"Long before it's in the papers"
September 10, 2012

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Doctors’ caring—not just care—found to matter in patient outcomes

Sept. 10, 2012
Courtesy of Thomas Jefferson University
and World Science staff

Pa­tients of doc­tors who are more em­path­ic have bet­ter out­comes and few­er com­plica­t­ions, at least where di­a­be­tes is con­cerned, ac­cord­ing to a large new study.

The re­search, by sci­en­tists of Thom­as Jef­fer­son Uni­vers­ity in Phil­a­del­phia and col­leagues in It­a­ly, eval­u­at­ed rela­t­ion­ships be­tween phy­si­cian em­pa­thy and clin­i­cal out­comes among 20,961 di­a­bet­ics and their 242 phy­si­cians in It­a­ly.

Pub­lished in the Sep­tem­ber is­sue of the jour­nal Ac­a­dem­ic Med­i­cine, the study is a fol­low-up to a smaller one pub­lished in the same jour­nal in March 2011. That study in­clud­ed 891 di­a­bet­ic pa­tients and 29 phy­si­cians and led to si­m­i­lar find­ings.

“This new, large-scale re­search study has con­firmed that em­path­ic phy­si­cian-pa­tient rela­t­ion­ships is an im­por­tant fac­tor in pos­i­tive out­comes,” said Mo­ham­madreza Ho­jat, a psy­chi­a­trist at the uni­vers­ity who led the stu­dy. “Com­pared to our in­i­tial stu­dy, it has a much larg­er num­ber of pa­tients and phy­si­cians, a dif­fer­ent tan­gi­ble clin­i­cal out­come, hos­pi­tal ad­mis­sion for acute met­a­bol­ic com­plica­t­ions, and a cross-cultural fea­ture that will al­low for gen­er­al­iz­a­tion of the find­ings in dif­fer­ent cul­tures, and dif­fer­ent health care sys­tems.”

The re­search­ers used the Jef­fer­son Scale of Em­pa­thy, a ques­tion­naire de­vel­oped in 2001 to of­fer a stand­ard­ized meas­ure of em­pa­thy in the con­text of med­i­cal educa­t­ion and pa­tient care. The scale char­ac­ter­izes em­pa­thy as as an at­ti­tude that in­volves un­der­stand­ing of pa­tient’s con­cerns, pain, and suf­fer­ing, and an in­ten­tion to help. It in­cludes 20 items an­swered on a seven-point scale.

In the 2011 stu­dy, to meas­ure how a phy­si­cian’s em­pa­thy im­pact­ed a di­a­bet­ic pa­tient’s treat­ment out­comes, the re­search­ers used the re­sults of two med­i­cal tests: the hemo­globin A1c test and cho­les­ter­ol lev­els meas­urements. They found a di­rect as­socia­t­ion be­tween a high­er phy­si­cian em­pa­thy score and a bet­ter con­trol of pa­tients’ hemo­globin A1c and cho­les­ter­ol lev­el.

In the new work, re­search­ers looked at a dif­fer­ent clin­i­cal out­come: acute met­a­bol­ic com­plica­t­ions among di­a­bet­ic pa­tients. These com­plica­t­ions in­clud­ed co­ma and con­di­tions known as hy­pe­r­os­mo­lar state and di­a­bet­ic ke­toacides. The com­plica­t­ions in ques­tion were stud­ied be­cause they re­quire hos­pi­tal­iz­a­tion, can de­vel­op rath­er quick­ly, and their pre­ven­tion is more likely to be in­flu­enced by the pri­ma­ry care doc­tors.

A to­tal of 123 pa­tients were hos­pi­talized be­cause of acute met­a­bol­ic com­plica­t­ions in 2009. The re­sults, sci­en­tists said, showed that phy­si­cians in the high­er em­pa­thy score group had a low­er rate of pa­tients with acute met­a­bol­ic com­plica­t­ions. For ex­am­ple, phy­si­cians with high­er em­pa­thy lev­els had 29 (out of 7,224) pa­tients ad­mit­ted to the hos­pi­tal, where­as phy­si­cians with low­er lev­els had 42 (out of 6,434) pa­tients.

Many fac­tors add to the strength of the stu­dy, ac­cord­ing to the au­thors. First, be­cause of uni­ver­sal health care cov­er­age in It­a­ly, there was no ma­jor wor­ry that dif­fer­ences in insur­ance cov­er­age or fi­nan­cial bar­ri­ers to care would in­flu­ence the re­sults.

