RETRACTED ARTICLE: Doctors’ and Patients’ Perceptions of Impacts of Doctors’ Communication and Empathy Skills on Doctor–Patient Relationships During COVID-19

BackgroundDuring the COVID-19 pandemic, the performance of Chinese doctors may have led to improved doctor–patient relationships (DPRs). However, it is unclear how doctors and patients perceived the impact of doctors’ communication and empathy skills on DPRs during the COVID-19 pandemic.ObjectiveTo examine the perceptions of doctors and patients on how doctors’ communication skills and empathy skills influence DPRs during COVID-19.Main MeasuresDoctors’ and patients’ perceptions of doctors’ communication skills were measured using the Chinese version of the SEGUE Framework. To measure empathy skills and DPRs, the Jefferson Scale of Empathy and Difficult Doctor-Patient Relationship Questionnaire were administered to doctors, and the Consultation and Relational Empathy Measure and Patient-Doctor Relationship Questionnaire were administered to patients.ResultsA total of 902 doctors and 1432 patients in China were recruited during the pandemic via online or offline surveys (overall response rate of 69.8%). Both doctors and patients rated doctors’ empathy skills as more impactful on DPRs than communication skills. Doctors believed that only their empathy skills influenced DPRs. But patients believed that there was a significant bi-directional relationship between doctors’ communication and empathy skills and these two skills interacted to directly and indirectly influence DPRs, and doctors’ empathy had a greater mediating effect than their communication.ConclusionsDuring COVID-19, there were both similarities and differences between Chinese doctors’ and patients’ views on how doctors’ communication and empathy skills influenced DPRs. The greater effect of doctors’ empathy skills suggests that both doctors and patients attach more importance to doctors’ empathy in doctor–patient interactions. The bi-directional effect on patient outcomes suggests that both doctors’ communication and empathy skills are important to patients’ perceptions of DPRs.KEY WORDS: Doctor–patient relationship, Doctors’ communication skills, Doctors’ empathy skill, COVID-19, China     

Respiratory physicians’ awareness and referral of pulmonary rehabilitation in China: a cross-sectional study

BackgroundPulmonary rehabilitation (PR) has demonstrated physiological, symptom reducing, psychosocial, and health care savings benefits in multiple outcome areas for patients with chronic respiratory diseases. Physicians’ PR awareness and PR referral practices are key in PR promotion. However, PR awareness and referral among respiratory physicians in China have rarely been studied. This study aims to explore respiratory physicians’ perceptions towards PR and assess the referral of PR in China.MethodsA self-administered questionnaire was distributed via WeChat and emails to respiratory physicians in hospitals to assess their attitudes toward and knowledge of PR and identify treatment barriers. The study was conducted from June through October 2019.ResultsAs reported in the 520 questionnaires collected through October 2019 most respondents had heard about PR, and many had knowledge of PR practice, but relatively few had referred patients to PR before having responded to the survey. Education, region of practice, and duration of practice are significant factors that influenced the participating respiratory physicians’ awareness of PR. The percentage of referral was influenced by physicians’ education, region, and duration of practice. The absence of PR facilities was the main barrier to respiratory physicians’ referral of patients to PR.ConclusionsChinese respiratory physicians’ awareness of PR and referral to PR remain insufficient to support the delivery of PR to patients with chronic respiratory diseases. PR training for respiratory physicians and building PR centers are necessary to remedy these conditions.     

How Do Patients Want Us to Use the Computer During Medical Encounters?—A Discrete Choice Experiment Study

