Consequences of the presence and absence of empathy during consultations in primary care: A focus group study with patients

ObjectiveThere is general consensus that explicit expression of empathy in patient-GP communication is highly valued. Yet, little is known so far about patients’ personal experiences with and expectations of empathy. Insight into these experiences and expectations can help to achieve more person-centeredness in GP practice care.MethodsParticipants were recruited by a press report in local newspapers. Inclusion criteria: adults, a visit to the GP in the previous year. Exclusion criterion: a formal complaint procedure. Five focus groups were conducted. The discussions were analyzed using constant comparative analysis.ResultsIn total 28 participants took part in the focus group interviews. Three themes were identified: (1) Personalized care and enablement when empathy is present; (2) Frustrations when empathy is absent; (3) Potential pitfalls of empathy. Participants indicated that empathy helps build a more personal relationship and makes them feel welcome and at ease. Furthermore, empathy makes them feel supported and enabled. A lack of empathy can result in avoiding a visit to the GP.ConclusionEmpathy is perceived as an important attribute of patient-GP communication. Its presence results in feelings of satisfaction, relief and trust. Furthermore, it supports patients, resulting in new coping strategies. A lack of empathy causes feelings of frustration and disappointment and can lead to patients avoiding visiting their GP.Practice implicationsMore explicit attention should be given to empathy during medical education in general and during vocational GP-training.     

Virtual environments to study emotional responses to clinical communication: A scoping review

ObjectiveThis scoping review explores the potential for virtual environments (VE) to evaluate emotional outcomes in clinical communication research. Authors representing multiple disciplines use review results to propose potential research opportunities and considerations.MethodsWe utilized a structured framework for scoping reviews. We searched four literature databases for relevant articles. We applied multidisciplinary perspectives to synthesize relevant potential opportunities for emotion-focused communications research using VE.ResultsTwenty-one articles met inclusion criteria. They applied different methodological approaches, including a range of VE technologies and diverse emotional outcome measures, such as psychophysiological arousal, emotional valence, or empathy. Major research topics included use of virtual reality to provoke and measure emotional responses, train clinicians in communication skills, and increase clinician empathy.ConclusionResearchers may leverage VE technologies to ethically and systematically examine how characteristics of clinical interactions, environments, and communication impact emotional reactions and responses among patients and clinicians. Variability exists in how VE technologies are employed and reported in published literature, and this may limit the internal and external validity of the research. However, virtual reality can provide a low-cost, low-risk, experimentally controlled, and ecologically valid approach for studying clinician-patient communication.Practice implicationsFuture research should leverage psychophysiological measures to further examine emotional responses during clinical communication scenarios and clearly report virtual environment characteristics to support evaluation of study conclusions, study replicability, and meta-analyses.     

Development and national consensus finding on patient-centred high stakes communication skills assessments for the Swiss Federal Licensing Examination in Medicine

ObjectiveTo describe and evaluate a consensus finding and expert validation process for the development of patient-centred communication assessments for a national Licensing Exam in Medicine.MethodsA multi-professional team of clinicians and experts in communication, assessment and role-play developed communication assessments for the Swiss Federal Licensing Examination. The six-month process, informed by a preceding national needs-assessment, an expert symposium and a critical literature review covered the application of patient-centred communication frameworks, the development of assessment guides, concrete assessments and pilot-tests. The participants evaluated the process.ResultsThe multiple-step consensus process, based on expert validation of the medical and communication content, led to six high-stakes patient-centred communication OSCE-assessments. The process evaluation revealed areas of challenge such as calibrating rating-scales and case difficulty to the graduates’ competencies and integrating differing opinions. Main success factors were attributed to the outcome-oriented process and the multi-professional exchange of expertise. A model for developing high stakes patient-centred communication OSCE-assessments was derived.ConclusionsConsensus finding was facilitated by using well-established communication frameworks, by ensuring outcome-orientated knowledge exchange among multi-professional experts, and collaborative validation of content through experts.Practice implicationsWe propose developing high-stakes communication assessments in a multi-professional expert consensus and provide a conceptual model.     

