The impact of financial incentives on physician empathy: A study from the perspective of patients with private and statutory health insurance

Objective

We hypothesized that patients’ ratings of physician empathy (PE) would be higher among those with private health insurance (PHI, referring to financial incentive) than among patients with statutory health insurance (SHI).

Methods

A postal survey was administered to 710 cancer patients. PE was assessed using the Consultation-and-Relational-Empathy measure. T-tests were conducted to analyse whether PHI and SHI-patients differ in their ratings of PE and variables relating to contact time with the physician. Structural-equation-modelling (SEM) verified mediating effects.

Results

PHI-patients rated physician empathy higher. SEM revealed that PHI-status has a strong significant effect on frequency of talking with the physician, which has a strong significant effect (1) on PE and (2) has a moderate effect on patients’ perception of medical staff stress, thereby also affecting patients’ ratings of PE.

Conclusions

Our findings suggest that PHI-status is one necessary precondition for physicians spending more time with the patient. Spending more time with the PHI-patient has two major effects: it results in a more positive perception of PE and positively impacts PHI-patients’ perception of medical staff stress, which in turn, again influences PE.

Practical implications

Health policy should discuss these findings in terms of equality in receiving high-quality care.     

Patients’ reflections on communication in the second-opinion hematology–oncology consultation

Objective

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients’ perceptions of their second-opinion hematology–oncology consultation to investigate physician–patient communication in malignant disease at a critical juncture in cancer patients’ care and decision-making.

Methods

In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations.

Results

Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians’ consideration of the unique elements of patients’ cases, and demonstrations of empathy and respect made patients’ feel positively about the encounter, regardless of the prognosis.

Conclusions

Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation.

Practice implications

Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.     

How do lay people assess the quality of physicians’ communicative responses to patients’ emotional cues and concerns? An international multicentre study based on videotaped medical consultations

Objective

to establish which kind of physician communicative responses to patient cues and concerns are appreciated by lay people.

Methods

A balanced sample (259 people) was recruited in public places to participate in a full day observation of four videotaped standardized medical consultations. In a two-step procedure participants gave their individual quality ratings of the whole consultations and then of a set of four fragments from each consultation. They contained a patient negative emotional expression and the subsequent physician response, according to the VR-CoDES.

Results

Higher quality ratings were given to physician responses which provided space to the patient to talk and to the explicit expressions of empathy. The explicit responses were favored above non-explicit responses. Participants’ global evaluation of the whole consultation affected their quality assessments of the fragments (halo-effect). In a multivariate model, lay people's background characteristics appeared to be relevant: to be female, of lower educational level and living in Belgium or Italy predicted higher ratings.

Conclusions

Providing space to patients is appreciated by all participants, combined with the need for tailor made communication.

Practice implications

To teach physicians listening skills and how to show empathy with distressed patients should be a core element in medical education.     

Gender bias in patients’ perceptions of patient-centered behaviors

Objective

This research examines whether patient perceptions are equivalently associated with patient-centered behavior in male and female medical students, and tests the impact of a message emphasizing the importance of patient-centeredness on analogue patients’ perceptions of male and female medical students’ performance.

Methods

Sixty-one medical students interacting with standardized patients (SPs) were viewed by 384 analogue patients (APs). APs were randomly assigned to receive a message emphasizing the value of patient-centeredness or of technical competence, or a neutral message, and then evaluated the medical students’ competence in the interactions. Students’ patient-centeredness was measured using the Four Habits Coding Scheme and Roter Interaction Analysis System.

Results

APs in the neutral and technical competence conditions gave higher competence ratings to more patient-centered male students, but not to more patient-centered female students. However, APs who received the patient-centeredness message gave higher competence ratings to both male and female students who were higher in patient-centeredness.

Conclusion

Making it clear that patient-centeredness is a dimension of physician competence eliminated a gender bias in evaluating performance.

Practice implications

Because patient perceptions are often used in evaluations, gender biases must be understood and reduced so both male and female providers receive appropriate credit for their patient-centered behaviors.     