BackgroundPrimary care physicians (PCPs) now widely use electronic health records (EHRs) during medical encounters. Experts in clinical communication issued recommendations for a patient-centered use of EHRs. However, they have never been validated by patients themselves.ObjectiveTo explore patients’ preferences regarding physicians’ EHR-related behaviors.DesignDiscrete choice experiment study.PatientsFrench-speaking patients waiting for a medical consultation at two outpatient clinics in Geneva, Switzerland.Main MeasuresWe invited patients to watch videos displaying 2 or 3 variations of four specific EHR-related behaviors and asked them to indicate which one they preferred. EHR-related behaviors were (1) typing: continuous/intermittent/handwriting in biomedical or psychosocial focused consultations; (2) maintaining contact while typing: visual/verbal/both; (3) signposting the use of EHR: with/without; (4) position of physicians’ hands and bust: on the keyboard and towards the patient/away from the keyboard and towards the patient/on the keyboard and towards the screen.Key ResultsThree hundred thirty-six patients participated (response rate 61.4%). They preferred intermittent typing versus handwriting or continuous typing for biomedical issues (32.7%; 95% CI: 26.0–40.2% vs 31.6%; 95% CI: 24.9–39.0% or 14.9%; 95% CI: 10.2–21.1%) and psychosocial issues (38.7%; 95% CI: 31.6–46.3% vs 24.4% 95% CI: 18.4–31.5% or 17.9%; 95% CI; 12.7–24.4%). They favored visual and verbal contact (38.9%; 95% CI: 31.9–46.3%) over verbal (30.3%; 95% CI: 23.9–37.5%) or visual contact only (11.4%; 95% CI: 7.5–17.1%) while the doctor was typing. A majority preferred signposting the use of EHR versus no signposting (58.9%; 95% CI: 53.5–64.0% vs 34.8%; 95% CI: 29.9–40.1%). Finally, half of the patients (49.7%; 95% CI: 42.0–57.4%) favored the position with the physician’s bust towards the patient and hands away from the keyboard.ConclusionsOur study shows that patients’ preferences regarding EHR-related behaviors are in line with most experts’ recommendations. Such recommendations should be more consistently integrated into under- and postgraduate communication skills training.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06753-1.KEY WORDS: Computer use, Electronic health record, Primary care, Communication skills, Patient-physician relation     

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

BackgroundCompassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).MethodsA systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.ResultsOne hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians’ perceptions of patients’ motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.DiscussionThe growth of evidence in the recent years reflects ECRC’s ongoing importance. However, evidence remains scattered, concentrates on physicians’ factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors’ effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07055-2.     

Empathy ability of nursing students: A systematic review and meta-analysis

Background:Empathy is an ability that nursing students need in clinical practice, there is no available data to assess nursing students’ empathy ability level . The main purpose of this study is to synthesize the evidence relating to the empathy ability in nursing students to systematically evaluate the empathy ability level among nursing students.Methods:Adhering to the preferred reporting items for Systematic Reviews and Meta-analyses guidelines, we searched PubMed, Cochrane, Web of Science, Scopus, ScienceDirect, Wiley Library, Embase, CNKI, Wanfang, and China biomedical literature service system ten databases to collect cross-sectional studies on nursing students’ empathy ability. Two researchers independently screened the literature, extracted the data, and evaluated the risk of bias in the included studies.Results:A total of 19 cross-sectional studies were included. The sample comprised 5407 nursing students. Meta-analysis showed that females have a higher empathy ability than males, and the empathy ability of rural students is higher than that of provincial students.Conclusions:The findings suggest that the empathy ability among nursing students worldwide is higher, but there needs further improvement. This result makes nursing educators pay more attention to the cultivation of the nursing students’ empathy ability; improving the empathy level is beneficial in improving the standards of health care and patients’ quality of life.     

Using a Do-It-Yourself Artificial Pancreas: Perspectives from Patients and Diabetes Providers

Background:A growing number of people with diabetes are choosing to adopt do-it-yourself artificial pancreas system (DIYAPS) despite a lack of approval from the US Food and Drug Administration.We describe patients’ experiences using DIYAPS, and patient and diabetes providers’ perspectives on the use of such technology.Methods:We distributed surveys to patients and diabetes providers to assess each group’s perspectives on the use of DIYAPS. The patient survey also assessed glycemic control and impact on sleep. The patient survey was distributed in February 2019 via Facebook and Twitter (n = 101). The provider survey was distributed via the American Association of Diabetes Educators’ e-mail newsletter in April 2019 and the Pediatric Endocrine Society membership e-mail list in May 2019 (n = 152).Results:Patients overwhelmingly described improvements in glycemic control and sleep quality: 94% reported improvement in time in range, and 64% reported improvement in all five areas assessed. Eighty-nine percent of patients described DIYAPS as “Safe” or “Very Safe,” compared to only 27% of providers. Most felt encouraged by their diabetes provider to continue using DIYAPS, but few described providers as knowledgeable regarding its use. Providers cited a lack of experience with such systems and an inability to troubleshoot them as their most significant challenges.Conclusions:Despite evidence that DIYAPS usage is increasing, our surveys suggest that patients’ adoption of this technology and trust in it is outpacing that of diabetes providers. Providers must be aware of this growing population of patients and familiarize themselves with DIYAPS to support patients using this technology.     

