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

Primary care transformation in Scotland: a qualitative evaluation of the views of patients

BACKGROUND

The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs.

AIM

To explore patients' views on the changes in general practice in Scotland since the inception of the new contract.

DESIGN AND SETTING

Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas).

METHOD

In-depth semi-structured interviews with thematic analysis.

RESULTS

Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas.

CONCLUSION

Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

Towards an empathic hidden curriculum in medical school: A roadmap

The "hidden curriculum" in medical school includes a stressful work environment, un-empathic role models, and prioritisation of biomedical knowledge. It can provoke anxiety and cause medical students to adapt by becoming cynical, distanced and less empathic. Lower empathy, in turn, has been shown to harm patients as well as practitioners. Fortunately, evidence-based interventions can counteract the empathy dampening effects of the hidden curriculum. These include early exposure to real patients, providing students with real-world experiences, training role models, assessing empathy training, increasing the focus on the biopsychosocial model of disease, and enhanced wellbeing education. Here, we provide an overview of these interventions. Taken together, they can bring about an "empathic hidden curriculum" which can reverse the decline in medical student empathy.

Beyond empathy training for practitioners: Cultivating empathic healthcare systems and leadership

Empathic care benefits patients and practitioners, and empathy training for practitioners can enhance empathy. However, practitioners do not operate in a vacuum. For empathy to thrive, healthcare consultations must be situated in a nurturing milieu, guided by empathic, compassionate leaders. Empathy will be suppressed, or even reversed if practitioners are burned out and working in an unpleasant, under-resourced environment with increasingly poorly served and dissatisfied patients. Efforts to enhance empathy must therefore go beyond training practitioners to address system-level factors that foster empathy. These include patient education, cultivating empathic leadership, customer service training for reception staff, valuing cleaning and all ancillary staff, creating healing spaces, and using appropriate, efficiency saving technology to reduce the administrative burden on healthcare practitioners. We divide these elements into environmental factors, organisational factors, job factors, and individual characteristics.

Patients' experiences of GP consultations following the introduction of the new GP contract in Scotland: a cross-sectional survey

BACKGROUND

The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities.

AIM

To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland.

DESIGN AND SETTING

In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken.

METHOD

Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI).

RESULTS

In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05).

CONCLUSION

Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

Interventions for Compassion Fatigue in Healthcare Providers-A Systematic Review of Randomised Controlled Trials

BACKGROUND

Compassion fatigue is a significant issue considering its consequences including negative feelings, impaired cognition, and increased risk of long-term morbidities. We aimed to assess current evidence on the effects of interventions for compassion fatigue in healthcare providers (HCP).

METHODS

We used the Cochrane methodology for Systematic Reviews and Meta-Analyses (PRISMA) for conducting and reporting this review.

RESULTS

Fifteen RCTs (n = 1740) were included. The sample size of individual studies was small ranging from 23 to 605. There was significant heterogeneity in participant, intervention, control, and outcome characteristics. The tools for assessing intervention effects on compassion fatigue included ProQOL, compassion fatigue scale, and nurses compassion fatigue inventory. Thirteen out of the fifteen included RCTs had overall high risk of bias (ROB). Meta-analysis could not be performed given the significant heterogeneity.

CONCLUSIONS

Current evidence on interventions for reducing compassion fatigue in HCPs is inadequate. Given the benefits reported in some of the included studies, well-designed and adequately powered RCTs are urgently needed.

Differences in empathy levels among physicians based on specialty: a nationwide cross-sectional study

PURPOSE OF STUDY

A physician's ability to empathize is crucial for patient health outcomes, and this differs according to speciality, personal characteristics, and environmental factors. This study aimed to examine the empathy levels among physicians based on their specialities and to identify the influencing factors.

STUDY DESIGN

A nationwide, online, cross-sectional survey was conducted using the Nikkei Business Publication online physician member homepage. Participants were 5441 physicians in Japan registered as members of Nikkei Medical Online across 20 specialities. We used the Jefferson Scale of Empathy (JSE) to measure the physicians' empathy levels. Cronbach's alpha was 0.84.

RESULTS

The mean JSE score was 100.05, SD = 15.75. Multivariate analyses showed that the highest JSE scores were for general medicine [+5.58, 95% confidence interval (CI) 2.60-8.56], general surgery (+3.63, 95% CI 0.97-6.28), psychiatry (+3.47, 95% CI 1.76-5.17), and paediatrics (+1.92, 95% CI 0.11-3.73). Factors associated with higher JSE scores were being female (+5.86, 95% CI 4.68-7.04), managers (+1.11, 95% CI 0.16-2.07), working in a small hospital (+2.19, 95% CI 0.23-4.15), and with children (+3.32, 95% CI 2.29-4.36).

CONCLUSIONS

A significant decrease in the empathy levels was found when the parent of the participant was also a medical provider. Being a general medicine physician or a female physician in a high position who has children was positively and significantly correlated with high empathy levels.

