Empathic concern and professional characteristics associated with clinical empathy in French general practitioners

Analyzing the Factor Structure of the Toronto Empathy Questionnaire: Dimensionality, Reliability, Validity, Measurement Invariance and One-Year Stability of the German Version

In the face of heterogeneity in the measurement of empathy, the Toronto Empathy Questionnaire (TEQ; Spreng et al., Journal of Personality Assessment, 91(1), 62-71 (2009)) was developed as a brief unidimensional tool by statistically forming a consensus from existing measures of the construct. The present study aimed to (1) validate a German version of the TEQ, and (2) contribute empirical evidence to the ongoing debate regarding a singular versus multidimensional factor structure of the TEQ. One cross-sectional and two longitudinal studies were performed, with a total of 1,075 participants. Our initial exploratory factor analyses suggested either a one- or a two-factor structure (with the two-factors clustering straight and reverse-scored items); the two-factor model outperformed the one-factor model using confirmatory factor analyses. However, after negated items were replaced by positively reworded alternatives, both models fit the data equally well. A comparison of the correlation patterns with numerous external measures indicated that a second factor of the TEQ is a methodological artifact of item wording. Finally, a unidimensional TEQ scale showed sufficient internal consistency, two-week test-retest reliability, one-year stability, as well as convergent and discriminant validity with measures of empathy, emotion recognition, emotion regulation, altruism, social desirability, and the Big Five personality traits.

Empathy levels in Australian chiropractic students

OBJECTIVE

Empathy is an important modifiable quality of health care practitioners that relates to the quality of patient care. The educative process may adversely affect the empathy levels of health care students at key phases of training. This topic remains unexplored in chiropractic students to date.

METHODS

A voluntary and anonymous questionnaire was distributed to all chiropractic students in an Australian university-based program in April 2021. This questionnaire recorded age, sex, year of study, and Toronto Empathy Questionnaire scores.

RESULTS

Chiropractic student empathy scores approximated those of other Australian health care students. No statistical differences were found when comparing the mean scores of empathy levels across the 5 student cohorts. The empathy levels of female chiropractic students' were significantly higher than those of the male chiropractic students.

CONCLUSION

This study provides a baseline from which further explorations on empathy may be conducted in chiropractic students. This holds the potential to improve practitioners' quality of life and patient outcomes and for educators to identify subject matter that may negatively affect empathy levels.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

The Intricate Relationship Between Client Perceptions of Physician Empathy and Physician Self-Assessment: Lessons for Reforming Clinical Practice

Objectives: Clinical empathy is an important predictor of patient outcomes. Several factors affect physician’s empathy and client perceptions. We aimed to assess the association between physician and client perception of clinical empathy, accounting for client, physician, and health system factors. Methods: We conducted a hospital-based cross-sectional study in 3 departments (family medicine, internal medicine, and surgery) of King Saud Medical City in Riyadh, Saudi Arabia. We interviewed 30 physicians and 390 clients from 3 departments. Physicians completed the Jefferson Scale of Empathy (JSE) and the clients responded to the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). We used a hierarchical multilevel generalized structural equation approach to model factors associated with JSE and JSPPPE and their inter-relationship. Results: Mean (SD) score of client-rated physician empathy was 26.6 (6) and that of physician self-rated was 111 (12.8). We found no association between the 2 (b  =  0.06; 95% confidence intervals CI: −0.1, 0.21), even after adjusting for client, physician, and health system factors. Physician's nationality (0.49; 0.12, 0.85), adequate consultation time (1.05; 0.72, 1.38), and trust (1.33; 0.9, 1.75) were positively associated whereas chronic disease (−0.32; −0.56, −0.07) and higher waiting times (−0.26; −0.47, −0.05) were negatively associated. Conclusion: A physician's self-assessed empathy does not correlate with clients’ perception. We recommend training and monitoring to enhance clinical empathy.