Patients’ Views About the Disclosure of Collateral Findings in Pragmatic Clinical Trials: a Focus Group Study

BackgroundPragmatic clinical trials (PCTs) are increasingly being conducted to efficiently generate evidence to inform healthcare decision-making. Despite their growing acceptance, PCTs may involve a variety of ethical issues, including the management of pragmatic clinical trial-collateral findings (PCT-CFs), that is, information that emerges in PCTs that is unrelated to the primary research questions but may have implications for patients, clinicians, and health systems.ObjectiveWe sought to understand patients’ views about PCT-CF disclosure, including how, by whom, and the nature and extent of information provided.DesignProspective, qualitative focus group study.ParticipantsFocus groups were conducted in Baltimore, MD; Houston, TX; and Seattle, WA (overall N = 66), during July and August 2019.ApproachAll groups discussed a hypothetical scenario involving the detection of a PCT-CF of contraindicated medications. Participants were asked about their reactions to the PCT-CF and issues related to its disclosure.Key ResultsReactions to learning about the PCT-CF were mixed, ranging from fear of a significant health problem, anger that the contraindicated medications had gone unnoticed and/or for being included in research without their permission, to gratitude for the information. Preferences for how such disclosures are made varied but were driven by several consistent desires, namely minimizing patient harm and anxiety and demonstrating trust and respect. Many wanted their treating clinician to be informed of the PCT-CF so that they would be prepared to answer patients’ questions and to discuss treatment options.ConclusionsThe detection of PCT-CFs is likely to increase with further expansion of PCTs. As such, clinicians will undoubtedly become involved in the management of PCT-CFs. Our data illustrate some of the challenges clinicians may face when their patients are informed of a PCT-CF and the need to develop guidance for disclosing PCT-CFs in ways that align with patients’ preferences and values.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06113-5) contains supplementary material, which is available to authorized users.KEY WORDS: pragmatic clinical trial, patient perspective, collateral finding     

Factors Impacting Physician Referral To and Patient Attendance at Weight Management Programs Within a Large Integrated Health System

BackgroundIdentifying which patients receive referrals to and which ones attend weight management programs can provide insights into how physicians manage obesity.ObjectiveTo describe patient factors associated with referrals, which primarily reflect physician priorities, and attendance, which reflects patient priorities. We also examine the influence of the individual physician by comparing adjusted rates of referral and attendance across physicians.DesignRetrospective cohort study.ParticipantsAdults with a body mass index (BMI) ≥ 30 kg/m² who had a primary care visit between 2015 and 2018 at a large integrated health systemMain MeasuresReferrals and visits to programs were collected from the EHR in 2019 and analyzed in 2019–2020. Multilevel logistic regression models were used to identify the association between patient characteristics and (1) receiving a referral, and (2) attending a visit after a referral. We compared physicians’ adjusted probabilities of referring patients and of their patients attending a visit.Key ResultsOur study included 160,163 adults, with a median BMI of 35 kg/m². Seventeen percent of patients received ≥ 1 referral and 29% of those attended a visit. The adjusted odds of referral increased 57% for patients with a BMI 35–39 (versus 30–34) and 32% for each comorbidity (p < 0.01). Attending a visit was less strongly associated with BMI (aOR 1.18 for 35–39 versus 30–34, 95% CI 1.09–1.27) and not at all with comorbidity. For the physician-level analysis, the adjusted probability of referral had a much wider range (0 to 83%; mean = 19%) than did the adjusted probability of attendance (range 27 to 34%).ConclusionsFew patients attended a weight management program. Physicians vary greatly in their probability of referring patients to programs but not in their patients’ probability of attending.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06520-8.     

Truth Telling and Treatment Strategies in End-of-Life Care in Physician-Led Accountable Care Organizations: Discrepancies Between Patients’ Preferences and Physicians’ Perceptions