Feasibility of a Cinematic-Virtual Reality Training Program for Health Professional Students: A Single-Arm Pre-Post Study

BACKGROUND

Cinematic-virtual reality (cine-VR) has demonstrated improvements in cultural self-efficacy, diabetes attitudes, and empathy among healthcare providers, but its impact on health professional students is unknown. The purpose of the single-arm pre-post study was to examine the feasibility of this cine-VR diabetes training program as well as to assess changes in cultural self-efficacy, diabetes attitudes, and empathy among health professional students.

METHOD

Participants viewed 12 cine-VR 12 simulations about a 72-year-old patient with type 2 diabetes. Pre-training and post-training, they completed the Transcultural Self-Efficacy Tool, Diabetes Attitude Scale-3, and Jefferson Scale of Empathy.

RESULTS

All 92 participants completed the full training. No participants reported technological difficulties or adverse events. For the assessment, 66 participants completed the pre-post measures for a response rate of 71.7% (mean age = 21.1 ± 1.9 years, 82.6% [n = 57] women; 84.1% [n = 58] white). We observed positive improvements in all three cultural self-efficacy subscales: "Cognitive" (t value = -4.705, P < .001), "Practical" (mean change = -.99, t value = -4.240, P < .001), and "Affective" (t value = -2.763, P = .008). Similarly, we observed positive improvements in four of the five diabetes attitude subscales: "Need for special training" (Z = -4.281, P < .001), "Seriousness of type 2 diabetes" (Z = -3.951, P < .001), "Value of tight glucose control" (Z = -1.676, P = .094), "Psychosocial impact of diabetes" (Z = -5.892, P < .001), and "Attitude toward patient autonomy" (Z = -2.889, P = .005). Finally, we observed a positive improvement in empathy (t value = -5.151, P < .001).

CONCLUSIONS

Findings suggest that the cine-VR diabetes training program has the potential to improve cultural self-efficacy, diabetes attitudes, and empathy among health professional students. A randomized controlled trial is needed to confirm its effectiveness.

Empathy competence and future specialty among medical residents in Japan: a nationwide cross-sectional study

Empathy is essential for physicians to provide patient-centered care. Nevertheless, the degree to which empathy varies among medical residents based on their desired future specialty remains undetermined. This nationwide cross-sectional study compared empathy levels (Jefferson Scale of Empathy, JSE) of 824 year one and two postgraduate residents in Japan by intended medical specialty, individual characteristics, and training and working environment characteristics. Empathy levels were compared with applicants for general medicine, which emphasizes patient-centeredness. The highest mean JSE and the highest percentage of women residents were observed in general medicine (M = 109.74; SD = 14.04), followed by dermatology (M = 106.64; SD = 16.90), obstetrics and gynecology (M = 106.48; SD = 14.31), and pediatrics (106.02; SD 12.18). Residents interested in procedure-centered departments (e.g. ophthalmology, orthopedics) garnered lower JSE scores. Multivariate regression revealed that future general medicine candidates achieved the highest JSE scores ([Formula: see text] = 6.68, 95% CI 2.39-10.9, p = 0.002). Women achieved significantly higher JSE scores than men ([Formula: see text] = 2.42, 95% CI 0.11-4.73, p = 0.041). The results have implications for empathy training and postgraduate education strategy in different clinical specialties.

Quantitative measurement of empathy and analysis of its correlation to clinical factors in korean patients with chronic diseases

BACKGROUND

Empathy is the core of the physician-patient relationship. The Consultation and Relational Empathy (CARE) measure is a useful tool for assessing patient-rated empathy. There have been scarce data on empathy in chronic disease patients in Korea. We aim to evaluate empathy using the Korean CARE measure in patients from various clinical environments and the factors influencing the degree of empathy in patients with chronic disease.

METHODS

Data were collected from patients with chronic diseases. Patients were from primary, secondary, and tertiary clinics. Characteristics of the patients, physicians, and disease status were collected. The difference in CARE score was studied according to the clinical factors.

RESULTS

A total of 162 patients with chronic diseases were included. About 60% of patients were male. The mean age was 62 years. They had an average number of 2.6 diseases. More than half of patients experienced overt cardiovascular disease. About half of them had a history of hospitalization due to cardiovascular disease. The overall average CARE score was 45.6 ± 7.0. The CARE score was not significantly different according to the characteristics of the patient, physician, or disease status. Regarding marital status, the CARE score was significantly lower for the small number of patients (n = 4, 2.5%) who refused to provide their marital status than for other groups. Except for four patients, there was no significant difference in the CARE score among married, unmarried, or divorced groups. This trend was maintained in hypertensive patients.

CONCLUSIONS

The Korean CARE measure could assess patient-rated empathy in various clinical practices. The empathy of patients was high regardless of multiple factors.