Consensus guidelines for management of patellofemoral instability

BackgroundThe aim of this consensus process was to provide robust national guidelines to assist with decision making with regards to surgical management of patellofemoral instability.MethodsA national group of surgeons, physiotherapists, basic scientists and a radiologist with expert experience in patellofemoral instability was convened. A formal consensus process was undertaken using validated methodology. They reviewed the existing literature, performed a group consensus meeting to develop recommendations and followed this with a wider consultation meeting with an open invitation for final ratification. The guidelines were reviewed and authorised by the BASK executive committee, followed by the British Orthopaedic Association prior to final publication.ResultsThe review of the literature confirmed a significant absence of an evidence base to guide clinicians in the surgical management of patellofemoral instability. The consensus process outlined guidance relating to diagnosis and clinical assessment, appropriate imaging modalities, recommendations for surgical options and appropriate post operative physiotherapy. Following wide invitation to contribute to the final document, 102 people responded. Twenty six of those provided additional comments which were blinded, discussed and included or excluded following further discussion amongst the working group.ConclusionPatellofemoral instability is a complex pathology with multiple surgical options available to those who decide surgery is indicated. In the absence of a strong evidence base, these guidelines aim to assist with that decision making process and will pave the way for more robust clinical trials in the future.     

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

ObjectiveWhile the benefits of patient-centered care have been consistently demonstrated in the health literature, there exists a dearth of pathway research within health outcome research, especially within the chronic pain context. This study examined the relationship between perceived physician empathy and patient psychological distress and its underlying mechanism.MethodsA community sample of 259 adults with chronic pain completed online questionnaires measuring patient-perceived physician empathy, treatment satisfaction, depressive and anxiety symptoms. Analyses were conducted using correlational and mediation analyses.ResultsResults revealed perceived empathy to be positively and strongly correlated with treatment satisfaction (r = .72, p < .001). A significant negative correlation was also demonstrated between perceived empathy and depressive symptoms (r = -.13, p < .05), but not between perceived empathy and anxious symptoms (r = .03, p = .65). Results revealed significant mediation models between perceived empathy and patient depressive symptoms (indirect effect: B = -.19, SE =.06, 95 % CI [-.31, -.09]) and anxious symptoms (indirect effect: B = -.24, SE = .06, 95 % CI [-.35, -.14]), via treatment satisfaction as mediator and including covariates.ConclusionChronic pain patients who perceive greater levels of physician empathy experience fewer depressive and anxious symptoms, as mediated by treatment satisfaction.Practice implicationsClinical training and practice should promote empathetic components of health communication within chronic pain treatment.     

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

ObjectiveThis study examines whether students in the clinical phase show reduced well-being and lower empathy scores compared to preclinical students. Furthermore, it explores students’ most stressful experiences.MethodsA cross-sectional mixed-methods study was conducted among medical students of the revised patient- and student-centred curriculum at Witten/Herdecke University (Germany). An online survey included questions regarding empathy (JSPE-S), well-being (WHO-5), distressing factors in the learning and clinical environments, mistreatment and thoughts of dropping out.Results176 (34 %) of 517 medical students completed the questionnaire, 73 being preclinical and 103 clinical students. Despite lower well-being, clinical student did not demonstrate lower empathy levels. Main stressors during the clinical phase were negative physician role models and financially focussed care rather than challenging patient encounters. Compared to preclinical students, clinical students showed more mistreatment experiences and higher ratings towards thoughts of dropping out.ConclusionOur results illustrate contemporary challenges to establishing a learner-centred clinical environment that nurtures well-being and empathy of medical students. The sustainment of empathy despite more stressful experiences and lower well-being may be due to protective factors.Practice ImplicationsThe paper suggests activities to support clinical students to find ways to adapt the clinical learning environment to students’ needs.     