Providing patient-centered care from preventive medicine to end-of-life care in order to improve care quality and reduce medical cost is important for accountable care. Physicians in the accountable care organizations (ACOs) are suitable for participating in supportive end-of-life care especially when facing issues in truth telling and treatment strategy. This study aimed to investigate patients’ attitudes toward truth telling and treatment preferences in end-of-life care and compare patients’ attitudes with their ACOs physicians’ perceptions.This nationwide study applied snowball sampling to survey physicians in physician-led ACOs and their contracted patients by questionnaire from August 2010 to July 2011 in Taiwan. The main outcome measures were beliefs about palliative care, attitudes toward truth telling, and treatment preferences.The data of 314 patients (effective response rate = 88.7%) and 177 physicians (88.5%) were analyzed. Regarding truth telling about disease prognosis, 94.3% of patients preferred to be fully informed, whereas only 80% of their physicians had that perception (P < 0.001). Significant differences were also found in attitudes toward truth telling even when encountering terminal disease status (98.1% vs 85.3%). Regarding treatment preferences in terminal illness, nearly 90% of patients preferred supportive care, but only 15.8% of physicians reported that their patients had this preference (P < 0.001).Significant discrepancies exist between patients’ preferences and physicians’ perceptions toward truth telling and treatment strategies in end-of-life care. It is important to enhance physician–patient communication about end-of-life care preferences in order to achieve the goal of ACOs. Continuing education on communication about end-of-life care during physicians’ professional development would be helpful in the reform strategies of establishing accountable care around the world.     

Sitting at the Bedside: Patient and Internal Medicine Trainee Perceptions

BackgroundSitting at the bedside may strengthen physician–patient communication and improve patient experience. Yet despite the potential benefits of sitting, hospital physicians, including resident physicians, may not regularly sit down while speaking with patients.ObjectiveTo examine the frequency of sitting by internal medicine residents (including first post-graduate year [PGY-1] and supervising [PGY-2/3] residents) during inpatient encounters and to assess the association between patient-reported sitting at the bedside and patients’ perceptions of other physician communication behaviors. We also assessed residents’ attitudes towards sitting.DesignIn-person survey of patients and email survey of internal medicine residents between August 2019 and January 2020.ParticipantsPatients admitted to general medicine teaching services and internal medicine residents at The Johns Hopkins Hospital.Main MeasuresPatient-reported frequency of sitting at the bedside, patients’ perceptions of other communication behaviors (e.g., checking for understanding); residents’ attitudes regarding sitting.Key ResultsOf 334 eligible patients, 256 (76%) completed a survey. Among these 256 respondents, 198 (77%) and 166 (65%) reported recognizing the PGY-1 and PGY-2/3 on their care team, respectively, for a total of 364 completed surveys. On most surveys (203/364, 56%), patients responded that residents “never” sat. Frequent sitting at the bedside (“every single time” or “most of the time,” together 48/364, 13%) was correlated with other positive behaviors, including spending enough time at the bedside, checking for understanding, and not seeming to be in a rush (p < 0.01 for all). Of 151 residents, 77 (51%) completed the resident survey; 28 of the 77 (36%) reported sitting frequently. The most commonly cited barrier to sitting was that chairs were not available (38 respondents, 49%).ConclusionsPatients perceived that residents sit infrequently. However, sitting was associated with other positive communication behaviors; this is compatible with the hypothesis that promoting sitting could improve overall patient perceptions of provider communication.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07231-4.     

Experimental evidence of physician social preferences

Physicians’ professional ethics require that they put patients’ interests ahead of their own and that they should allocate limited medical resources efficiently. Understanding physicians’ extent of adherence to these principles requires understanding the social preferences that lie behind them. These social preferences may be divided into two qualitatively different trade-offs: the trade-off between self and other (altruism) and the trade-off between reducing differences in payoffs (equality) and increasing total payoffs (efficiency). We experimentally measure social preferences among a nationwide sample of practicing physicians in the United States. Our design allows us to distinguish empirically between altruism and equality–efficiency orientation and to accurately measure both trade-offs at the level of the individual subject. We further compare the experimentally measured social preferences of physicians with those of a representative sample of Americans, an “elite” subsample of Americans, and a nationwide sample of medical students. We find that physicians’ altruism stands out. Although most physicians place a greater weight on self than on other, the share of physicians who place a greater weight on other than on self is twice as large as for all other samples—32% as compared with 15 to 17%. Subjects in the general population are the closest to physicians in terms of altruism. The higher altruism among physicians compared with the other samples cannot be explained by income or age differences. By contrast, physicians’ preferences regarding equality–efficiency orientation are not meaningfully different from those of the general sample and elite subsample and are less efficiency oriented than medical students.