Social responsiveness: The key ingredient to achieve social accountability in education and health care

While social accountability (SA) is regarded as an obligation or mandate for medical school administration, it runs the danger of becoming a bureaucratic checkbox. Compassion which leads to social responsiveness (SR), in contrast, is often recognized as an individual characteristic, detached from the public domain. The two, however, complement each other in practice. Institutions must be truly socially accountable, which is possible if there is spontaneous SR to the needs, and is fueled by compassion. Compassion in this article is defined as a "feeling for other people's sufferings, and the desire to act to relieve the suffering." Compassion has a long history, whereas SA is more recently described concept that follows the historical development of social justice. SR is the moral or ethical duty of an individual to behave in a way that benefits society. Not everyone feels the need to do something for others. Even if the need is felt, there may be a lack of will to act for the needs or to act effectively to fulfill the needs of society. The reasons are many, some visible and others not. SR provides the basis for being compassionate; hence, medical schools need to include SR as a criterion in their admissions process for student recruitment and inculcate compassion in health professions education and health care. By fostering SR and engaging compassion and self-compassion to achieve SA, we can humanize medical education systems and health care.

The Role of Compassionate Care in Medicine: Toward Improving Patients' Quality of Care and Satisfaction

INTRODUCTION

Despite its description as a cornerstone of a healthcare provider's professional identity, the impact of compassionate care on various aspects of medicine has been poorly defined. In this review, we aimed to elucidate the role of compassionate care in various aspects of medicine and healthcare delivery.

METHODS

Four databases were searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol for a literature review regarding compassionate care and its intersection with medical education, patient-provider communication, patient care, and clinical outcomes, patient and provider characteristics, telemedicine and artificial intelligence, caregiver compassion fatigue, and cost of care.

RESULTS

Twenty-two articles met the inclusion criteria. Analysis revealed that clinical outcomes are correlated with the degree of patients' perception of empathy and compassion from their providers. Along with enhanced patient outcomes, compassionate care was shown to reduce the costs of care, compassion fatigue and burnout, and the number of malpractice claims. However, compassion can be perceived differently among patients of various cultural and ethnic backgrounds. Compassion training sessions can be implemented among residents in surgical and nonsurgical medical specialties to improve perceived compassion. Furthermore, the use of telehealth modalities may positively or negatively impact compassionate care, requiring further exploration.

CONCLUSIONS

Compassionate care plays a crucial role in improving patient care and clinical outcomes while reducing caregiver burnout and the risk of malpractice litigation. However, a lack of compassion training and caregiver compassion fatigue may detract from the delivery of effective compassionate care.

Empathy levels among health professional students at a large midwestern public university - a cross-sectional study

BACKGROUND

Empathic care is considered extremely important by patients and providers alike but there is still an ample need for assessing empathy among healthcare students and professionals and identifying appropriate educational interventions to improve it. This study aims to assess empathy levels and associated factors among students at different healthcare colleges at the University of Iowa.

METHODS

An online survey was delivered to healthcare students, including nursing, pharmacy, dental, and medical colleges (IRB ID #202,003,636). The cross-sectional survey included background questions, probing questions, college-specific questions, and the Jefferson Scale of Empathy-Health Professionals Student version (JSPE-HPS). To examine bivariate associations, Kruskal Wallis and Wilcoxon rank sum tests were used. A linear model with no transformation was used in the multivariable analysis.

RESULTS

Three hundred students responded to the survey. Overall JSPE-HPS score was 116 (± 11.7), consistent with other healthcare professional samples. There was no significant difference in JSPE-HPS score among the different colleges (P = 0.532).

CONCLUSION

Controlling for other variables in the linear model, healthcare students' view of their faculty's empathy toward patients and students' self-reported empathy levels were significantly associated with students' JSPE-HPS scores.

Mortalidade de idosos por causas sensíveis e cobertura de Atenção Primária no Distrito Federal

RESUMO Objetivos: Descrever os coeficientes de mortalidade entre idosos por condições sensíveis, de 2008 a 2018, e verificar a associação com a cobertura da Atenção Primária à Saúde (Modelo Estratégia Saúde da Família e Atenção Básica) no Distrito Federal. Métodos: Estudo ecológico tipo série temporal da mortalidade dos idosos no Distrito Federal, entre 2008 e 2018. Para análise das associações, aplicou se o modelo de regressão Poisson, sendo consideradas significantes as que apresentaram p<0,05, com IC de 95%. Resultados: Houve70.503 óbitos. Observou-se diminuição do risco de morrer dos idosos por doenças cardiovasculares e diabetes. A cobertura da Atenção Primária diminuiu a chance de morrer por condições sensíveis tanto na Atenção Básica (OR: 0,994, IC: 0,990-0,998) quanto na Estratégia Saúde da Família (OR: 0,997, IC: 0,995-0,999). Conclusões: A cobertura de Atenção Primária foi associada a menor chance de morrer dos idosos por condições sensíveis à Atenção Primária, sobretudo na Atenção Básica.

Elderly Mortality due to Ambulatory Care Sensitive Conditions and Primary Health Care Coverage in the Federal District

OBJECTIVES

To describe the mortality coefficients of elderly due to primary care sensitive conditions, from 2008 to 2018, and determine its association with the coverage of the Primary Health Care (Family Health Strategy and Basic Care models) in the Federal District.

