Physician's empathy directly associated with positive clinical outcomes, a large study of italian diabetic patients confirms

The study was published in the September 2012 issue of Academic Medicine, and serves as a follow up to a smaller study published in the same journal in March 2011 from Thomas Jefferson University investigating physician empathy and its impact on patient outcomes. That study included 891 diabetic patients and 29 physicians and concluded similar findings: patients of physicians with high empathy scores had better clinical outcomes than patients of other physicians with lower scores.

"This new, large-scale research study has confirmed that empathic physician-patient relationships is an important factor in positive outcomes," said Mohammadreza Hojat, Ph.D., research professor, Department of Psychiatry and Human Behavior; and director, Jefferson Longitudinal Study of Medical Education in the Center for Research in Medical Education and Health Care at Jefferson Medical College. "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."

Participants in this study were 20,961 diabetic patients from a population of over 284,000 adult patients in the Local Health Authority, Parma, Italy, enrolled with one of 242 primary care physicians.

Researchers used the Jefferson Scale of Empathy (JSE) -- developed in 2001 as an instrument to measure empathy in the context of medical education and patient care. This validated instrument relies on the definition of empathy in the context of patient care as a predominately cognitive attribute that involves an understanding of patient's concerns, pain, and suffering, and an intention to help. The scale includes 20 items answered on a seven-point Likert-type scale (strongly agree = 7, strongly disagree = 1). The 242 physicians completed the JSE.

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 JSE score and a better control of patients' hemoglobin A1c and cholesterol level.

Here, researchers sought a different, tangible clinical outcome. The presence of acute metabolic complications among diabetic patients, including hyperosmolar state, diabetic ketoacides, and coma, for patients who were hospitalized in 2009 was used as the outcome measure. Acute metabolic complications were used because they require hospitalization, can develop rather quickly, and their prevention is more likely to be influenced by the primary care physicians.

A total of 123 patients were hospitalized because of acute metabolic complications in 2009. Results 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.

There are many factors that add to the strength of the study. Firstly, because of universal health care coverage in Italy, there is no confounding effect of difference in insurance, lack of insurance or financial barriers to access care.

"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 co-author Daniel Z. Louis, Managing Director for the Center for Research in Medical Education and Health Care and research associate professor of family and community medicine at JMC. "Italy has a lower rate of switching doctors, facilitating long-lasting physician patient relationships," added co-author Vittorio Maio, PharmD, M.S., MSPH, associate professor at the Jefferson School of Population Health.

According to the 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 approximately 2 million new cases per year. Worldwide, the number of total cases jumps to 180 million.

"Results of this study confirmed our hypothesis that a validated measure of physician empathy is significantly associated with the incidence of acute metabolic complications in diabetic patients, and provide the much-needed, additional empirical support for the beneficial effects of empathy in patient care" said Dr. Hojat. "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."

The study's other co-authors include Stefano Del Canale, M.D., Ph.D., research coordinator of the Local Health Authority of Parma; Xiaohong Wang, M.S., research programmer/analyst, Center for Research in Medical Education and Health Care at JMC; Giuseppina Rossi, M.D., head, Department of Development and Integration of Primary Care Services, Local Health Authority of Parma; and Joseph S. Gonnella, M.D., Founder and Director, Center for Research in Medical Education and Health Care.