Residents’ and standardized patients’ perspectives on empathy: Issues of agreement

Objective

We investigated correlations between residents’ scores on the Jefferson Scale of Empathy (JSE), residents’ perceptions of their empathy during standardized-patient encounters, and the perceptions of standardized patients.

Methods

Participants were 214 first-year residents in internal medicine or family medicine from 13 residency programs taking standardized patient-based clinical skills assessment in 2011. We analyzed correlations between residents’ JSE scores; standardized patients’ perspectives on residents’ empathy during OSCE encounters, using the Jefferson Scale of Patient Perceptions of Physician Empathy; and residents’ perspectives on their own empathy, using a modified version of this scale.

Results

Residents’ JSE scores correlated with their perceptions of their own empathy during encounters but correlated poorly with patients’ assessments of resident empathy.

Conclusion

The poor correlation between residents’ and standardized patients’ assessments of residents’ empathy raises questions about residents’ abilities to gauge the effectiveness of their empathic communications. The study also points to a lack of congruence between the assessment of empathy by standardized patients and residents as receivers and conveyors of empathy, respectively.

Practice implications

This study adds to the literature on empathy as a teachable skill set and raises questions about use of OSCEs to assess trainee empathy.     

Psychosocial predictors of attitudes toward physician empathy in clinical encounters among 4732 1st year medical students: A report from the CHANGES study

Objective

Medical school curricula intended to promote empathy varies widely. Even the most effective curricula leave a significant group of students untouched. Pre-existing student factors influence their response to learning experiences. We examined the individual predictors of first semester medical students’ attitudes toward the value of physician empathy in clinical encounters.

Methods

First year students (n = 4732) attending a stratified random sample of 49 US medical schools completed an online questionnaire that included measures of dispositional characteristics, attitudes and beliefs, self-concept and well-being.

Results

Discomfort with uncertainty, close-mindedness, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept and well-being all independently predicted first year medical students’ attitudes toward the benefit of physician empathy in clinical encounters.

Conclusion

Students vary on their attitude toward the value of physician empathy when they start medical school. The individual factors that predict their attitudes toward empathy may also influence their response to curricula promoting empathic care.

Practice implications

Curricula in medical school promoting empathic care may be more universally effective if students’ preexisting attitudes are taken into account. Messages about the importance of physician empathy may need to be framed in ways that are consistent with the beliefs and prior world-views of medical students.     

Impact of communication training on physician expression of empathy in patient encounters

Objective

To examine whether an educational intervention that focused on physician communication training influenced physician empathic expression during patient interactions.

Methods

This study used a quantitative research method to investigate the influence of communication training on physician-expressed empathy using two measures (global and hierarchical) of physician empathic behavior.

Results

The differences in global empathy scores in the physician training group from baseline to follow-up improved by 37%, and hierarchical scores of physician empathic expression improved by up to 51% from baseline scores for the same group.

Conclusions

The results strongly supported the hypotheses that training made a significant difference in physician empathic expression during patient interactions demonstrated by both outside observer measures of global ratings and hierarchical ratings of physician empathic behavior.

Practice implications

These findings have significant implications for program design and development in medical education and professional training with the potential to improve patient outcomes.     

Physicians’ influence on veterans’ decision to use acupuncture

Objective

To compare patients’ acupuncture use with physician's attitudes toward and history of referral for acupuncture.

Methods

A questionnaire was administered to patients of the Atlanta Veterans Affairs Medical Center and the physicians whom they identified as most influencing their healthcare decisions. A total of 114 patients were matched with 33 physicians.

Results

Physicians’ history of referral was not significantly related to patients’ acupuncture use. Physicians’ belief that acupuncture would increase patient satisfaction, however, was associated with higher rates of patient acupuncture use (p = 0.01). Qualitative analysis of an open-ended question that probed further into physicians’ attitudes regarding acupuncture revealed three key themes: lack of knowledge about the treatment; misperceptions regarding availability of acupuncture at VA; and lack of VA providers to meet demand.

Conclusion

These results indicate that physicians’ referral patterns are not associated with patients’ acupuncture use. However, some evidence shows a link between patients’ acupuncture use and physicians’ beliefs that the treatment will increase patient satisfaction, showing that physician attitudes may have some influence on patients’ acupuncture use.