METHODS

Ecological time series of mortality in Federal District elderly, from 2008 to 2018. The Poisson regression model was applied, considering as significant those with p<0.05, with a CI of 95%.

RESULTS

There were 70,503 deaths. There was a decrease in the risk of death of elders due to cardiovascular diseases and diabetes. Higher primary care coverage decreased the chance of death by sensitive conditions, both in Basic Care (OR: 0.994, CI: 0.990-0.998) and in the Family Health Strategy (OR: 0.997, CI: 0.995-0.999).

CONCLUSIONS

Primary Care coverage was associated with a lower chance of death of the elderly due to Ambulatory Care Sensitive Conditions, especially in Basic Care.

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.

Empathic communication in dignity therapy: Feasibility of measurement and descriptive findings

OBJECTIVE

Dignity therapy (DT) is a guided process conducted by a health professional for reviewing one's life to promote dignity through the illness process. Empathic communication has been shown to be important in clinical interactions but has yet to be examined in the DT interview session. The Empathic Communication Coding System (ECCS) is a validated, reliable coding system used in clinical interactions. The aims of this study were (1) to assess the feasibility of the ECCS in DT sessions and (2) to describe the process of empathic communication during DT sessions.

METHODS

We conducted a secondary analysis of 25 transcripts of DT sessions with older cancer patients. These DT sessions were collected as part of larger randomized controlled trial. We revised the ECCS and then coded the transcripts using the new ECCS-DT. Two coders achieved inter-rater reliability (κ = 0.84) on 20% of the transcripts and then independently coded the remaining transcripts.

RESULTS

Participants were individuals with cancer between the ages of 55 and 75. We developed the ECCS-DT with four empathic response categories: acknowledgment, reflection, validation, and shared experience. We found that of the 235 idea units, 198 had at least one of the four empathic responses present. Of the total 25 DT sessions, 17 had at least one empathic response present in all idea units.

SIGNIFICANCE OF RESULTS

This feasibility study is an essential first step in our larger program of research to understand how empathic communication may play a role in DT outcomes. We aim to replicate findings in a larger sample and also investigate the linkage empathic communication may have in the DT session to positive patient outcomes. These findings, in turn, may lead to further refinement of training for dignity therapists, development of research into empathy as a mediator of outcomes, and generation of new interventions.

Evaluation and Revision of the Kiersma-Chen Empathy Scale

Objective. This study aimed to provide further validity evidence for the Kiersma-Chen Empathy Scale (KCES) by analyzing data collected from multiple administrations of the scale and conducting cognitive interviews of students in pharmacy and nursing programs to identify needed revisions.Methods. De-identified data from previous administrations of the KCES were used to evaluate the scale. Evidence of response process was enhanced through cognitive interviews with 20 pre-pharmacy and pharmacy students at Cedarville University. After survey revisions, the cognitive interview process was repeated with 10 University of Wyoming nursing students.Results. Based on psychometric data and cognitive interviews, the KCES was revised as follows: key components of cognitive and affective empathy were retained, scaling was changed to reflect necessity and empathy ability, negatively worded items were removed, and the single scale was converted into two parallel subscales.Conclusion. This study used data from thousands of geographically and professionally diverse samples. Based on potential problems identified in quantitative analyses, cognitive interviews with nursing and pharmacy students were conducted, and modifications to the KCES were made. Further psychometric validation is needed regarding the KCES-R.

Perspectives of 360-Degree Cinematic Virtual Reality: Interview Study Among Health Care Professionals

BACKGROUND

The global market for medical education is projected to increase exponentially over the next 5 years. A mode of delivery expected to drive the growth of this market is virtual reality (VR). VR simulates real-world objects, events, locations, and interactions in 3D multimedia sensory environments. It has been used successfully in medical education for surgical training, learning anatomy, and advancing drug discovery. New VR research has been used to simulate role-playing and clinical encounters; however, most of this research has been conducted with health professions students and not current health care professionals. Thus, more research is needed to explore how health care professionals experience VR with role-playing and clinical encounters.

OBJECTIVE

The aim of this study was to explore health care professionals' experiences with a cinematic VR (cine-VR) training program focused on role-playing and clinical encounters addressing social determinants of health, Appalachian culture, and diabetes. Cine-VR leverages 360-degree video with the narrative storytelling of cinema to create an engaging educational experience.

METHODS

We conducted in-depth telephone interviews with health care professionals who participated in the cine-VR training. The interviews were audio recorded and transcribed verbatim. A multidisciplinary team coded and analyzed the data using content and thematic analyses with NVivo software.