In a classic article, Kenneth Arrow (1) argued that asymmetric information pervades the health-care market. Patients rely on physicians’ expert knowledge in planning their medical care. Health insurers and government agencies (Medicare and Medicaid) largely rely on physicians to decide which treatments are appropriate for their patients. This deference to physicians’ authority may be justified given their superior expertise and informational advantages (2). However, the dual role of recommending and providing treatments creates opportunities for physicians to place their interests ahead of their patients’ interests, for example by recommending profitable tests and treatments that offer little or no health benefits. A second risk is more subtle. Physicians must trade off their individual patients’ interests in getting care, even if the benefit is likely to be small, against society’s interest in allocating limited medical resources efficiently, in order to generate the greatest benefits for the overall health of a population.The norms of physician professionalism—including, in particular, the patient-centered norms that constitute physicians’ traditional professional ethic—are intended to address the risk of selfishness. Arrow argues that due to information asymmetry, the principle of“buyer beware” that governs ordinary consumer markets should be replaced, in health care, by the physicians’ professional responsibility to put patients’ interests ahead of their own (1). Physician leaders publicly promote the importance of professionalism, while exhorting physicians to act altruistically. For example, the editors of the New England Journal of Medicine have asserted that “medicine is one of the few spheres of human activity in which the purposes are unambiguously altruistic” (3), while the American Board of Internal Medicine similarly asserts that “altruism is the essence of professionalism … the best interest of patients, not self-interest, is the rule” (4). On the other hand, empirical studies have suggested that, at least in some situations, some physicians create “supplier-induced demand,” which influences a patient’s demand for care “against the physician’s interpretation of the best interest of the patient” (5), contributing to skepticism about whether physicians do in fact behave altruistically. [Such skepticism is not limited to medicine. Legal ethics, for example, has long sought to control lawyers’ abuse of discretion through professional norms of client loyalty and care (6). But skeptics have cast these norms as self-serving, and the law governing lawyers increasingly subjects them to elaborate institutionalized mechanisms of bureaucratic control.]While the effects of professional norms on physician behavior are difficult to measure directly, a clearer understanding of physicians’ social preferences can help to illuminate whether professional norms and physicians’ individual preferences are oppositional or aligned. Our study therefore helps to evaluate the likely effectiveness of both professional norms and the turn to bureaucracy. While altruism and related professional norms are important in many other professions (7), the distinct characteristics of the market for medical care, namely information asymmetry and uncertainty in the relationship between medical treatments and patient outcomes (1), render it especially critical to study these issues among physicians.Health care systems in the US and elsewhere address the second risk—concerning efficiency—in more complex ways. Although professional ethics give physicians a responsibility to conserve scarce medical resources (8), the norm that directs individual physicians to put their patients first may render a norm-based approach inadequate to the problem of efficiency (9). Health insurers therefore use bureaucratic mechanisms and financial incentives to manage the information asymmetry between a physician who knows the specific patient’s situation and the insurer which does not (9).^*We deploy an incentivized economic experiment to investigate both altruism (the trade-off between self and other) and equality–efficiency orientation (the trade-off between reducing self–other differences in payouts and increasing payout totals) in practicing US physicians, and we compare our results with analogous experiments that measure parallel behaviors in other populations. A vast literature considers social preferences, and laboratory experiments have been very fruitful in both establishing the empirical reliability of such preferences and directing theoretical attention to them. [We will not attempt to review the enormous body of work in behavioral and experimental economics on social preferences. Camerer (10) provides a comprehensive discussion, if now somewhat dated, of the vast body of experimental and theoretical research in economics focusing on dictator, ultimatum, and trust games. Engel (11) provides the most comprehensive meta-study of dictator games.] After presenting our results, we relate them to the results from prior work that are particularly relevant to our study (Discussion). We note that the social preferences of physicians and professionals more generally remain relatively understudied, and our discussion of the relationship between our study and prior work explains the specific contributions that we make.Our sample consists of 284 physicians from 36 medical groups around the United States, including physicians in primary care (internal medicine and family medicine) and cardiology, and physicians in private practices and employed by hospitals. Our experiment gives subjects broad discretion to implement their preferences, free from bureaucratic control or even surveillance. Our results therefore inform the question whether norms are likely to affect physician choices along both dimensions of behavior. Our study measures altruism in a large multisite sample of practicing physicians and measures both dimensions of social preferences.Our experiment asked subjects to make trade-offs between their own self-interest and the interest of an anonymous other and, at the same time, between equality and efficiency. These two aspects of social preferences often operate together, but they remain conceptually distinct. [Social preferences can be weighted toward equality (reducing differences in payoffs) or weighted toward efficiency (increasing total payoffs) and range from pure utilitarian