Clinical empathy in GP-training: Experiences and needs among Dutch GP-trainees. “Empathy as an element of personal growth”

ObjectiveClinical empathy has been described as a key component of effective person-centeredness in patient-physician communication. Yet little is known about general practitioner (GP) trainees’ experiences and opinions regarding clinical empathy, empathy-education and the development of empathic skills. This study aimed to explore trainees’ experiences with clinical empathy during GP training.MethodsThis study used focus group interviews. GP trainees at two Dutch universities were approached by e-mail. Focus groups were conducted between April and November 2018. Six focus groups were conducted: two with starting trainees, two with trainees at the end of their first year and two with trainees at the end of their 3 years’ training. Two experienced qualitative researchers analyzed the focus groups. During the thematic analysis the differences and similarities between the various stages of education were taken into account and a framework for the identified themes and subthemes was developed.ResultsThirty-five GP trainees took part. Four main themes could be identified. Starting trainees experienced frictions regarding the influence of personal affective reactions on their medical competencies. Trainees at the end of their first year indicated that they reached a balance between empathic involvement and their responsibility to carry out relevant medical tasks, such as following GP guidelines. Trainees at the end of their three years’ training recognized the mutual relationship between the development of the behavioral part of clinical empathy and personal growth. All trainees stated that their needs concerning education changed during their GP training and proposed changes to the curriculum.ConclusionsGP trainees face various obstacles in developing empathic skills and behavior. Particularly they mention handling personal affective reactions. Trainees express a clear wish for clinical empathy, in its theoretical as well as its skill and emotional aspects, to play a central role in the curriculum.Practice implicationsMore explicit attention to be paid to empathy by embedding theoretical education, explicit attention to skill training and assessment of empathic behavior by patients and supervisors     

The relationship between medical students’ empathy and burnout levels by gender and study years

ObjectiveTo investigate the multifaceted factors affecting empathy in medical students.Methods1293 medical students from 15 South Korean medical schools participated in an online survey. Affective empathy was measured with the ‘empathy concern’ and ‘personal distress’ dimensions from the Interpersonal Reactivity Index for Medical Students (IRI-MS). Cognitive empathy was assessed with IRI-MS’ ‘perspective taking’ and Jefferson Scales for Physician Empathy for Student (JSPE-S). Maslach Burnout Inventory for Medical Students (MBI-MS) assessed the burnout levels of the participants.ResultsA significant gender difference in affective and cognitive empathy was found using JSPE-S. Different patterns were seen in the empathy dimensions between the study years and genders. Burnout scores showed no gender differences, while exhaustion and cynicism increased, and academic efficacy decreased with seniority. Academic efficacy was a consistently influential factor for both affective and cognitive empathy in both genders, all study years and the three domains of burnout.ConclusionAcademic efficacy was a significant factor influencing both affective and cognitive empathy.Practical implicationsThe comprehensive nature of empathy in medical students may be better investigated by applying multi-dimensional empathy measurement tools and by analyzing multiple factors such as gender, study year and burnout.     

Attachment styles as predictors of self-reported empathy in medical students during pre-clinical years

ObjectiveTo assess medical students’ attachment profile and to explore its relationship with empathy dimensions.MethodsThree cohorts of medical students were consecutively enrolled in the study at the beginning of their second year, before their clinical internship experience, and assessed using the Attachment Style Questionnaire (a self-report measure of attachment styles) and the Interpersonal Reactivity Index (a self-report measure of empathy). t-test, partial correlations, and multiple linear regression models were used to analyze relationships between attachment styles and gender, age, and empathy dimensions.ResultsA total of 361 out of 450 (80.2%) Italian second-year medical students participated in the study. Female students considered interpersonal relationships more important and showed a higher need for approval than did their male counterparts. Among the attachment styles, considering relationships as secondary to achievement was the most important significant predictor of both emotional and cognitive empathy variables.ConclusionsThis study shows that the attachment styles of medical students are related to self-evaluated empathy, over and above the effects of gender and age differences.Practice implicationsThe Attachment Style Questionnaire may be a useful tool for medical educators to identify medical students with low empathy scores during their pre-clinical years of study.     