RESULTS

We conducted 24 in-depth interviews with health care professionals (age=45.3, SD 11.3, years; n=16, 67%, women; n=22, 92%, White; and n=4, 17%, physicians) to explore their experiences with the cine-VR training. Qualitative analysis revealed five themes: immersed in the virtual world: seeing a 360-degree sphere allowed participants to immerse themselves in the virtual world; facilitated knowledge acquisition: all the participants accurately recalled the culture of Appalachia and listed the social determinants of health presented in the training; empathized with multiple perspectives: the cine-VR provided a glimpse into the real life of the main character, and participants described thinking about, feeling, and empathizing with the character's frustrations and disappointments; perceived ease of use of cine-VR: 96% (23/24) of the participants described the cine-VR as easy to use, and they liked the 360-degree movement, image resolution, and sound quality but noted limitations with the buttons on the headsets and risk for motion sickness; and perceived utility of cine-VR as a teaching tool: participants described cine-VR as an effective teaching tool because it activated visual and affective learning for them.

CONCLUSIONS

Participants emphasized the realism of the cine-VR training program. They attributed the utility of the cine-VR to visual learning in conjunction with the emotional connection to the VR characters. Furthermore, participants reported that the cine-VR increased their empathy for people. More research is needed to confirm an association between the level of immersion and empathy in cine-VR training for health care professionals.

Clinician views on optimism and empathy in primary care consultations

Background

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

Aim

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

Design & setting

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

Method

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

Results

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

Conclusion

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

'I need someone to believe in me and walk the journey with me': A qualitative analysis of preferred approaches to weight management discussions in clinical care among adults with type 2 diabetes

AIMS

To explore the preferences of adults with type 2 diabetes regarding the approach to weight management discussions in clinical care.

METHODS

Online survey of Australian adults with type 2 diabetes, recruited via a national diabetes registry. Three open-ended questions explored participants' experiences and ideal approach to discussing weight management with health professionals. Data subjected to inductive thematic template analysis.

RESULTS

Participants were 254 adults, 58% aged 60+ years, 52% women and 35% insulin-treated. Five themes were developed to categorise participants' preferences for, as well as differing experiences of, weight management discussions: (1) collaborative, person-centred care: working together to make decisions and achieve outcomes, taking personal context into consideration; (2) balanced communication: open, clear messages encouraging action, empathy and kindness; (3) quality advice: knowledgeable health professionals, providing specific details or instructions; (4) weight management intervention: suitable modalities to address weight management and (5) system-wide support: referral and access to appropriate multi-disciplinary care.

CONCLUSIONS

Participants expressed preferences for discussing weight management in collaborative, person-centred consultations, with quality advice and personalised interventions across the health system, delivered with empathy. By adopting these recommendations, health professionals may build constructive partnerships with adults with type 2 diabetes and foster weight management.

Incorporating Integrated Personalised Diabetes Management (iPDM) in Treatment Strategy: A Pragmatic Approach

Diabetes is a global public health concern. Vigilant monitoring and effective management of glycaemic variations are essential to prevent complications of diabetes. Effectively incorporating monitoring strategies in management of diabetes is a serious challenge. Patient-centered approach is necessary to customise monitoring and therapy of diabetes. This has been made possible by integrating technology with personalised therapeutic strategy. The integrated personalised diabetes management (iPDM) is a holistic, patient-centered approach that focuses on personalising diabetes management to streamline therapy and improve outcome. iPDM helps strengthen the care process, facilitates communication between patients and their healthcare team, and integrates digital tools that visualise and analyse data. The five E's which includes enthusiasm, education, expertise, empathy and engagement are the key pillars of a strong foundation for the iPDM model. iPDM model is a convenient and easily accessible tool that shifts the management paradigm from an "algorithmic" to "personalized" care to optimise treatment outcomes. Structured self-monitoring of blood glucose (SMBG) should be available as part of the self-management process for people with sub-optimally controlled type 2 diabetes, including those not on insulin therapies. Different SMBG regimens should be followed based on factors such as diabetes type, treatment approach (diet, oral antidiabetic medication, or insulin), glycaemic control, available resources, and patient's level of education.

The biopsychosociotechnical model: a systems-based framework for human-centered health improvement

The biopsychosocial model is among the most influential frameworks for human-centered health improvement but has faced significant criticism- both conceptual and pragmatic. This paper extends and fundamentally re-structures the biopsychosocial model by combining it with sociotechnical systems theory. The resulting biopsychosociotechnical model addresses key critiques of the biopsychosocial model, providing a more "practical theory" for human-centered health improvement. It depicts the determinants of health as complex adaptive system of systems; includes the the artificial world (technology); and provides a roadmap for systems improvement by: differentiating between "health status" and "health and needs assessment", [promoting problem framing]; explaining health as an emergent property of the biopsychosociotechnical context [imposing a systems orientation]; focusing on "interventions" vs. "treatments" to modify the biopsychosociotechnical determinants of health, [expanding the solution space]; calling for a participatory design process [supporting systems awareness and goal-orientation]; and including intervention management to support the full lifecycle of health improvement.