to maxmin or Rawlsianism. As the dispute between Harsanyi (12, 13) and Rawls (14) shows, fair-minded people (who are all perfectly impartial between self and other) can disagree about how to trade off equality and efficiency. The work of Harsanyi and Rawls, and of the many others who have followed them, has had broad-reaching influence across many disciplines, including philosophy, economics, and law.] To capture both of these features in our experiment, we employ a modified dictator game (15–17) in which we ask physicians to allocate real money between themselves and an anonymous other drawn from a broadly representative sample of the US population. Our experiment presents subjects with allocation decisions in which the “price of giving” varies across decision problems—sometimes the subject may need to sacrifice more than a token (the experimental currency)—to give a single token to other (the recipient); in other decisions, it may cost only a fraction of a token. These decisions are made through an intuitive “point-and-click” graphical interface in which the choices are represented as a budget line where each point represents a possible allocation. The slope of the line captures the price of giving tokens to other.^†Intuitively, this method allowed us to collect a rich dataset capable of measuring both altruism and equality–efficiency orientation at the level of the individual subject. [The importance of studying individual heterogeneity in social preferences is emphasized by Andreoni and Miller (17). Because of this heterogeneity, it is necessary to investigate behavior at an individual level. Our experimental design allows subjects to make numerous choices over a wide range of budget lines, and this yields a rich dataset that is well-suited to analysis at the individual level. It is clearly advantageous to estimate individual-level parameters and then generate individual-level distributions of the estimations rather than to pool data and then estimate population-level parameters.] The degree of altruism is reflected in the amount subjects give on average, whereas equality–efficiency orientation is captured by how subjects respond to the price of giving. Increasing the fraction of the budget spent on other as the price of giving increases indicates social preferences weighted toward equality (reducing the difference in payoffs between self and other), whereas decreasing it when the price of giving increases indicates social preferences weighted toward efficiency (increasing the total payoffs to self and other). We rely on techniques developed in our prior work (15, 16, 18) to evaluate the consistency of physicians’ choices (i.e., whether they reflect a complete and transitive preference ordering) and to explore the structure of the social utility functions that rationalize the observed data.We further compare physicians’ preferences with preferences previously measured in three other populations using equivalent experiments: 1) a broadly representative sample of US adults (18), 2) an “elite” subsample of those who hold a graduate degree and have an annual household income over $100,000 (15, 18), and 3) a sample of medical students from nine schools around the United States (19, 20). The social preferences of these populations provide important benchmarks against which physicians’ social preferences can be assessed; furthermore, the comparison with medical students may shed light on whether physicians’ distinctive social preferences reflect a “selection effect” based on who enters medicine or a “treatment effect” of practicing medicine.^‡We begin our analysis of the experimental data by using classical revealed preference theory (21–23) to test whether subjects’ choices are consistent with the essence of all traditional models of economic decision-making—utility maximization.^§ Our physician subjects exhibit a remarkably high degree of consistency when compared with other populations, including medical students and also students from Yale Law School (YLS), the population that had exhibited the highest degree of consistency in prior experiments (15). [In our subsequent analysis, we do not draw detailed comparisons between our physician sample and the sample YLS students (15). The experimental design in Fisman et al. (15) differs from the current one in that the YLS student subjects were asked to allocate money between themselves and another student, rather than an individual drawn from a sample broadly representative of the US adults.] This result reveals that our physician subjects are highly adept at implementing a consistent, well-behaved social preference ordering. This makes it natural to estimate—at the level of the individual subject—the substantive social preferences that physicians display.We then estimate social preferences at the level of the individual physician using a constant elasticity of substitution (CES) utility function commonly employed by economists in demand analysis. The CES functional form is appealing because the degree of altruism and equality–efficiency orientation are each independently represented in a precise and transparent manner through its two parameters, which we estimate separately for each subject (further details on the CES specification and estimation are provided in Empirical Framework).We find that physicians are more altruistic than any other population, while physicians’ preferences concerning the trade-off between equality and efficiency are almost indistinguishable graphically from the preferences of the American Life Panel (ALP) elites and also the broader ALP sample. These findings on physicians’ distinctive social preferences have direct and concrete implications for professionalism, incentives, and bureaucratic rules directed at physicians. Insofar as physicians are altruistic, they may be more likely to live up to the professional ideal of putting patients’ interests ahead of their own. At the same time, altruism as captured in our experiment is far from ubiquitous, even among physicians and, furthermore, physicians’ efficiency orientation is indistinguishable from than that of the general population. Taken together, our findings suggest that the ideal of physician professionalism—putting the patient first—is not merely a self-serving myth but that other mechanisms may be required to support the quality of medical care and to promote efficient allocation of medical resources.     