Defining and assessing intrinsic capacity in older people: A systematic review and a proposed scoring system

IntroductionThe World Health Organization has introduced the term ‘intrinsic capacity’ (IC) as a marker of healthy ageing. However, controversy exists on the definition and assessment of IC. We aimed to review the definitions and methods used for the assessment of IC in older adults. In addition, we proposed a new IC scoring method.MethodsA systematic search was performed in PubMed, Web of Science, Cochrane Library, Scopus and SPORTDiscus (up to February 10th, 2022) for studies assesing IC in older adults (>60 years).ResultsThirty-three studies were included. There is overall consensus on the definition of IC as well as on its different dimensions, that is: locomotion, vitality, sensory, cognition and psychological. However, the methods for assessing each of these five dimensions differ substantially across studies and there is no consensus on the best method to compute an eventual global compound score to evaluate IC taking into account all its different dimensions.ConclusionsThe IC represents a highly relevant clinical concept that has been unfortunately underutilized. We propose a standardization for the assessment of each dimension of IC, with a global 0 (worst) to 10 (highest) score.     

“Same same or different?” A review of reviews of person-centered and patient-centered care

Objective

To provide a synthesis of already synthesized literature on person-centered care and patient-centered care in order to identify similarities and differences between the two concepts.

Hypereosinophilic syndrome

ObjectiveTo summarize the identified molecular and cellular mechanisms relevant to clinicians evaluating patients with hypereosinophilic syndrome (HES).Data SourcesReview of relevant peer-reviewed literature.Study SelectionsStudies on the pathogenesis of HES in relation to consensus definitions, disease classification, mechanisms of disease, and diagnosis and treatment are included.ResultsChanges to the definition of HES have been proposed based on recent studies identifying specific cellular and molecular disease phenotypes. Identification of specific mechanisms of disease may have clinical and therapeutic significance. Despite recent advances, in most cases the molecular pathogenesis of HES remains unknown.ConclusionIdentification of specific HES disease mechanisms empowers the practicing clinician to offer specific mechanism-based treatment options to patients with HES in their clinical practice.     

Artificial intelligence in brain MRI analysis of Alzheimer’s disease over the past 12 years: A systematic review

IntroductionMultiple structural brain changes in Alzheimer’s disease (AD) and mild cognitive impairment (MCI) have been revealed on magnetic resonance imaging (MRI). There is a fast-growing effort in applying artificial intelligence (AI) to analyze these data. Here, we review and evaluate the AI studies in brain MRI analysis with synthesis.MethodsA systematic review of the literature, spanning the years from 2009 to 2020, was completed using the PubMed database. AI studies using MRI imaging to investigate normal aging, mild cognitive impairment, and AD-dementia were retrieved for review. Bias assessment was completed using the PROBAST criteria.Results97 relevant studies were included in the review. The studies were typically focused on the classification of AD, MCI, and normal aging (71% of the reported studies) and the prediction of MCI conversion to AD (25%). The best performance was achieved by using the deep learning-based convolution neural network algorithms (weighted average accuracy 89%), in contrast to 76-86% using Logistic Regression, Support Vector Machines, and other AI methods.DiscussionThe synthesized evidence is paramount to developing sophisticated AI approaches to reliably capture and quantify multiple subtle MRI changes in the whole brain that exemplify the complexity and heterogeneity of AD and brain aging.     

The power of clinician-expressed empathy to increase information recall in advanced breast cancer care: an observational study in clinical care,exploring the mediating role of anxiety

ObjectiveExperimental studies have found that clinician-expressed empathy improves patients’ information recall in (advanced) cancer consultations. It remains unclear, however, whether these results are generalizable to clinical care and, if so, what the underlying mechanism is. We aimed to i) determine the relationship between clinician-expressed empathy and patients’ information recall in clinical advanced breast cancer consultations; and ii) test whether the relationship between clinician-expressed empathy and recall is mediated by a decrease in patients’ anxiety.MethodsForty-one consultations between oncologists and female patients with advanced breast cancer were audio recorded. Patients’ post-consultation information recall and pre- and post-consultation anxiety (0-100) were assessed. Recall was scored according to a self-created questionnaire. Clinician-expressed empathy (0-100) was assessed by observers. Structural Equation Modelling was used for all analyses.ResultsParticipants remembered 61% of the information discussed. Clinician-expressed empathy significantly increased patients’ total information recall (p = .041) and recall of treatment aims/positive effects (p = .028). The mediating role of anxiety could not be established.ConclusionAlthough the underlying mechanism remains unclear, clinicians have a powerful tool to improve seriously ill breast cancer patients’ recall of information: empathy.Practice implicationsThese insights should encourage clinicians to express empathy; practical communication training might prove helpful.     

