INTRODUCTION

Difficult patient encounters (DPEs) are defined as encounters with patients that cause strong negative emotions in attending physicians.1, 2 A survey of outpatient primary care physicians revealed that approximately 15% of outpatient encounters are difficult.3,4,5,6 DPEs force the attending physician to explain, test, and treat somatization symptoms and patients’ excessive demands, which can cause fatigue and stress in the attending physician.7 Physician-patient communication problems caused by the burden on physicians can lead to increased patient dissatisfaction, complaints, and lawsuits.8 In addition, this tends to increase healthcare utilization, which increases medical costs.8 DPEs are also known to be a cause of diagnostic errors.9,10,11 As such, DPEs not only affect physicians but also cause disadvantages for the patients themselves.3

The factors affecting the physician’s perceptions of an encounter being difficult include physician-related, patient-related, and situational factors;8, 12 patients alone are not the problem.5 Physician-related factors include years of experience, exhaustion due to overwork, lack of sleep, depression, dogmatism, and lack of skills related to psychiatric care and communication.2, 3, 5, 7, 13, 14 Patient-related factors include mental illnesses, such as depressive, anxiety, or personality disorders; presenting more than five somatic symptoms; poor functional status; threatening and abrasive personalities; unmet expectations; and high utilizers of healthcare services.3, 5, 7, 8 Situational factors include time pressures during visits, patient-staff conflict, or complex social problems.12 Therefore, it is important to identify factors that lead to DPEs and practice appropriate patient care while building good patient-physician relations.13, 15

Physician empathy is crucial for develo** good patient-physician relations.16 It includes not only perceiving a patient’s thoughts but also objectively understanding and being able to communicate with them clearly and accurately.17,18,19 Empathetic patient care can help establish good patient-physician relations and ensure a smooth diagnostic process.18,19,20 In other words, DPEs may cause diagnostic errors by reducing the possibility of a doctor using their intuitive thinking (System 1: intuitive diagnosis)21; therefore, develo** empathy may be important for the diagnostic process.9,10,11 A high level of self-reported empathy may also improve the management of lifestyle-related diseases, such as diabetes and dyslipidemia, patients’ adherence to treatment, patient satisfaction, and patient stress.13, 18, 22

Our study’s purpose was to evaluate the relationship between DPEs and physicians’ empathy.

METHODS

Study Design

This study is a cross-sectional study.

Participants

The investigation was conducted in August–September 2018 and April–May 2019 at six facilities, including city hospitals and clinics. Participants were consenting generalist physicians with 3 to 8 years of experience since their graduation from medical school. Physicians with over 10 years of experience were excluded because it has been found that those with less than 10 years of practice experience more encounters as difficult.5 The participating doctors were working at the Department of General Medicine, Chiba University Hospital, after completing 2 years of postgraduate training. This department offers regular education and training on managing DPEs. For uniformity, patients were limited to first-time adult outpatients who visited hospitals or clinics with the chief complaint of a physical symptom.

Measurements

The Jefferson Scale of Empathy (JSE)

There are several empathy scales that are reliable, valid, and internally consistent.19 Of these, the JSE was created to measure empathy specifically in physicians and is the most widely used.23

The 20-item JSE has three components: perspective taking, compassionate care, and ability to fill a patient’s shoes. Items are rated on a scale from 1 (Strongly disagree) to 7 (Strongly agree), which are then summed to obtain the total score.18 A higher score indicates a higher degree of empathy. The validity and reliability of the Japanese version of the JSE has been established.18, 24

The Difficult Doctor-Patient Relationship Questionnaire-10 (DDPRQ-10)

The DDPRQ-10 is a valid and reliable self-report tool to assess DPEs.25 The DDPRQ-10 has 10 questions, composed of three components: negative personalities of patients, difficulty in communication with patients, and negative emotional reactions of physicians toward patients.26 Ten items are rated on a scale from 1 (Not at all) to 6 (A great deal); a total score of 31 or higher is classified as a DPE.26