“More than just giving them a piece of paper”: Interviews with Primary Care on Social Needs Referrals to Community-Based Organizations

BackgroundPrimary care practices are responding to calls to incorporate patients’ social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients’ social conditions, yet little is known about the referral process.ObjectiveTo characterize referrals to community-based organizations by primary care practices.DesignQualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization.ParticipantsAdministrators at 50 diverse US healthcare organizations with efforts to address patients’ social risks.Main MeasuresApproaches used in primary care to implement social needs referral to community-based organizations.ResultsInterviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market.Conclusion and RelevanceReferrals to community-based organizations were used in primary care to improve patients’ social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07531-3.KEY WORDS: social determinants of health, primary care, clinicians, social risks, referrals     

Validation of a 5-Item Tool to Measure Patient Assessment of Clinician Compassion in Hospitals

BackgroundWe previously validated a 5-item compassion measure to assess patient experience of clinician compassion in the outpatient setting. However, currently, there is no validated and feasible method for health care systems to measure patient experience of clinician compassion in the inpatient setting across multiple hospitals.ObjectiveTo test if the 5-item compassion measure can validly and distinctly measure patient assessment of physician and nurse compassion in the inpatient setting.DesignCross-sectional study between July 1 and July 31, 2020, in a US health care network of 91 community hospitals across 16 states consisting of approximately 15,000 beds.PatientsAdult patients who had an inpatient hospital stay and completed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.MeasurementsWe adapted the original 5-item compassion measure to be specific for physicians, as well as for nurses. We disseminated both measures with the HCAHPS survey and used confirmatory factor analysis for validity testing. We tested reliability using Cronbach’s alpha, as well as convergent validity with patient assessment of physician and nursing communication and overall hospital rating questions from HCAHPS.ResultsWe analyzed 4756 patient responses. Confirmatory factor analysis found good fit for two distinct constructs (i.e., physician and nurse compassion). Both measures demonstrated good internal consistency (alpha > 0.90) and good convergent validity but reflected a construct (compassionate care) distinct from what is currently captured in HCAHPS.ConclusionWe validated two 5-item tools that can distinctly measure patient experience of physician and nurse compassion for use in the inpatient hospital setting in conjunction with HCAHPS.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06733-5.Key Words: compassion, empathy, patient satisfaction, patient experience     

The Role of Physician Professional Networks in Physicians’ Receipt of Pharmaceutical and Medical Device Industries’ Payments

BackgroundFinancial relationships between physicians and the pharmaceutical and medical device industries are common, but the factors associated with physicians receiving payments are unknown.ObjectiveThe objective of this study is to evaluate the influence of physicians’ professional networks’ characteristics on the receipt of payments among physicians.DesignNetwork analysis of cross-sectional dataParticipantsUS physicians who shared Medicare patients with other physicians in 2015 (N=357,813).Exposure (Intervention)Proportion of a physician’s professional network that received industry payments and other network characteristics including number of physician connections, how central the physician is within the network, and the tightness of the referral network in which a physician is located.Main Outcome MeasuresRelative risk of receiving industry payments. We used modified Poisson regression to control for confounding by gender, time since graduation, practice size, and practice setting (teaching hospital vs. not). We included dummy variables for specialty and hospital referral region level.Key ResultsThe proportion of a physician’s peers in their professional network that received payments was strongly associated with receipt of pharmaceutical or device industry payments by the physician (top vs bottom quartile aRR=1.28, 95%CI=1.25–1.31). Physician’s centrality within a network had a small positive effect on receiving payment (top vs bottom quartile aRR=1.02, 95%CI=1.01–1.04). Network density also had a small negative association with receipt of payment (top vs bottom quartile aRR=0.97, 95%CI=0.96–0.98).ConclusionsNetwork characteristics, particularly the receipt of payments among physicians one shares patients with, are associated with whether a physician receives payments. This finding has implications for institutional regulation of industry payments to physicians and demonstrates how institutional policy may impact not only the physicians within the institution but also physicians outside of the institution.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06802-9.     

