgent patient. However, the more urgent patient was also perceived as less difficult, and exploratory analyses showed that perceived patient difficulty was associated with lower caring and motivation to help, particularly in the less urgent patient.

CONCLUSIONS

This is the first work to experimentally test the relationship between the urgency of patient presentation and compassion in health care. Although the association between urgency and difficulty is complex, our findings are consonant with evolutionary views in which urgent distress elicits greater compassion. A system-wide orientation towards efficiency and urgency may exacerbate this 'bias' which must be addressed to ensure more equitable compassion in health care.

Beliefs, experiences and concerns of using artificial intelligence in healthcare: A qualitative synthesis

Objective

Artificial intelligence (AI) is a developing field in the context of healthcare. As this technology continues to be implemented in patient care, there is a growing need to understand the thoughts and experiences of stakeholders in this area to ensure that future AI development and implementation is successful. The aim of this study was to conduct a literature search of qualitative studies exploring the opinions of stakeholders such as clinicians, patients, and technology experts in order to establish the most common themes and ideas that have been presented in this research.

Methods

A literature search was conducted of existing qualitative research on stakeholder beliefs about the use of AI use in healthcare. Twenty-one papers were selected and analysed resulting in the development of four key themes relating to patient care, patient-doctor relationships, lack of education and resources, and the need for regulations.

Results

Overall, patients and healthcare workers are open to the use of AI in care and appear positive about potential benefits. However, concerns were raised relating to the lack of empathy in interactions of AI tools, and potential risks that may arise from the data collection needed for AI use and development. Stakeholders in the healthcare, technology, and business sectors all stressed that there was a lack of appropriate education, funding, and guidelines surrounding AI, and these concerns needed to be addressed to ensure future implementation is safe and suitable for patient care.

Conclusion

Ultimately, the results found in this study highlighted that there was a need for communication between stakeholder in order for these concerns to be addressed, mitigate potential risks, and maximise benefits for patients and clinicians alike. The results also identified a need for further qualitative research in this area to further understand stakeholder experiences as AI use continues to develop.

Parental experience of an early developmental surveillance programme for autism within Australian general practice: a qualitative study

OBJECTIVES

Implementing support and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental conditions including autism. This study examined parents'/caregivers' experiences and perceptions about a digital developmental surveillance pathway for autism, the autism surveillance pathway (ASP), and usual care, the surveillance as usual (SaU) pathway, in the primary healthcare general practice setting.

DESIGN

This qualitative study involves using a convenience selection process of the full sample of parents/caregivers that participated in the main programme, 'General Practice Surveillance for Autism', a cluster-randomised controlled trial study. All interviews were audio-recorded, transcribed and coded using NVivo V.12 software. An inductive thematic interpretive approach was adopted and data were analysed thematically.

PARTICIPANTS

Twelve parents/caregivers of children with or without a developmental condition/autism (who participated in the main programme) in South Western Sydney and Melbourne were interviewed.

SETTINGS

All interviews were completed over the phone.

RESULTS

There were seven major themes and 20 subthemes that included positive experiences, such as pre-existing patient-doctor relationships and their perceptions on the importance of knowing and accessing early support/services. Barriers or challenges experienced while using the SaU pathway included long waiting periods, poor communication and lack of action plans, complexity associated with navigating the healthcare system and lack of understanding by general practitioners (GPs). Common suggestions for improvement included greater awareness/education for parents/carers and the availability of accessible resources on child development for parents/caregivers.

CONCLUSION

The findings support the use of digital screening tools for developmental surveillance, including for autism, using opportunistic contacts in the general practice setting.

TRIAL REGISTRATION NUMBER

ANZCTR (ACTRN12619001200178).

Profiles of GPs with high and low self-reported physician empathy—personal, professional, and antibiotic prescribing characteristics

Background

General Practitioners’ (GPs) professional empathy has been hypothesized to have substantial impact on their healthcare delivery and medication prescribing patterns. This study compares profiles of personal, professional, and antibiotic prescribing characteristics of GPs with high and low empathy.

Methods

We apply an extreme group approach to a unique combined set of survey and drug register data. The survey included questions about demographic, professional, and antibiotic prescribing characteristics, as well as the Jefferson Scale of Empathy for Health Professionals (JSE-HP) to assess self-reported physician empathy. It was sent to a stratified sample of 1,196 GPs comprising 30% of the Danish GP population of whom 464 (38.8%) GPs responded. GPs in the top and bottom decile of empathy levels were identified. All intra- and inter-profile descriptive statistics and differences were bootstrapped to estimate the variability and related confidence intervals. 