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

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

Forum theater staging of difficult encounters with patients to increase empathy in students: evaluation of efficacy at The University of Angers Medical School

BACKGROUND

Physician empathy has been associated with improved clinical outcomes and lower physician burnout. We evaluated whether forum theater (FT), a form of applied drama that allows participants to enter the performance and represent the actions associated with emotions, would foster empathy in medical students, and which underlying variables would be associated to empathy scores.

METHODS

Three classes totaling 488 fourth-year medical students participated in the study. Forum theater was used to explore difficult encounters with patients and family members: announcement of cancer, fall at home of an elderly person requiring hospitalization, appointment with a patient suffering from depression, announcement of diabetes in an adolescent. The first scene was played by actors in front of a group of students, then audience members were asked to enter the performance and, by taking over the role of the "physician-actor," to explore alternative interactions. All the students followed two sessions as actors and observers in random order and were randomly assigned to FT sessions after 36 or 56 weeks of clinical rotations. They completed the Jefferson Scale of Physician Empathy (JFSE) anonymously.

RESULTS

Students were 22.1 ± 1.5 years old (43% males). Empathy scores increased after each session: 102.0 ± 9.8 before the sessions, 106.3 ± 9.8 after session 1 and 107.8 ± 11.5 after session 2 (p <  0.05). In regression models, gender (F vs. M, + 3.0 ± 1.0, p <  0.001) and position in the session (actor vs. observer, + 2.1 ± 1.0, p < 0.05) were significant determinants of JFSE scores, whereas age, session theme, and duration of clinical rotation were not.

CONCLUSION

Being an actor in forum theater was a valuable tool for enhancing empathy scores in medical students.

Association between emergency physician self-reported empathy and patient satisfaction

Background

Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting.

Objective

To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience.

Research design

A prospective observational study conducted in a tertiary care hospital ED.

Methods

Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models.

Results

Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107–122) and senior physicians had the highest scores (median 119.5; IQR: 111–129). Similarly, EM residents had the lowest percentage of “very satisfied” responses (65%) and senior physicians had the highest reported percentage of “very satisfied” responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07).

Conclusion

This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.

Are alexithymia and empathy predicting factors of the resilience of medical residents in France?

OBJECTIVES

To explore resilience, resilience predicting factors and resilience distribution in French medical residents.

METHODS

A cross-sectional study was conducted in which general practice residents (n = 380) were asked to answer the Jefferson Scale of Physician Empathy, the Connor-Davidson Resilience Scale, and the Toronto Alexithymia Scale. One hundred thirty-seven (137) responses were collected. The scores of the different scales have been calculated. The score differences were examined using the Student's t-test or analysis of variance. The correlations were estimated using the Pearson correlation coefficient. The relationships between scores were analysed by multiple linear regression. The heterogeneity of the sample was examined by non-hierarchical cluster analysis.

RESULTS

Resilience and empathy were positively correlated (r(135) = .36, p< .001). Alexithymia was negatively correlated with resilience, r(135) = -.40,p<.001, and empathy, r(135) = -.38, p<.001. Resilience was influenced by alexithymia, b = -.284, p = .001, empathy, b= .255, p = .002, gender (female < male), b = -.231, p = .002 and year of formation, β= .157, p = .036. Two clusters of residents were characterized. They differed by their empathy and resilience profiles and by alexithymia trait.

CONCLUSIONS

Alexithymia, empathy, gender and year of formation correspond to predicting factors of resilience. This suggests that the resilience of vulnerable residents can be enhanced by increasing their empathy and by reducing their alexithymia. Thus, teaching teams could sustain their students' well-being through educational programs aiming to develop their understanding of their own emotions and those of their patients.

Level of empathy among dietitians: A pilot study

AIM

The health-care providers' empathy has been linked to better patient outcomes. The increased demand for dietetics services has called for dietitians to examine their clinical practices and encounters with patients. To date, there are limited studies published on empathy among dietitians. Hence, this study aimed to determine the clinical dietitians' empathy level in Malaysia.

