Empathy in Medical Care Jessica Ogle (D Empathy in Medical Care Jessica Ogle (D. Psych (Clin) Candidate), John Bushnell (PhD FNZCCPsych), & Peter Caputi (PhD) Jessica Ogle

Background The role of empathy in a clinician-patient interaction has been explored more often in the context of psychotherapy than in medical practice In medical care, the definition of empathy emphasises three specific features of empathy: cognition, understanding, and communication Conceptually, empathic communication and behaviour should play a critical role in the effectiveness of the clinical encounter Given the aim of medical schools to produce clinically competent doctors it is important to investigate the relationship between empathy and competence

A Theoretical Framework The theoretical link between empathic clinician-patient engagement and clinical competence is based on three perspectives(Hojat, 2007). Medical perspective – empathic relationship enables increased honesty regarding symptoms and concerns leading to a more accurate medical history and therefore more precise diagnosis Psychological perspective – empathic relationship enables patient to view clinician as a secure base leading to a genuine human connection and space to explore their illness and disclose real fears Sociological perspective - an empathic relationships enables to patient to view the clinician as a helpful member of a social support system

Hypotheses There has been recent evidence that higher levels of empathy are associated with higher levels of clinical competence and positive patient outcomes The purpose of this study was to investigate the relationship of empathy to clinical competence among medical students. It was hypothesised that those students who were more empathic during the clinical interaction would gain higher clinical competence scores. It was also expected that self-ratings of empathy would be positively associated with clinical competence scores.

Methods Participants: Year 3 students of a regional and rural Australian Graduate School of Medicine 23 males, 37 females OSCE Background The OSCE was originally developed as a way of obtaining reliable and objective assessment of clinical skills Medical students enter a simulated clinical encounter (known as a 'station') and demonstrate their clinical skills on a standardised patient (SP), with the aim to show competence in a particular skill or management of the patient.

Methods Assessment of Clinical Competence Students participated in a summative OSCE 13 x 9 minute SP cases (surgery, paediatrics, obstetrics an gynaecology, general medicine, and psychiatry) The current study assessed 10 of the 13 stations Total Competence Score (judged by medical professionals): Process Score Content Score Patient Rating Videotaping of the OSCE

Method Assessment of Empathy Jefferson Scale of Physician Empathy (JSPE-S): Self report of empathy applicable to medical care as provided by medical students 20 items on a 7 point Likert scale Total score ranges from 20-140 Rating Scales for the Assessment of Empathic Communication in Medical Interviews (REM) Comprises of 6 items related to empathy and 3 items related to confrontation Empathy is measured on a seven-point Likert scale - the two endpoints are described in specific behavioural terms A higher value indicates greater empathy and less confrontation

Method Procedure Participants were asked to complete the JSPE-S, in addition to consenting to release their grades and video recordings of the summative OSCE. The summative OSCE was videotaped for the purpose of enabling additional examiners to rate the student performance should there be uncertainty or disagreement about the level of student performance. Participants were graded by examiners and patients on their OSCE performance. Participant empathy was assessed in each videotaped simulated consultation using the REM.

Results: Correlation Analysis (REM) Station Patient Score Process Score (Examiner 1) Content Score (Examiner 1) Total Score (Examiner 1) Process Score (Examiner 2) Content Score (Examiner 2) Total Score (Examiner 2) 1 .410** .574** .444** .532** .626** .311* .496** 2 .536** .439** .580** .625** .456** .520** .575** 3 .018 .470** .681** .687** .435* .642** 4 .589** .366* .656** .690** .515** .550** .665** 5 .586** .619** .715** .512** .571** .636** 6 .523** .645** .669** .716** .367* .519** 7 .547** .721** .667** .756** .517** .539** .615** 8 .407** .482** .273 .409** .390** .554** .566** 9 .673** .408** .434** .564** .483** .599** .654** 10 .436** .474** .569** .612** .548** .643** .708**

Results: Correlation Analysis (JSPE-S) Station Patient Score Process Score (Examiner 1) Content Score (Examiner 1) Total Score (Examiner 1) Process Score (Examiner 2) Content Score (Examiner 2) Total Score (Examiner 2) 1 .056 -.055 -.109 -.088 .045 -.128 -.067 2 .066 -.091 -.058 -.052 .067 .139 .119 3 .151 .137 .180 .181 .126 .134 .160 4 -.137 .115 -.060 .011 -.074 -.073 5 -.179 -.170 -.182 .068 -.173 -.113 6 .006 .005 .040 .031 .244 .152 .189 7 -.147 .255 .228 .216 .106 .101 .084 8 -.010 .169 .053 .089 -.024 .007 9 -.134 -.021 -.196 -.121 -.164 10 .144 .071 .099 .010 -.051 -.011

Results: Descriptive Statistics Low Empathy (REM) High Empathy (REM) Mean Total Competence Score 165.86 (SD=12.93) 190.35 (SD=14.00) Low Empathy (JSPE-S) High Empathy (JSPE-S) Mean Total Competence Score 179.46 (SD=16.90) 183.13 (SD=17.69)

Results: Comparison of Mean Scores Independent T-Test: t df Sig Total Competence (as a function of REM score) 6.283 55 .000 Total Competence (as a function of JSPE-S Score .639 51 .525 A t test revealed a statistically reliable difference between the mean total competence score for those low in observed empathy (M = 165.86, SD = 12.93) and for those high in observed empathy (M = 190.35, SD = 14.00), t(55) = 6.283, p = .000, α ≤ .01. There was no statistically reliable difference observed for mean total competence score for low self-rated empathy (M = 179.46, SD = 16.90) and high self-rated empathy (M = 183.13, SD = 17.69), t(51) = .639, p = .525.

Results Rating of student empathy by an independent observer was strongly associated with examiners judgements of greater clinical competence. Self-rated empathy, however, was not associated with clinical competence. The results of this study indicate an association between observed empathy and clinical competence across a range of medical conditions and disorders, and different clinical tasks involving history-taking, procedural and examination skills, and patient education. The reasons for a lack of congruence between the independent-observer rated measure of empathy, and the student’s self reported empathy are not immediately obvious.

Discussion Two major findings: Strong association between clinical competence and observer-rated empathy Discrepancy between self- and observer-ratings of empathy Reasons for lack of congruence between self- and observer-ratings of empathy? Self-report instruments may not be indicative of the quality and effectiveness of the use of empathy in a clinical interaction Rating scales may be measuring different constructs Medical students modify their behaviours in the context of a summative examination in order to perform in a way they believe the examiners desire

Future Research Explore the discrepancies between self- and observer-ratings of empathy by comparing individual differences among medical students. Specifically, whether medical students who demonstrated discrepancies in self- and observer-ratings of empathy differ from those who did not demonstrate discrepancies with regards to personality constructs, attachment subscales, and clinical competence

Conclusion The use of self-assessment tools may not sufficiently predict empathic behaviour Empathy may be an enabling factor in clinical competence Despite the discrepancy between self- and observer-ratings, the patient’s need for an empathic doctor will always be important.