Mindfulness predicts student nurses’ communication self-efficacy: A cross-national comparative study

ObjectivesThe aim of this study was to compare student nurses’ communication self-efficacy, empathy, and mindfulness across two countries, and to analyse the relationship between these qualities.MethodsThe study had a cross-sectional design. Data was collected from final year student nurses in Norway and Sweden. Communication self-efficacy, empathy, and mindfulness were reported by questionnaires; Clear-cut communication with patients, Jefferson Scale of Empathy, and Langer 14 items mindfulness scale.ResultsThe study included 156 student nurses, 94 (60%) were Swedish. The mean communication self-efficacy score was 119 (95% CI 116–122), empathy score 115 (95% CI 113–117) and mindfulness score 79 (95% CI 78–81). A Mann-Whitney test showed that Swedish students scored significantly higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. When adjusted for age, gender, and country in a multiple linear regression, mindfulness was the only independent predictor of communication self-efficacy.ConclusionThe Swedish student nurses in this study scored higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. Student nurses scoring high on mindfulness rated their communication self-efficacy higher.Practice implicationsA mindful learning approach may improve communication self-efficacy and possibly the effect of communication skills training.     

Towards non-reductionistic medical anthropology,medical education and practitioner–patient-interaction: The example of Anthroposophic Medicine

ObjectiveTo develop the hypothesis that reductionism in medical anthropology, professional education and health care influences empathy development, communication and patient satisfaction.MethodWe identified relevant literature and reviewed the material in a structured essay. We reflected our hypothesis by applying it to Anthroposophic Medicine (AM), an example of holistic theory and practice.ResultsReductionism in medical anthropology such as in conventional medicine seems to lead to a less empathetic and less communicative health care culture than holism such as in CAM disciplines. However, reductionism can be transformed into a systemic, multi-perspective holistic view, when the emergent properties of the physical, living, psychic, spiritual and social levels of human existence and the causal relations between them are more carefully accounted for in epistemology, medical anthropology and professional education. This is shown by the example of AM and its possible benefits for communication with and satisfaction of patients.ConclusionA non-reductionistic understanding of the human being may improve communication with patients and enhance patient benefit and satisfaction.Practice implicationsInterdisciplinary qualitative and quantitative studies are warranted to test this hypothesis and to understand the complex relations between epistemology, medical anthropology, education, health care delivery and benefit for patients.     

Students’ patient-centered-care attitudes: The contribution of self-efficacy,communication, and empathy

ObjectivesPatient-centered-care (PCC) attitudes are important to enhance PCC behavior, but research on perceptions and attitudes that contribute to PCC attitudes is limited. We tested a new model, assessing whether the association between self-efficacy and PCC attitudes is mediated by communication and empathy attitudes. Furthermore, we assessed medical-school-stage and gender differences in these variables.MethodsMedical/dentistry students (N = 653) completed self-reported questionnaires. Analyses were performed using Pearson's-correlations, PROCESS macro, and independent samples t-tests.ResultsThe association between communication self-efficacy and PCC attitudes was completely mediated by communication and empathy attitudes. Students in clinical years had more positive attitudes toward PCC and empathy, and higher communication self-efficacy. Females had more positive attitudes toward PCC, communication, and empathy.ConclusionsThe results emphasize the importance of communication self-efficacy and the mediating role of communication and empathy attitudes in enhancing PCC attitudes. This highlights the need to focus on learners' affective matter (what they feel/think) about their competencies and attitudes.Practice implicationsEducational interventions should improve understanding of the benefits of applying good communication skills, of learning the importance of empathy and its relevance to patient care, and strengthening students' confidence in applying these skills. Attention to these is important for enhancing students' PCC attitudes.     