METHODS

Using a purposive sampling method, this study was conducted on dietitians practising in the Malaysian hospitals (government and private). The Toronto Empathy Questionnaire (TEQ), a validated 16-item questionnaire was self-administered, either by online survey method or face-to-face method. Additional information on gender, ethnicity, years of experience and percentage of working time spent on clinical, administrative and other areas were collected.

RESULTS

A total of 69 dietitians participated in the study (private (n = 36) and government (n = 33)). The dietitians' mean total TEQ scores were 49.72 ± 5.62 (score ranged between 35 and 63). Significant difference of mean total TEQ scores was found between dietitians from private (51.06 ± 5.26) and government hospitals (48.27 ± 5.72). There was no significant difference in the level of empathy by gender, ethnicity, years of experience and percentage of time spent on clinical consultations, administration or others while at work.

CONCLUSIONS

Results from this study showed that there were differences in empathy level of Malaysian dietitians by work setting. This preliminary finding serves as a baseline for future studies and could facilitate the development of dietetics education in Malaysia.

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

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

Associations Between Physician Empathy, Physician Characteristics, and Standardized Measures of Patient Experience

PURPOSE

To identify correlates of physician empathy and determine whether physician empathy is related to standardized measures of patient experience.

METHOD

Demographic, professional, and empathy data were collected during 2013-2015 from Cleveland Clinic Health System physicians prior to participation in mandatory communication skills training. Empathy was assessed using the Jefferson Scale of Empathy. Data were also collected for seven measures (six provider communication items and overall provider rating) from the visit-specific and 12-month Consumer Assessment of Healthcare Providers and Systems Clinician and Group (CG-CAHPS) surveys. Associations between empathy and provider characteristics were assessed by linear regression, ANOVA, or a nonparametric equivalent. Significant predictors were included in a multivariable linear regression model. Correlations between empathy and CG-CAHPS scores were assessed using Spearman rank correlation coefficients.

RESULTS

In bivariable analysis (n = 847 physicians), female sex (P < .001), specialty (P < .01), outpatient practice setting (P < .05), and DO degree (P < .05) were associated with higher empathy scores. In multivariable analysis, female sex (P < .001) and four specialties (obstetrics-gynecology, pediatrics, psychiatry, and thoracic surgery; all P < .05) were significantly associated with higher empathy scores. Of the seven CG-CAHPS measures, scores on five for the 583 physicians with visit-specific data and on three for the 277 physicians with 12-month data were positively correlated with empathy.

CONCLUSIONS

Specialty and sex were independently associated with physician empathy. Empathy was correlated with higher scores on multiple CG-CAHPS items, suggesting improving physician empathy might play a role in improving patient experience.

Assessing empathy development in medical education: a systematic review

CONTEXT

Empathy in doctor-patient relationships is a familiar topic for medical scholars and a crucial goal for medical educators. Nonetheless, there are persistent disagreements in the research literature concerning how best to evaluate empathy among physicians, and whether empathy declines or increases across medical education. Some researchers have argued that the instruments used to study 'empathy' may not measure anything meaningful to clinical practice or patient satisfaction.

METHODS

We performed a systematic review to learn how empathy is conceptualised in medical education research. We examined how researchers define the central construct of empathy and what they choose to measure, and investigated how well definitions and operationalisations match.

RESULTS

Among the 109 studies that met our search criteria, 20% failed to define the central construct of empathy at all and only 13% used an operationalisation that was well matched to the definition provided. The majority of studies were characterised by internal inconsistencies and vagueness in both the conceptualisation and operationalisation of empathy, constraining the validity and usefulness of the research. The methods most commonly used to measure empathy relied heavily on self-report and cognition divorced from action, and may therefore have limited power to predict the presence or absence of empathy in clinical settings. Finally, the large majority of studies treated empathy itself as a 'black box', using global construct measurements that are unable to shed light on the underlying processes that produce an empathic response.

CONCLUSIONS

We suggest that future research should follow the lead of basic scientific research that conceptualises empathy as relational - an engagement between a subject and an object - rather than as a personal quality that may be modified wholesale through appropriate training.