Feasibility of an Activity Control System in Patients with Diabetes: A Study Protocol of a Randomised Controlled Trial

PURPOSE

Patients with diabetes mellitus have an increased risk of developing various serious health problems that could be life-threatening. These problems are associated with the difficulty of these patients in managing their lifestyle, which may even lead to the abandonment of treatment. The present study was designed to evaluate the feasibility of a multipurpose activity control solution for home activity (home activity control system), which will provide information on the activities of daily living carried out outside in real time, to improve adherence to each of the therapeutic objectives agreed on with the diabetic patient.

PATIENTS AND METHODS

A pilot randomised controlled feasibility study will be carried out to evaluate a home activity control system (Beprevent) in managing patients with type 2 diabetes mellitus. Twenty patients with type 2 diabetes mellitus will be included (10 in the intervention group and 10 in the control group). Data on satisfaction with the tool will be collected from professionals and patients, as well as other clinical/epidemiological data from their digital health records and several questionnaires, at baseline and six months. In addition, data will also be recorded regarding the degree of adherence to the behaviors agreed on with the patients before starting the study to assess changes throughout the study and their relationship with clinical results (glycosylated haemoglobin (HbA1c), cholesterol, etc), and to compare these outcomes between two study groups.

DISCUSSION

This project involves the incorporation of telemedicine in the management of patients with diabetes. Thus, according to the currently published bibliography, the use of smart devices in this population could help improve the quality of life of these people, reduce medical visits and improve adherence to home care patterns for diabetes mellitus. There are currently no published clinical trials or protocols that monitor activities of daily living in patients with diabetes individually using artificial intelligence (AI) devices.

Validation of the Romanian Version of the Toronto Empathy Questionnaire (TEQ) among Undergraduate Medical Students

Medical professionals require adequate abilities to identify others’ emotions and express personal emotions. We aimed to determine the validity and reliability of an empathy measuring tool in medical students for this study. We employed Spreng’s Toronto Empathy Questionnaire (TEQ) as a starting point for this validation. The process was performed in several steps, including an English-Romanian-English translation and a focus group meeting to establish each question’s degree of understandability and usability, with minor improvements of wording in each step. We checked internal and external consistency in a pilot group (n = 67). For construct and convergent validity, we used a sample of 649 students. The overall internal and external reliability performed well, with Cronbach’s alpha = 0.727 and respective ICC = 0.776. The principal component analysis resulted in 3 components: prosocial helping behavior, inappropriate sensitivity, dismissive attitude. Component 1 includes positively worded questions, and components 2 and 3 include negatively worded questions. Women had significantly higher scores than men in convergent validity, but we did not highlight any differences for other demographic factors. The Romanian version of the TEQ is a reliable and valid tool to measure empathy among undergraduate medical students that may be further used in subsequent research.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Harnessing Placebo Effects in Primary Care: Using the Person-Based Approach to Develop an Online Intervention to Enhance Practitioners' Communication of Clinical Empathy and Realistic Optimism During Consultations

Background: Empathic communication and positive messages are important components of "placebo" effects and can improve patient outcomes, including pain. Communicating empathy and optimism to patients within consultations may also enhance the effects of verum, i.e., non-placebo, treatments. This is particularly relevant for osteoarthritis, which is common, costly and difficult to manage. Digital interventions can be effective tools for changing practitioner behavior. This paper describes the systematic planning, development and optimization of an online intervention-"Empathico"-to help primary healthcare practitioners enhance their communication of clinical empathy and realistic optimism during consultations. Methods: The Person-Based Approach to intervention development was used. This entailed integrating insights from placebo and behavior change theory and evidence, and conducting primary and secondary qualitative research. Systematic literature reviews identified barriers, facilitators, and promising methods for enhancing clinical empathy and realistic optimism. Qualitative studies explored practitioners' and patients' perspectives, initially on the communication of clinical empathy and realistic optimism and subsequently on different iterations of the Empathico intervention. Insights from the literature reviews, qualitative studies and public contributor input were integrated into a logic model, behavioral analysis and principles that guided intervention development and optimization. Results: The Empathico intervention comprises 7 sections: Introduction, Empathy, Optimism, Application of Empathico for Osteoarthritis, Reflection on my Consultations, Setting Goals and Further Resources. Iterative refinement of Empathico, using feedback from patients and practitioners, resulted in highly positive feedback and helped to (1) contextualize evidence-based recommendations from placebo studies within the complexities of primary healthcare consultations and (2) ensure the intervention addressed practitioners' and patients' concerns and priorities. Conclusions: We have developed an evidence-based, theoretically-grounded intervention that should enable practitioners to better harness placebo effects of communication in consultations. The extensive use of qualitative research throughout the development and optimization process ensured that Empathico is highly acceptable and meaningful to practitioners. This means that practitioners are more likely to engage with Empathico and make changes to enhance their communication of clinical empathy and realistic optimism in clinical practice. Empathico is now ready to be evaluated in a large-scale randomized trial to explore its impact on patient outcomes.

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.