Results

61% of GPs in the top decile of the empathy score were female. GPs in this decile reported the following person-centered factors as more important for their job satisfaction than the bottom decile: The Patient-physician relationship, interaction with colleagues, and intellectual stimulation. High-empathy scoring GPs prescribed significantly less penicillin than the low-empathy GPs. This was true for most penicillin subcategories. There were no significant differences in age, practice setting (urban vs. rural), practice type (partnership vs. single-handed), overall job satisfaction, or GP’s value of prestige and economic profit for their job satisfaction. The intra profile variation index and confidence intervals show less prescribing uncertainty among GPs with high empathy.

Conclusions

This study reveals that high empathy GPs may have different personal, professional, and antibiotic prescribing characteristics than low empathy GPs and have less variable empathy levels as a group. Furthermore, person-centered high empathy GPs on average seem to prescribe less penicillins than low empathy GPs.

Predictors of Physician Compassion, Empathy, and Related Constructs: a Systematic Review

BACKGROUND

Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).

METHODS

A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.

RESULTS

One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.

DISCUSSION

The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.

General practitioner responses to concerns in chronic care consultations for patients with a history of cancer

We investigated general practitioners' (GPs') responses to patients' concerns in chronic care consultations. Video recordings of 14 consultations were analyzed with conversation analysis. We found two categories of responses: exiting and exploring the patient's concerns. Most GPs exited the concern by interrupting the patient, acknowledging the concern but then referring back to the progression of the consultation, or affiliating with the concern without exploring it. Only a few raised concerns were explored, and then most often the somatic rather than the emotional aspects of them. The findings point to the risk of missing patients' voiced concerns in consultations with a fixed agenda.

Empathy, well-being, and mental health: do gender differences diminish by the end of medical school?

This study aims to investigate if medical students demonstrate differences related to gender in terms of empathy, burnout, tolerance, openness to spirituality, well-being, and mental health, and to examine whether these differences vary across levels of medical training. A cross-sectional study was conducted in the first semester of 2015 in a Brazilian medical school. The following were evaluated: quality of life (WHOQOL-Bref), burnout (Oldenburg), mental health (DASS-21), empathy (Empathy Inventory and ESWIM), and tolerance, well-being, and openness to spirituality (ESWIM). We investigated how these outcomes varied in terms of gender, stage of medical training, and its interaction using a two-way MANOVA. A total of 776 students were included and important differences were observed. As medical training advanced, the differences between genders that were present during students' initial years (greater empathy, worse quality of life, and worse mental health among women) tended to become nonsignificant during the clerkship years. In addition, a significant interaction between stage and gender was found for ESWIM Wellness; WHOQOL; DASS Anxiety and DASS Stress. These results may denote a shortcoming in the way medical schools approach gender differences. Educators should consider these findings when restructuring curricula to respect gender differences, thus fostering their respective potentials.

Frequent attenders' experiences of encounters with healthcare personnel: A systematic review of qualitative studies

Rather than measure demographic factors such as socioeconomics, the aim of this study was to examine the lived experience of frequent attenders by synthesizing findings on their encounters with healthcare personnel. The Scopus, CINAHL, PsycARTICLES, and PubMed (Medline) databases were searched in May 2020 in order to screen studies by title and abstract (n = 1794) and full-text (n = 20). Findings from the included studies (n = 6) were then pooled using meta-aggregation, yielding the following results: difficulties in resolving frequent attenders' situations may create "service circles," frustrating patients with their situation; frequent attenders' own expertise regarding their condition should be recognized and valued alongside that of healthcare professionals when performing collaborative care; a lack of empathy and disparagement may make frequent attenders feel misunderstood and unappreciated; frequent attenders should be recognized as individuals by taking their circumstances into account and providing support accordingly. Frequent attenders' experiences demonstrate the importance of shared decision-making, continuity of care, and acknowledging these patients' individual circumstances. Identifying the variety of frequent attenders' service needs by synthesizing their experiences is a practical way of organizing patient-centered healthcare services.

Women's appraisal of the management of vulvodynia by their general practitioner: a qualitative study

BACKGROUND

Provoked Vulvodynia (PVD) is the most common cause of vulvar pain. General practitioners (GPs) are insufficiently familiar with it, causing a delay in many women receiving correct diagnosis and treatment. Besides patients factors, this delay can partly be explained by the reluctance of GPs to explore the sexual context of PVD and by their negative emotional reactions such as helplessness and frustration when consulted by patients with medically unexplained symptoms like PVD.