Personal profile of medical students selected through a knowledge-based exam only: are we missing suitable students?

INTRODUCTION

A consistent body of literature highlights the importance of a broader approach to select medical school candidates both assessing cognitive capacity and individual characteristics. However, selection in a great number of medical schools worldwide is still based on knowledge exams, a procedure that might neglect students with needed personal characteristics for future medical practice. We investigated whether the personal profile of students selected through a knowledge-based exam differed from those not selected.

METHODS

Students applying for medical school (N=311) completed questionnaires assessing motivations for becoming a doctor, learning approaches, personality traits, empathy, and coping styles. Selection was based on the results of MCQ tests. Principal component analysis was used to draw a profile of the students. Differences between selected and non-selected students were examined by Multivariate ANOVAs, and their impact on selection by logistic regression analysis.

RESULTS

Students demonstrating a profile of diligence with higher conscientiousness, deep learning approach, and task-focused coping were more frequently selected (p=0.01). Other personal characteristics such as motivation, sociability, and empathy did not significantly differ, comparing selected and non-selected students.

CONCLUSION

Selection through a knowledge-based exam privileged diligent students. It did neither advantage nor preclude candidates with a more humane profile.

Empathy: what does it mean for GPs? A qualitative study

BACKGROUND

Research has highlighted empathy as an important and effective factor in patient-physician communication. GPs have extensive practical experience with empathy. However, little is known about the personal views of GPs regarding the meaning and application of empathy in daily practice.

OBJECTIVES

To explore GP's experiences and the application of empathy in daily practice and to investigate the practical use of empathy. Facts such as preconditions, barriers and facilitating possibilities are described.

METHODS

Qualitative interview study; 30 in-depth interviews were performed between June 2012 and January 2013 with a heterogeneous sample of Dutch GPs. Interviews were recorded and transcribed verbatim; content analysis was performed with the help of ATLAS-ti.

RESULTS

Empathy was seen as an important quality-increasing element during the patient-GP consultation. The application of non-verbal and verbal techniques was described. Attention to cues and references to previous consults were reported separately. Required preconditions were: being physically and mentally fit, feeling no time pressure and having an efficient practice organization. Not feeling connected to the patient and strict medical guidelines and protocols were identified as obstacles. A key consideration was the positive contribution of empathy to job satisfaction.

CONCLUSIONS

The opinions of GPs in this research can be considered as supplementing and strengthening the findings of previous researches. The GPs in this study discussed, in particular, ideas important to the facilitation of empathy. These included: longer consultations, smaller practices, efficient telephonic triage by practice assistants, using intervision to help reflect on their work and drawing financiers' attention to the effectiveness of empathy.

To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice

Background

General practice is stressful and burnout is common among family physicians. A growing body of evidence suggests that the way physicians relate to their patients could be linked to burnout. The goal of this study was to examine how patterns of empathy explained physicians’ burnout.

Methods

We surveyed 294 French general practitioners (response rate 39%), measured burnout, empathic concern (EC) and perspective taking (PT) using self-reported questionnaires, and modeled burnout levels and frequencies with EC, PT and their interaction in linear and logistic regression analyses.

Results

Multivariate linear models for burnout prediction were associated with lower PT (β = −0.21, p < 0.001) and lower EC (β = −0.17, p < 0.05). Interestingly, the interaction (EC x PT) also predicted burnout levels (β = 0.11, p < 0.05). The investigation of interactions revealed that high scores on PT predicted lower levels of burnout independent from EC (odd ratios (OR) 0.37; 95% confidence interval (95% CI) 0.21–0.65 p < 0.001), and high scores on both EC and PT were protective against burnout: OR 0.31; 95% CI 0.15–0.63, p < 0.001).

Conclusions

Deficits in PT alone might be a risk factor for burnout, whereas higher PT and EC might be protective. Educators should take into account how the various components of empathy are potentially associated with emotional outcomes in physicians.