What is clinical empathy? Perspectives of community members,university students,cancer patients,and physicians

ObjectivesTo explore what undergraduates, community members, oncology patients, and physicians consider empathic behavior in a physician.Methods150 undergraduates, 152 community members, 95 physicians, and 89 oncology patients rated 49 hypothetical physician behaviors for how well they fit their personal definition of physician empathy. Dimensions of empathy were explored and compared across groups.ResultsThree dimensions of empathy were Conscientious and Reassuring, Relationship Oriented, and Emotionally Involved. Relationship Oriented was the most strongly endorsed, followed by Emotionally Involved, with Conscientious and Reassuring coming in last. There were no group differences for Conscientious and Reassuring, but the Relationship Oriented factor was more endorsed by the clinical groups (physicians and patients) than the non-clinical groups. The Emotionally Involved factor was endorsed by physicians notably more than by patients.ConclusionWhat is considered clinical empathy is not the same across individuals and stakeholder groups.Practice ImplicationsPhysicians and patients differ in how much they include the physicians’ emotionality and emotion-related actions in their definition of empathy. Communication training for physicians that emphasizes behaviors associated with empathy (listening, understanding a person’s feelings and perspectives, and showing interest in and concern for the whole person) may enhance patients’ perception of clinical empathy.     

The association between oxytocin receptor gene polymorphism (OXTR) and trait empathy

BackgroundOxytocin exerts well accepted effects on one of the key social processes: empathy. Previous researches have demonstrated that oxytocin promotes emotional and cognitive aspects of empathy, by exogenous administration as well as on gene level. However, the effect of diverse gene locus haplotypes of oxytocin receptor gene (OXTR) on trait empathy lacks reliable evidence.MethodsParticipants consisted of 101 genetically unrelated, non-clinical Chinese subjects (46 males and 55 females). Interpersonal Reactivity Index (IRI) was applied to measure the trait empathy from four dimensions: empathy concern, personal distress, perspective taking and fantasy. Fantasy and perspective taking measured cognitive aspect of empathy, while empathy concern and personal distress measured emotional aspect of empathy. Ten single tagging SNPs on OXTR rs2268491, rs1042778, rs53576, rs7632287, rs2254298, rs13316193, rs237897, rs237887, rs4686302, and rs2268493 were tested.ResultsGenotype difference in emotional empathy was found on rs237887 and rs4686302 whereas cognitive empathy varied on SNPs rs2268491 and rs2254298 between homozygous and variant carriers. For IRI score, there is a genotype and gender interaction on rs4686302 and rs13316193.LimitationThe sample sizes from the current study were not so optimal that these results should have to be interpreted with caution when amplified into a larger population.ConclusionThe findings demonstrate that natural variants of OXTR associated with trait empathy; specifically, individuals with certain OXTR genotype did perform better on trait empathy, while others did not. Our findings also provide genetic evidence for gender-related difference on empathy, indicating the popular fact that females who displayed more empathy than males could be likely to trace back to the genetic variants.     

Genetic evaluation of cardiomyopathy: a clinical practice resource of the American College of Medical Genetics and Genomics (ACMG)

PurposeThe purpose of this document is to provide updated guidance for the genetic evaluation of cardiomyopathy and for an approach to manage secondary findings from cardiomyopathy genes. The genetic bases of the primary cardiomyopathies (dilated, hypertrophic, arrhythmogenic right ventricular, and restrictive) have been established, and each is medically actionable; in most cases established treatments or interventions are available to improve survival, reduce morbidity, and enhance quality of life.MethodsA writing group of cardiologists and genetics professionals updated guidance, first published in 2009 for the Heart Failure Society of America (HFSA), in a collaboration with the American College of Medical Genetics and Genomics (ACMG). Each recommendation was assigned to teams of individuals by expertise, literature was reviewed, and recommendations were decided by consensus of the writing group. Recommendations for family history, phenotype screening of at-risk family members, referral to expert centers as needed, genetic counseling, and cardiovascular therapies, informed in part by phenotype, are presented in the HFSA document.ResultsA genetic evaluation of cardiomyopathy is indicated with a cardiomyopathy diagnosis, which includes genetic testing. Guidance is also provided for clinical approaches to secondary findings from cardiomyopathy genes. This is relevant as cardiomyopathy is the phenotype associated with 27% of the genes on the ACMG list for return of secondary findings. Recommendations herein are considered expert opinion per current ACMG policy as no systematic approach to literature review was conducted.ConclusionGenetic testing is indicated for cardiomyopathy to assist in patient care and management of at-risk family members.