Practice implications

In order to cultivate shared-decision making between patients and their physicians it will be important to address gaps in provider knowledge about acupuncture and its availability.     

Patient trust in physicians and adoption of lifestyle behaviors to control high blood pressure

Objective

To assess the relationship between patients’ trust in their physician and self-reported adoption of lifestyle modification behaviors and medication adherence for control of hypertension.

Methods

Longitudinal analysis of data from a randomized controlled trial of interventions to enhance hypertensive patients’ adherence to medications and recommended lifestyle modifications. Two hundred patients were seen by 41 physicians at 14 urban primary care practices in Baltimore, Maryland, and followed for 12 months.

Results

Seventy percent of patients reported complete trust in their physician. In adjusted analyses, patients with complete trust had higher odds of reporting that they were trying to lose weight (OR = 2.27, 95% CI = 1.38–3.74) than did patients with less than complete trust in their physician. Though not statistically significant, the odds of reporting trying to cut back on salt and engaging in regular exercise were greater in patients with complete trust. We observed no association for reports of medication adherence.

Conclusion

Trust in one's physician predicts attempts to lose weight among patients with hypertension, and may contribute to attempts to reduce salt and increase exercise.

Practice implications

Strengthening patient–physician relationships through efforts to enhance trust may be a promising strategy to enhance patients’ engagement in healthy lifestyle behaviors for hypertension.     

Nosocomial bacteremia: Impact of empirical antimicrobial treatment on the patients’ outcome

Objective

To determine the impact on patients’ outcome of clinical effectiveness of empirical antimicrobial treatment of nosocomial bacteremia.

Patients and methods

Setting: 904-bed hospital, comprising acute care wards, rehabilitation and intermediate care wards and long-term care wards, that provides care primarily for aged (880 beds); design: prospective cohort analysis to access the evidence regarding the effectiveness of empirical antimicrobial treatment in patients with nosocomial bacteremia, when the Gram stain result was communicated to the physician; data collection: data collected concerned patients’ characteristics at the early bacteremia, microbiology, antimicrobial treatment and patients’ outcome within 30 days; analysis: patients with clinical signs of bacteremia after the Gram stain result were compared with those without symptoms, in univariate analysis.

Results

Significant differences were not found for age, sex, underlying diseases, comorbidities, hospitalization wards, sources of bacteremia, microorganisms or patients’ outcome. However, antimicrobial therapies were more often changed in symptomatic patients after the announcement of the Gram stain result (RR = 1.87; [1.03–3.37]; p = 0.04).

Conclusion

This study supports the notion that the outcomes for patients are similar whether patients have symptoms or not when the Gram stain result of the first positive blood culture is communicated to the clinician.     

Toward a greater understanding of breast cancer patients’ decisions to discuss cancer-related internet information with their doctors: An exploratory study

Objective

To investigate differences between breast cancer patients who do and do not discuss cancer-related internet information (CRII) with their doctors.

Methods

70 breast cancer patients completed questionnaires regarding internet use, discussions about CRII, and the doctor–patient relationship.

Results

No significant differences were noted across patient, disease, or visit characteristics, or physician reliance between those who intended to discuss CRII and those who did not. Patients who intended to discuss CRII rated significantly higher pre-consultation anxiety levels. No significant differences in satisfaction, anxiety reduction, or trust in physician were found between patients who had discussed and those who had not. Patients’ reasons for discussing or not discussing are detailed.

Conclusion

Factors influencing patients’ decisions to discuss CRII are complex and differ from those identified as leading patients to seek internet information. Future research about internet discussions should investigate the impact of patients’ preferred role in treatment, the doctor–patient relationship, anxiety level, attributes of CRII, and physician trust.

Practice implications

Understanding the characteristics of patients who do and do not discuss internet information is important given the impact internet information has on healthcare communication and the doctor–patient relationship, including the development of interventions aimed at improving such interactions.     

What patients want

Objective

Although most health care professionals im- or explicitly will assume that they tend to use patient-centered communication strategies, there are reasons to believe that this might not always be a valid assumption. In everyday practice, professionals’ own value system is often the dominant steering guide. This Special Issue aims to bring together ongoing research and reflections about the quality of health care communication from the patients’ own perspective. In short: what do patients want?