The Center for Epidemiological Studies Depression Scale (CES-D)

The CES-D was used to evaluate depressive symptoms in the general population during the past week. The 20 items of the CES-D are rated on a scale of 0 (best) to 3 (worst), based on the frequency of symptoms. The total score ranges from 0 (best) to 60 (worst), and a score of 16 or higher indicates depression. The validity and reliability of the Japanese version of the CES-D have been adequately demonstrated in previous studies.27, 28

Patients’ Information

The patients’ sex and age were obtained from hospital records. The patients’ mental health histories were obtained through the physicians either in the medical history section of the questionnaire or directly during the consultation.

Procedure

The inclusion criteria were (1) working as a physician, (2) consenting to participate in the study, and (3) not experiencing depressive symptoms. Eighteen physicians were approached, and all consented to participate. The empathy level of participating physicians was assessed using the JSE; physicians with JSE scores from 96–113 and 114–126 were classified into low and high empathy groups, respectively, because the median JSE score of all participants was 114 (range: 96–126) (Fig. 1). The physicians were not notified of the score results or to which group they belonged until the end of the study. Previous studies have also confirmed that years of experience as a doctor and depression are physician-related factors that make DPEs prevalent.5, 7, 14 Thus, in addition to physicians’ and patients’ ages and sex, we considered these factors. Moreover, a history of mental illness is a confirmed patient-related factor for DPEs.29

Fig. 1
figure 1

Study flow. JSE, Jefferson Scale of Empathy; CES-D, Center for Epidemiological Studies Depression Scale; DPEs, difficult patient encounters. JSE scores of the low empathy group range from 96 to 113. JSE scores of the high empathy group range from 114 to 126.

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The participants completed the DDPRQ-10 immediately after examining each first-time adult outpatient who visited their community hospital or clinic with a chief complaint of a physical symptom with or without a history of prior hospital visits. The participants were surveyed once a week, for a total of 8 weeks, to secure the minimum sample size for the patients. Out-of-hours patients, emergency room patients, and re-visiting patients were not included in the analyses.

Data Analyses

All statistical analyses were performed using Stata 17.0 (MP StataCorp., TX, USA), and p < 0.05 indicated statistical significance. The t-test, Mann-Whitney test, and χ2 test were used to compare the physician and patient characteristics between low and high empathy groups. We implemented multilevel mixed-effects logistic regression models to examine the association between physicians’ empathy and DPE, considering physician-level clustering effects. The intra-class correlation (ICC) was estimated in the null model to estimate the clustering effect. We also employed a multivariable adjustment for patient-level covariates such as age, sex, and history of mental disorders.

As a sensitivity analysis, we analyzed the Pearson correlations between the JSE and DDPRQ-10 scores for all participants.

Establishment of Survey Period

The participants were 18 generalist physicians. Further, a total of 398 (199 × 2) patients were needed to ensure enough patients in each group. For the 18 doctors to examine 398 patients in total, each doctor was required to examine at least 23 patients. Interviews conducted in advance allowed us to estimate that each doctor saw around three first-time outpatients per day, so we determined that eight outpatient visit surveys would be needed to meet the required patient count per doctor. Therefore, considering one outpatient day per week, the survey period was set to 8 weeks.

Ethics Approval and Consent to Participate

This study was conducted with the approval of the Chiba University Graduate School of Medicine Ethics Committee. Participants were briefed, as part of an informed consent process, before obtaining their consent.

RESULTS

The physician participants (15 men; 3 women) ranged in age from 26 to 39 years (the median age was 29). A total of 584 patients participated. There were no missing data in any variables. The overall prevalence rate of DPEs was 16%. Of the 584 patients evaluated by the DDPRQ-10, 240 and 344 patients were examined by physicians in the low and high empathy groups, respectively (Table 1).