“What’s more, this sec­ond study was con­ducted in a health care sys­tem in which all res­i­dents en­roll with a pri­ma­ry care phy­si­cian re­sult­ing in a bet­ter de­fined rela­t­ion­ship be­tween the pa­tients and their pri­ma­ry care phy­si­cians than what ex­ists in the Un­ited States,” said study co-author Dan­iel Z. Lou­is of Jef­fer­son Med­i­cal Col­lege in Phil­a­del­phia. “Italy has a low­er rate of switch­ing doc­tors, fa­cil­i­tating long-lasting phy­si­cian pa­tient rela­t­ion­ships,” added co-author Vit­to­rio Maio, al­so at Jef­fer­son Uni­vers­ity.

Ac­cord­ing to the U.S. Cen­ters for Dis­ease Con­trol and Pre­ven­tion, over 25 mil­lion peo­ple in the U.S. popula­t­ion have been di­ag­nosed with di­a­be­tes, with al­most 700,000 hos­pi­tal­iz­a­tions per year. There are about 2 mil­lion new cases per year. World­wide, the num­ber of to­tal cases jumps to 180 mil­lion.

“These find­ings al­so sup­port the rec­om­menda­t­ions of such pro­fes­sion­al or­gan­iz­a­tions as the As­socia­t­ion of Amer­i­can Med­i­cal Col­leges and the Amer­i­can Board of In­ter­nal Med­i­cine of the im­por­tance of as­sess­ing and en­hanc­ing em­path­ic skills in un­der­grad­u­ate and grad­u­ate med­i­cal educa­t­ion,” said Ho­jat.

* * *

Patients of doctors who are more empathic have better outcomes and fewer complications, according to a large new study of diabetes patients. The research, by scientists of Thomas Jefferson University in Philadelphia and colleagues in Italy, evaluated relationships between physician empathy and clinical outcomes among 20,961 diabetics and 242 physicians in Italy. Published in the September issue of the journal Academic Medicine, the study is a follow-up to a smaller one published in the same journal in March 2011. That study included 891 diabetic patients and 29 physicians and concluded similar findings. “This new, large-scale research study has confirmed that empathic physician-patient relationships is an important factor in positive outcomes,” said Mohammadreza Hojat, a psychiatrist at the university who led the study. “It takes our hypothesis one step further. Compared to our initial study, it has a much larger number of patients and physicians, a different tangible clinical outcome, hospital admission for acute metabolic complications, and a cross-cultural feature that will allow for generalization of the findings in different cultures, and different health care systems.” The researchers used the Jefferson Scale of Empathy, a questionnaire developed in 2001 to offer a standardized measure of empathy in the context of medical education and patient care. The scale characterizes empathy as as an attitude that involves understanding of patient’s concerns, pain, and suffering, and an intention to help. It includes 20 items answered on a seven-point scale. In the 2011 study, to measure how a physician’s empathy impacted a diabetic patient’s treatment outcomes, the researchers used the results of two medical tests: the hemoglobin A1c test and cholesterol levels measurements. They found a direct association between a higher physician empathy score and a better control of patients’ hemoglobin A1c and cholesterol level. In the new work, researchers looked at a different clinical outcome: acute metabolic complications among diabetic patients. These complications included coma and conditions known as hyperosmolar state and diabetic ketoacides. The complications in question were studied because they require hospitalization, can develop rather quickly, and their prevention is more likely to be influenced by the primary care doctors. A total of 123 patients were hospitalized because of acute metabolic complications in 2009. The results, scientists said, showed that physicians in the higher empathy score group had a lower rate of patients with acute metabolic complications. For example, physicians with higher empathy levels had 29 (out of 7,224) patients admitted to the hospital, whereas physicians with lower levels had 42 (out of 6,434) patients. Many factors add to the strength of the study, according to the authors. First, because of universal health care coverage in Italy, there was no major worry that differences in insurance coverage or financial barriers to care would influence the results. “What’s more, this second study was conducted in a health care system in which all residents enroll with a primary care physician resulting in a better defined relationship between the patients and their primary care physicians than what exists in the United States,” said study co-author Daniel Z. Louis of Jefferson Medical College in Philadelphia. “Italy has a lower rate of switching doctors, facilitating long-lasting physician patient relationships,” added co-author Vittorio Maio, also at Jefferson University. According to the U.S. Centers for Disease Control and Prevention, over 25 million people in the U.S. population have been diagnosed with diabetes, with almost 700,000 hospitalizations per year. There are about 2 million new cases per year. Worldwide, the number of total cases jumps to 180 million. “These findings also support the recommendations of such professional organizations as the Association of American Medical Colleges and the American Board of Internal Medicine of the importance of assessing and enhancing empathic skills in undergraduate and graduate medical education,” said Hojat.