Primary care and the COVID-19 pandemic: Schrödinger's cat

We read with interest the article by Tomoset al. [1] reporting on the low death rates during the coronavirus disease 2019 (COVID-19) pandemic crisis in Greece. The authors underlined the importance of primary care in the management of suspected and mild cases and the reduction of inappropriate hospital referrals [1]. With good intentions, the authors offered their own view by stating that the key issue for the reported “Greek success story” is that the primary healthcare system is based on specialist doctors and not general practitioners [1]. They also suggested an algorithm that will help physicians to stratify the risk of infection, highlighting the importance of telemedicine [1]. We also support the usefulness of this conceptual framework. For large population groups that mainly benefit from rural primary care, limited access to private services can be an additional benefit.

The #COVID19 pandemic crisis requires the collaboration of all healthcare providers. Every contribution is welcome to gain time during the phase of “system state” superposition.https://bit.ly/3m4SBxY

Motives for Empathy among Clinical Nurses in China: A Qualitative Study

PURPOSE

This study aimed to explore the motives of clinical nurses for experiencing empathy with patients and their families based on a self-determination theory framework.

METHODS

Semi-structured face-to-face interviews with twenty-one nurses at four tertiary hospitals in Anhui, China, were conducted, recorded and transcribed. A content analysis with a directed approach was performed.

RESULTS

An analysis of the interview transcripts revealed three categories of empathy motivation: autonomous motivation, controlled motivation and a lack of empathy motivation. Autonomous motivation included personal interests, enjoyment and a sense of value, pure altruism, assimilation, and recognition of the importance of empathy. Controlled motivation highlighted pressures from oneself and others, the possibility of tangible or intangible rewards, and avoidance of adverse effects. Finally, a lack of empathy motivation referred to a lack of intention for empathy and denial of the value of empathy.

CONCLUSION

This study provides a deep understanding of the motives underlying empathy in nurses. The results reveal the reasons for empathy and may support the development of effective strategies to foster and promote empathy in nurses.

Evaluation of winter pressures on general practice in Manchester: a cross-sectional analysis of nine GP practices

Background

The Nuffield Trust’s report on NHS winter pressures highlights a lack of data for primary care, with a consequential focus on secondary care. An increase in data is required on the scale of the winter demand on primary care, so the need for investment in this area can be clearly seen.

Aim

To quantify seasonal variation in workload in primary and secondary care.

Design & setting

Analysis of data for nine GP practices in Greater Manchester with a patient population of 75 421.

Method

Descriptive and comparative analyses were performed for winter and summer periods in 2018–2019. Data were obtained from the North of England Clinical Support Unit (NECSU) via the Rapid Actionable Insight Driving Reform (RAIDR) toolkit, and EMIS Enterprise clinical audit tools.

Results

Accident and emergency (A&E) attendances increased by 4% (P = 0.035) during winter with no difference in the number of hospital admissions (P = 0.668). The number of problems (defined as separate diagnoses or causes for a GP consultation, for example, chest infection or medication request) seen in general practice increased by 61% (P<0.001) in winter compared to summer, as did the number of GP consultations, which was also 61% (P<0.001). Respiratory diagnoses saw the greatest seasonal variation accounting for 10% in winter compared with 4% in summer (P<0.001). Self-referral accounted for 66% of all A&E attendance and increased by 16% in winter. GP referral accounted for 7% in winter and 6% in summer (P = 0.002).

Conclusion

General practice observed a greater seasonal increase in presenting patients compared with secondary care. Any winter pressures strategy should target both respiratory illness and patients who self-refer to A&E. Transferring 50% of self-referrals in Manchester to GP appointments would achieve a £2.3 million cost saving. Increasing provision in primary care requires funding and increased appointments, but more importantly improved patient opportunities to easily access timely advice and assistance.

Improving Empathy in Healthcare Consultations-a Secondary Analysis of Interventions

A recent systematic review of randomised trials suggested that empathic communication improves patient health outcomes. However, the methods for training healthcare practitioners (medical professionals; HCPs) in empathy and the empathic behaviours demonstrated within the trials were heterogeneous, making the evidence difficult to implement in routine clinical practice. In this secondary analysis of seven trials in the review, we aimed to identify (1) the methods used to train HCPs, (2) the empathy behaviours they were trained to perform and (3) behaviour change techniques (BCTs) used to encourage the adoption of those behaviours. This detailed understanding of interventions is necessary to inform implementation in clinical practice. We conducted a content analysis of intervention descriptions, using an inductive approach to identify training methods and empathy behaviours and a deductive approach to describe the BCTs used. The most commonly used methods to train HCPs to enhance empathy were face-to-face training (n = 5), role-playing (n = 3) and videos (self or model; n = 3). Duration of training was varied, with both long and short training having high effect sizes. The most frequently targeted empathy behaviours were providing explanations of treatment (n = 5), providing non-specific empathic responses (e.g. expressing understanding) and displaying a friendly manner and using non-verbal behaviours (e.g. nodding, leaning forward, n = 4). The BCT most used to encourage HCPs to adopt empathy behaviours was "Instruction on how to perform behaviour" (e.g. a video demonstration, n = 5), followed by "Credible source" (e.g. delivered by a psychologist, n = 4) and "Behavioural practice" (n = 3 e.g. role-playing). We compared the effect sizes of studies but could not extrapolate meaningful conclusions due to high levels of variation in training methods, empathy skills and BCTs. Moreover, the methods used to train HCPs were often poorly described which limits study replication and clinical implementation. This analysis of empathy training can inform future research, intervention reporting standards and clinical practice.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Primary medical care continuity and patient mortality: a systematic review

BACKGROUND

A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care.