Methods

This introduction presents a comprehensive overview of the papers in the special issue of Patient Education and Counseling within a framework that describes the collected papers according to the six functions of medical consultations, taking account of the studies’ applied methodologies: quantitative versus qualitative.

Results

Two functions of the medical consultation are strongly represented in the collected papers on the quality of communication from the patients’ perspective: ‘fostering the relationship’ and ‘information giving’. There is a remarkable difference between the qualiative and quantitative studies, showing that if patients are not limited to prestructured questionnaires but completely free to express themselves, they tend to focus on ‘fostering the relationship’ with an emphasis on personal attention, warmth and empathy.

Conclusions

Patients’ needs and preferences for personalized and humane medical care cannot be overestimated. For the rest, patient diversity is striking, showing the limited usefulness of general communication guidelines for the other five functions of the medical consultation. Researchers should be aware that patients’ views might be different dependent on the applied methodologies.     

Negative emotions in cancer care: Do oncologists’ responses depend on severity and type of emotion?

Objective

To examine how type and severity of patients’ negative emotions influence oncologists’ responses and subsequent conversations.

Methods

We analyzed 264 audio-recorded conversations between advanced cancer patients and their oncologists. Conversations were coded for patients’ expressions of negative emotion, which were categorized by type of emotion and severity. Oncologists’ responses were coded as using either empathic language or blocking and distancing approaches.

Results

Patients presented fear more often than anger or sadness; severity of disclosures was most often moderate. Oncologists responded to 35% of these negative emotional disclosures with empathic language. They were most empathic when patients presented intense emotions. Responding empathically to patients’ emotional disclosures lengthened discussions by an average of only 21 s.

Conclusion

Greater response rates to severe emotions suggest oncologists may recognize negative emotions better when patients express them more intensely. Oncologists were least responsive to patient fear and responded with greatest empathy to sadness.

Practice implications

Oncologists may benefit from additional training to recognize negative emotions, even when displayed without intensity. Teaching cancer patients to better articulate their emotional concerns may also enhance patient–oncologist communication.     

Breast cancer patients’ trust in physicians: The impact of patients’ perception of physicians’ communication behaviors and hospital organizational climate

Objective

To examine whether patients’ perception of a hospital's organizational climate has an impact on their trust in physicians after accounting for physicians’ communication behaviors as perceived by the patients and patient characteristics.

Methods

Patients undergoing treatment in breast centers in the German state of North Rhein-Westphalia in 2006 were asked to complete a standardized postal questionnaire. Disease characteristics were then added by the medical personnel. Multiple linear regressions were performed.

Results

80.5% of the patients responded to the survey. 37% of the variance in patients’ trust in physicians can be explained by the variables included in our final model (N = 2226; R² adj. = 0.372; p < 0.001). Breast cancer patients’ trust in their physicians is strongly associated with their perception of a hospital's organizational climate. The impact of their perception of physicians’ communication behaviors persists after introducing hospital organizational characteristics. Perceived physician accessibility shows the strongest association with trust.

Conclusions

A trusting physician–patient relationship among breast cancer patients is associated with both the perceived quality of the hospital organizational climate and perceived physicians’ communication behaviors.

Practice implications

With regard to clinical organization, efforts should be put into improving the organizational climate and making physicians more accessible to patients.     

Adaptive Conjoint Analysis as individual preference assessment tool: Feasibility through the internet and reliability of preferences

Objective

Patient values are not routinely assessed in clinical practice. Adaptive Conjoint Analysis (ACA) is increasingly applied in studies assessing treatment preferences, and could provide a means to routinely assess individual patients’ treatment preferences.

Methods

An ACA-questionnaire was administered three times (7–10 days apart) to 98 long-term rectal cancer survivors either on a portable computer or through internet, to assess whether (a) responses differ according to administration mode, (b) relative importances of rectal cancer treatment outcomes (survival, local control, incontinence, sexual problems) consolidate over time, (c) ACA-outcomes are sufficiently reliable (ICC) for use in individual decision-making. We also evaluated patients’ acceptance of ACA.