OBJECTIVE

To gain insight into how women with PVD perceive and evaluate condition management by their GP, in order to support GPs in the consultation of women with PVD.

METHODS

We performed face-to-face in-depth interviews with women diagnosed with PVD. The interviews were recorded, transcribed verbatim and thematically analysed. The Consolidated Criteria for reporting Qualitative Research (COREQ-criteria) were applied.

RESULTS

Analysis of the interviews generated four interrelated themes: Doctor-patient relationship, Lack of knowledge, Referral process and Addressing sexual issues. Empathy of the GP, involvement in decision-making and referral were important factors in the appreciation of the consultation for women with PVD who were referred to a specialist. Because women were reluctant to start a discussion about sexuality, they expected a proactive attitude from their GP. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP.

CONCLUSION

Women with PVD prefer a patient-centred approach and want GPs to acknowledge their autonomy and to address sexuality proactively.

Challenges and strategies for hypertension management: qualitative analysis of small primary care practices with varying blood pressure control

BACKGROUND

Electronic health record (EHR) data on blood pressure (BP) control among patients with hypertension show that practices' rates vary greatly. This suggests providers use different approaches in managing hypertension, and so we aimed to explore challenges small primary care practice providers face and strategies they use to manage patients' BP. We explored differences between providers with high and low BP control rates to help inform future quality improvement work.

METHODS

In 2015, we recruited practices in New York City with five or fewer providers. We employed a stratified purposeful sampling method, using EHR data to categorize small practices into groups based on the proportion of patients with hypertension whose last BP was <140/90: high control (>= 80%), average control (60-80%) and low control (<60%). We conducted semi-structured qualitative interviews with clinicians from 23 practices-7 high control, 10 average control and 6 low control-regarding hypertension management. We used a combined inductive/deductive approach to identify key themes, and these themes guided a comparison of high and low BP control providers.

RESULTS

Small practice providers reported treatment non-adherence as one of the primary challenges in managing patients' hypertension, and described using patient education, relationship building and self-management tools to address this issue. Providers differed qualitatively in the way they described using these strategies; high BP control providers described more actively engaging and listening to patients than low control providers did.

CONCLUSIONS

How providers communicate with patients may impact outcomes-future quality improvement initiatives should consider trainings to improve patient-provider communication.

Empathy Variation in General Practice: A Survey among General Practitioners in Denmark

Background: Previous studies have demonstrated that high levels of physician empathy may be correlated with improved patient health outcomes and high physician job satisfaction. Knowledge about variation in empathy and related general practitioner (GP) characteristics may allow for a more informed approach to improve empathy among GPs. Objective: Our objective is to measure and analyze variation in physician empathy and its association with GP demographic, professional, and job satisfaction characteristics. Methods: 464 Danish GPs responded to a survey containing the Danish version of the Jefferson Scale of Empathy for Health Professionals (JSE-HP) and questions related to their demographic, professional and job satisfaction characteristics. Descriptive statistics and a quantile plot of the ordered empathy scores were used to describe empathy variation. In addition, random-effect logistic regression analysis was performed to explore the association between empathy levels and the included GP characteristics. Results: Empathy scores were negatively skewed with a mean score of 117.9 and a standard deviation of 10.1 within a range from 99 (p5) to 135 (p95). GPs aged 45–54 years and GPs who are not employed outside of their practice were less likely to have high empathy scores (≥120). Neither gender, nor length of time since specialization, length of time in current practice, practice type, practice location, or job satisfaction was associated with odds of having high physician empathy. However, odds of having a high empathy score were higher for GPs who stated that the physician-patient relationship and interaction with colleagues has a high contribution to job satisfaction compared to the reference groups (low and medium contribution of these factors). This was also the trend for GPs who stated a high contribution to job satisfaction from intellectual stimulation. In contrast, high contribution of economic profit and prestige did not contribute to increased odds of having a high empathy score. Conclusions: Albeit generally high, we observed substantial variation in physician empathy levels among this population of Danish GPs. This variation is positively associated with values of interpersonal relationships and interaction with colleagues, and negatively associated with middle age (45–54 years) and lack of outside employment. There is room to increase GP physician empathy via educational and organizational interventions, and consequently, to improve healthcare quality and outcomes.