Factors Enhancing Trust in Electronic Communication Among Patients from an Internal Medicine Clinic: Qualitative Results of the RECEPT Study

BackgroundElectronic health records are now the norm in US healthcare. Bidirectional patient portals allow frequent communication between patients and their healthcare team. Many studies have examined the importance of patient engagement and trust between patients and their healthcare team, typically in the context of face-to-face interactions. Little is known about how patient trust and engagement are built or enhanced through electronic communications. COVID-19 provided a unique time in history for this novel exploration.ObjectiveOur objective was to learn how patients experience trust formation through electronic communication (patient messaging and video visits) with their healthcare team.DesignOur research was guided by grounded theory methodology. Qualitative interviews were conducted between February and December 2020 with patients or their caregivers from an internal medicine clinic in Colorado.ParticipantsFifty-one participants were recruited by age group and gender to represent the clinic’s adult ambulatory care demographics. Seven were patients’ caregivers who were purposefully recruited. Average age was 53 with an educated, middle class, and largely white predominance in our eventual sample.ApproachThirty-minute semi-structured interviews were conducted using an interview guide informed by a validated physician-patient trust scale. Interviews were conducted by telephone, recorded via Zoom, and transcribed. Results were analyzed and coded in ATLAS.ti utilizing the constant comparative method, with two coders.Key ResultsPatients experienced enhanced trust in their healthcare team through electronic communications. Interpersonal and system factors contributed to trust formation. Promptness of reply was the most salient factor in trust formation with a majority desiring same day response.ConclusionsPatients now rely on electronic communication with their healthcare team. Opportunities exist to leverage this to improve health outcomes. Important research in expanded demographic groups, along with ambulatory healthcare redesign, will be necessary to optimize benefits of electronic communication with patients and meet patient expectations.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07345-9.KEY WORDS: Patient trust, Patient engagement, Patient portal, Telehealth, Electronic health record, Patient secure messages     

Hypnosis associated with 3D immersive virtual reality technology during bronchoscopy under local anesthesia

BackgroundPatients undergoing flexible bronchoscopy under local anesthesia usually experience anxiety before and during the procedure. Different non-pharmacological techniques, including music and hypnosis, are used to distract patients’ attention, and to reduce anxiety. The new technique “virtual reality hypnosis (VRH)”, defined as a hypnotic induction suggestion delivered by personalized virtual reality software, can generate a simulation of a lifelike environment. No study has described the use of VRH during bronchoscopy. The objective is to investigate the anxiety reducing effect and the satisfaction of patients, physicians, and nurses using VRH during bronchoscopy.MethodsVRH was proposed to all patients who experienced anxiety before undergoing flexible bronchoscopy under local anesthesia. Local anesthesia was performed using 5% lidocaine spray only. No sedation was used. After the procedure, patients, physicians and nurses filled a standardized satisfaction form.ResultsTwenty consecutive patients who reported pre-procedure anxiety were included. The sex ratio was 16 women/4 men, the median age was 65 years. Eight patients (40%) had undergone a previous bronchoscopy under local anesthesia. The median duration of the procedure was 10 minutes, and all procedures were completed. The median level of anxiety of patients decreased from 9/10 before the procedure to 4/10 during the procedure. The median satisfaction rate regarding the use of VRH was 10/10. All patients agreed to use VRH again in case of a new bronchoscopy procedure.ConclusionsThis preliminary report has shown that VRH was useful to reduce patients’ anxiety during bronchoscopy under local anesthesia. VRH was easily implemented in the routine practice.     

Is the gender or age of the physician key to a good physician–patient with inflammatory bowel disease relationship?

Background and aimsA good patient–physician relationship in inflammatory bowel disease (IBD) is very important and physician empathy is its cornerstone. There is no evidence about if age and/or sex of physicians and patients could influence on perceived empathy by patients. The aim of the study was to assess the level of empathy of IBD specialist physicians perceived by their patients and if it varies according to the age and gender of the patient and the physician.MethodsWe performed a national cross-sectional study based on voluntary online survey to IBD patients that included the Consultation and Relational Empathy (CARE) scale.ResultsFive hundred sixty one responses to the survey were received. After applying exclusion criteria, 536 patients were included in the analysis. Total median score of CARE scale was 44.5 (maximum possible score: 50 points). Most of the patients (99.1%) considered the contents of the questionnaire to be an important issue. There were no significant differences in CARE scale scores in function of patient/physician age range or gender [physician gender: males vs. females: median 46 vs. 44, p = 0.139; physician age: <40 years, 40–60 years, >60 years: 45.5 vs. 44 vs. 44, p = 0.328].ConclusionSpanish inflammatory bowel disease patients have a great physician empathy perception, which is the key to a good patient–physician relationship, and this fact is not influenced by age or gender of patients or inflammatory bowel disease specialist.