Results

Mode did not affect ACA-completion or evaluation. Importance scores did not consolidate over time. ICCs were poor for sexual problems and fair for the other outcomes, and were at least equal or higher from first to second retest. Most participants valued completing the ACA-questionnaire and learning their results.

Conclusion

Values did not show consolidation over time. ACA-derived preferences should not determine which treatment patients should choose.

Practice implications

Findings extend ACA-validation studies to the health care setting and suggest that ACA-questionnaires might be appreciated as adjuncts to treatment decision-making in newly diagnosed patients.     

Understanding pharmacists’ experiences with advice-giving in the community pharmacy setting: A focus group study

Objective

To examine the experiences of community pharmacists providing advice about symptoms and complementary and alternative medicines (CAM).

Methods

Ten licensed pharmacists and 21 student pharmacists working in community settings participated in 4 focus groups to discuss: patients’ questions about symptoms and CAM, comfort level providing advice, and factors prompting physician referrals. Focus group recordings were transcribed verbatim and interpreted using thematic text analysis.

Results

Pharmacists’ dual role as advisors and medical liaisons emerged as primary themes. Participants reported that patients often seek their advice about self-care of symptoms to delay physician visits. Participants were comfortable giving advice; lack of medical history decreased their comfort level. Most were uncomfortable recommending CAM because of the lack of regulation and evidence. Participants suggested that pharmacy curricula expand training on symptom triage, pharmacist–patient communication, and CAM to prepare graduates for employment in community settings.

Conclusion

Student and licensed pharmacists of this study voiced that they are often asked for advice on symptom management, but reported needing training to help provide appropriate advice to patients.

Practice implications

The findings suggest that training strategies could help pharmacists appropriately triage and advise patients seeking self-care advice for their symptoms in the community setting.     

Turkish migrant GP patients’ expression of emotional cues and concerns in encounters with and without informal interpreters

Objective

The aim of this study was to compare patients’ expressions of emotional cues and concerns, and GPs’ responses during consultations with and without informal interpreters. Furthermore, informal interpreters’ expression of emotional cues and concerns and their responses were examined too.

Methods

Twenty-two audiotaped medical encounters with Turkish migrant patients, eleven with and eleven without an informal interpreter, were coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) and the Verona Codes for Provider Responses (VR-CoDES-P).

Results

In encounters with informal interpreters, patients expressed less emotional concerns than in encounters without informal interpreters. Only half of all patients’ cues is being translated by the informal interpreter to the GP. Furthermore, 20% of all cues in encounters with informal interpreters is being expressed by the interpreter, independent of patients’ expression of emotions.

Conclusion

The presence of an informal interpreter decreases the amount of patients’ expression of emotional concerns and cues. Furthermore, a substantial amount of cues is being expressed by the informal interpreter, corroborating the often-made observation that they are active participants in triadic medical encounters.

Practice implications

GPs should be trained in communication strategies that enable elicitation of migrant patients’ emotions, in particular in encounters with informal interpreters.     

A 3-stage model of patient-centered communication for addressing cancer patients’ emotional distress

Objective

To describe pathways through which clinicians can more effectively respond to patients’ emotions in ways that contribute to betterment of the patient's health and well-being.

Methods

A representative review of literature on managing emotions in clinical consultations was conducted.

Results

A three-stage, conceptual model for assisting clinicians to more effectively address the challenges of recognizing, exploring, and managing cancer patients’ emotional distress in the clinical encounter was developed. To enhance and enact recognition of patients’ emotions, clinicians can engage in mindfulness, self-situational awareness, active listening, and facilitative communication. To enact exploration, clinicians can acknowledge and validate emotions and provide empathy. Finally, clinicians can provide information empathetically, identify therapeutic resources, and give referrals and interventions as needed to help lessen patients’ emotional distress.

Conclusion

This model serves as a framework for future research examining pathways that link clinicians’ emotional cue recognition to patient-centered responses exploring a patient's emotional distress to therapeutic actions that contribute to improved psychological and emotional health.

Practical implications

Specific communicative and cognitive strategies are presented that can help clinicians better recognize a patient's emotional distress and respond in ways that have therapeutic value.