AIM

This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care.

DESIGN AND SETTING

Systematic review of studies published in English or French from database and source inception to July 2019.

METHOD

Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality.

RESULTS

Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated.

CONCLUSION

This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.

Provision of services in primary care for type 2 diabetes: a qualitative study with patients, GPs, and nurses in the East of England

BACKGROUND

There is little evidence on the impact of national pressures on primary care provision for type 2 diabetes from the perspectives of patients, their GPs, and nurses.

AIM

To explore experiences of primary care provision for people with type 2 diabetes and their respective GPs and nurses.

DESIGN AND SETTING

A qualitative primary care interview study in the East of England.

METHOD

Semi-structured interviews were conducted, between August 2017 and August 2018, with people who have type 2 diabetes along with their respective GPs and nurses. Purposive sampling was used to select for heterogeneity in glycaemic control and previous healthcare experiences. Interviews were audio-recorded and analysed thematically. The consolidated criteria for reporting qualitative research were followed.

RESULTS

The authors interviewed 24 patients and 15 GPs and nurses, identifying a changing landscape of diabetes provision owing to burgeoning pressures that were presented repeatedly. Patient responders wanted GP-delivered care with continuity. They saw GPs as experts best placed to support them in managing diabetes, but were increasingly receiving nurse-led care. Nurses reported providing most of the in-person care, while GPs remained accountable but increasingly distanced from face-to-face diabetes care provision. A reluctant acknowledgement surfaced among GPs, nurses, and their patients that only minimum care standards could be maintained, with aspirations for high-quality provision unlikely to be met.

CONCLUSION

Type 2 diabetes is a tracer condition that reflects many aspects of primary care. Efforts to manage pressures have not been perceived favourably by patients and providers, despite some benefits. Reframing expectations of care, by communicating solutions to both patients and providers so that they are understood, managed, and realistic, may be one way forward.

Medical Students' Empathy Level Differences by Medical Year, Gender, and Specialty Interest in Akdeniz University

BACKGROUND

As an important feature in patient-physician communication for both primary and clinical care, empathy is one of the basic competencies that physicians should possess. The primary aim of this study was to evaluate the level of empathy among medical students in all years of medical training using two different instruments: the Jefferson Scale of Physician Empathy (for clinical empathy level) and the Toronto Empathy Questionnaire (for general empathy level).

MATERIALS AND METHODS

This study is a cross-sectional descriptive study conducted in 2017-2018 academic year with students studying at Akdeniz University Faculty of Medicine. Data collection form, Toronto Empathy Questionnaire (TEQ) and Jefferson Scale of Physician Empathy (JSPE) was applied to the students by the researchers. The statistical analysis was carried out by using IBM-SPSS version 23 for Mac OS. T-test, ANOVA test, Spearman and Pearson correlation analysis were used for comparisons.

RESULTS

The mean TEQ score of the students was 52.8/65 and the JSPE-S score was 80.3/100. TEQ scores of students increased up to 4th year and then decreased, but the difference between the years was not statistically significant. The third year students' JSPE-S scores were significantly higher than that of the sixth year students.

CONCLUSION

While the clinical empathy levels of medical students decreased significantly after 3rd year, the general empathy levels decreased less. This result shows us that we should review our medical education curriculum and educational environment, and should initiate initiatives, and devote more time to empathy education in order to prevent the decrease in empathy level and increase empathy during medical education.

Interventions to Enhance Empathy and Person-Centered Care for Individuals With Dementia: A Systematic Review

Empathy, or the ability to imagine what someone else may be feeling or thinking, is a crucial component of meaningful care provision, including person-centered care (PCC), and has been shown to enhance care provider and patient well-being. The purpose of the current review was to examine the impact of interventions focused on improving the ability of health care providers or students to experience and/or communicate with empathy. Of 1,427 publications reviewed, 18 articles met inclusion criteria. All studies incorporated empathy or empathic communication competencies in their training or intended variables of change. PCC concepts were used in guiding the development of most interventions. Some interventions significantly improved participant empathy, attitudes toward patients with dementia, and certain verbal and nonverbal communication skills. Current study reports on improved positive interpersonal communication skills by nursing assistants are promising. Future study to improve therapeutic communication and delivery of dementia care with empathy using enhanced study design and measurement are needed. [Research in Gerontological Nursing, 13(3), 158-168.].