Table 1 Physician and patient characteristics in the low and high empathy groups
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Fewer encounters were experienced as difficult among physicians with higher empathy scores (11% vs. 23%, OR: 0.37; 95% CI = 0.19–0.72, p = 0.004, Table 2). Difficult encounters tended to involve older patients (OR: 1.03; 95% CI = 1.01–1.04, p < 0.001), women (OR: 1.32; 95% CI = 0.82–2.13, p = 0.026), and those with a mental illness history (OR: 4.31; 95% CI = 2.24–8.62, p < 0.001). There was a negative correlation between the JSE and DDPRQ-10 scores (r = −0.220, p < 0.001).

Table 2 Factors associated with DPE considering the cluster effects
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DISCUSSION

Japanese physicians experience encounters as difficult at similar rates to physicians in other countries.3,4,5,6 While previous studies have found a relationship between provider experience and difficulty, ours is the first to show that empathy is an important factor in experiencing encounters as difficult. Previous studies have shown that difficult encounters affect a number of patient and provider outcomes.26 We found that the JSE and DDPRQ-10 scores were negatively correlated. This suggests that improving physician’s empathy might strengthen the patient-physician relationship and reduce the prevalence of DPEs.18, 30 This hypothesis merits future consideration.

Empathy can improve with education and experience.31,32,33,34,35 Participatory and effective simulations, such as using professional simulated patients, may foster learning motivation and response skills to DPEs and enhance physicians’ empathy.15, 35 A previous study has found that the effectiveness of similar training programs varies between countries because of preferable communication patterns (verbal or nonverbal) in each country, and cultural differences (Japanese patients tend to prefer their doctors to be calm and unemotional).35 Therefore, it might be important to investigate the way of more effective education on empathy in each situation.

The median JSE of this study’s participants (114; range: 96–126) was higher than that reported in a study on generalist physicians (104; range: 49–137).36 This difference might be explained by the fact that the participants in the present study were receiving education and training on DPEs regularly; that is, younger and less experienced participants or cultural differences may have had an impact. For example, individuals raised in Asian cultures may be inclined to provide more socially desirable responses.

Limitations

There are several limitations to this study. First, the number of physician participants was low because this study was designed without assuming physician-level clustering effects. Considering the multilevel analysis would have originally resulted in a larger sample size required when ICCs were taken into account.37 Our findings need to be replicated in a larger cohort of providers.

Second, even though this was a multicenter study, the patient demographics differed; therefore, we may not have been able to accurately control for the confounding factors contributing to physicians’ empathy and DPEs. In addition, it may be essential that situational factors, such as the time of day of consults/examinations or the day of the week, be controlled. Early morning consults/examinations may be considered less difficult because the physician may be less tired at the beginning of the day; meanwhile, consults/examinations at the beginning of the week may be considered more difficult because of a possible backlog of patients on a Monday who could not be seen over the weekend. A previous study found that perceptions of DPEs are higher on Mondays than on other days.30

Finally, physicians’ empathy was evaluated using a self-assessment tool. Although a doctor’s understanding of a patient’s perspective is central to empathy, the doctor’s self-evaluated empathy and the patient’s evaluation of the doctor’s empathy may differ. A recent review showed that self-reports of cognitive empathy are only weakly associated with more objective measures, such as behavioral task performance; cognitive empathy self-reports only explain around 1% of the variance.38 As a non-self-assessment tool, the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) is used to assess patients’ perceptions of their physicians’ empathy,39 and while several studies have examined the relationship between the JSE and JSPPPE, the results have not been consistent.40, 41 As doctors with high self-evaluation may overestimate their empathy levels, multiple evaluations from not only patients but also medical staff including other doctors will be required to measure empathy as accurately as possible. Further research on this hypothesis is warranted. It is also essential for the study of DPEs that future research be conducted to verify whether the same patients are judged as DPEs by multiple doctors.

CONCLUSION

We found that highly empathetic physicians were less likely to experience DPEs. Based on this result, it is clear that verifying a relationship between DPEs and physicians’ empathy is paramount for develo** good patient-physician relations.