Jefferson Scale of Patient’s Perceptions of Physician Empathy: Preliminary Psychometric Data Aim To develop a brief scale for measuring patient’s perceptions of their physician’s empathic engagement and to provide preliminary evi- dence in support of aspects of the scale’s psychometrics. Method Study comprised 225 patients, out of 436 patients (52% re- sponse rate) seen by 166 residents in the internal medicine residency program at the Jefferson Hospital Ambulatory Clinic as part of their ambulatory training at Thomas Jefferson University Hospital. A 5-item questionnaire entitled the Jefferson Scale of Patient’s Perceptions of Physician Empathy was developed and administered to the study par- ticipants. Its factor structure, item-total score correlations, and correla- tions with several relevant criterion measures were examined. Results Factor analysis indicated that the scale was measuring a single factor of emphatic engagement. Item scores and total scores of the Jefferson Scale of Patient’s Perceptions of Physician Empathy yielded significant correlations with the American Board of Internal Medicine patient ratings form and with selected items from other relevant instru- ments measuring physicians’ humanistic behavior and the appraisal of physicians’ performance. Conclusions A brief scale for assessing physician empathy from the pa- tients’ perspective showed good psychometric characteristics and can be used for the assessment of patient outcomes. 1Department of Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA 2Center for Research in Medical Education and Health Care and Department of Psychiatry and Human Behavior, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA Gregory C. Kane1, Joanne L. Gotto1, Salvatore Mangione1, Susan West1, Mohammadreza Hojat2 Gregory C. Kane Department of Medicine Jefferson Medical College 1025 Walnut Street, 805 Philadelphia, PA 19107, USA gregory.kane@jefferson.edu > Received: October 16, 2006 > Accepted: December 22, 2006 > Croat Med J. 2007;48:81-6 > Correspondence to: Clinical ScienceClinical Science 81www.cmj.hr mailto: gregory.kane@jefferson.edu Croat Med J 2007;48:81-86 82 Empathy has been described as an important el- ement of professionalism in medicine (1-3). The importance of empathy as the foundation for positive relationships between patients and physicians has been discussed in medical edu- cation and health care research (4-7). Physi- cian empathy and effective communication skills increase patients’ satisfaction, improve patients’ compliance, and enhance physicians ability to diagnose and treat their patients (6,8). Improved outcomes may be a result of better compliance or the activation of psycho- logical factors that are formed in trusting rela- tionships (1,9). Viewed from the contrasting perspective, a lack of empathy can have negative effects on clinical outcomes. Resident’s humanistic qual- ities, communication skills, and professional- ism are considered important components of the trainee’s evaluation by both the American Board of Internal Medicine, which certifies in- ternists, as well as the Accreditation Counsel for Graduate Medical Education, which accredits programs in American Medical Schools(http:// www.acgme.org/outcome/comp/compHome.asp). While the new outcomes project of the Ac- creditation Counsel for Graduate Medical Edu- cation does not specifically call for an evaluation of physician empathic concern; interpersonal communication with patients, cultural sensitiv- ity, and professionalism are key components of the new evaluation process. Specifically, residents are expected to form effective therapeutic rela- tionships with patients and families, to build re- lationships through listening, narrative or non- verbal skills, and to develop skill in education and counseling of patients and their families (http:// www.acgme.org/outcome/comp/compHome.asp), all of which are relevant to physician-patient em- pathic engagement. Patients are considered as an important source for the assessment of these skills. Therefore, it is important to develop an in- strument to assess patient’s perceptions of phy- sician empathic engagement. This study was de- signed to examine the psychometric properties of such an instrument. Methods Participants Data for this study were collected in 2003 and 2004 for internal medicine residents at dif- ferent levels of training at Thomas Jefferson Uni- versity Hospital and from patient encounters in the resident ambulatory clinic, Jefferson Hospi- tal Ambulatory Clinic. Complete data (with no missing responses) were available for 225 patient encounters with 166 residents. Instruments Based on a review of literature, we developed the Jefferson Scale of Patient’s Perceptions of Physician Empathy. This is a brief instrument (5- item) intended to measure patient’s perceptions of his/her physician’s empathic concern and un- derstanding (Table 1). Patients were asked to re- spond to each item on their physicians by using a 5-point Likert-type scale (from 1 = strongly dis- agree to 5 = strongly agree). It takes a few min- utes to answer the scale. To examine the validity of the Jefferson Scale of Patient’s Perceptions of Physician Empathy we used The American Board of Internal Medi- cine patient rating form intended to measure as- pects of physician communication skills, human- istic qualities, and professionalism in medicine (10). This form was developed by the American Board of Internal Medicine to be used as part of a comprehensive evaluation for physician recertifi- cation and presents an opportunity to assess phy- sician-patient relationships at all levels of medi- cal education and practice. The American Board of Internal Medicine patient rating form used in this study included 9 items, each answered on a 5-point Likert scale (from 1 = strongly disagree to 5 = strongly agree). A “not applicable” option was also available. http://www.acgme.org/outcome/comp/compHome.asp http://www.acgme.org/outcome/comp/compHome.asp http://www.acgme.org/outcome/comp/compHome.asp http://www.acgme.org/outcome/comp/compHome.asp Kane et al: Patient’s Perception of Physician Empathy 83 Also, five items that were conceptually rele- vant to empathic physician-patient engagement were selected to be used as additional criterion measures for the validity study (Table 1). Four of these items were adapted from the Physicians’ Humanistic Behavior Questionnaire developed by Weaver et al (11), and one item was adapted from a questionnaire intended to measure pa- tients’ appraisal of physicians’ performance de- veloped by Matthews and Feinstein (12). Finally, we used scores of the Jefferson Scale of Physician Empathy that was administered to a sub-sample of residents to examine the concor- dance between patient’s perceptions of physician empathy and physician’s self-reported empathy. The Jefferson Scale of Physician Empathy is a 20- item scale with sound psychometric support that measures physician empathic orientation and be- havior (13-15). Procedures The approval of our institutional review board was obtained for this project. Patients were ap- proached in the waiting room upon checkout after completing their visit with their resident physician at the Jefferson Hospital Ambulatory Clinic. Patients were asked by a trained research assistant to voluntarily and confidentially com- plete the survey containing 3 demographic ques- tions, plus 19 survey items (5 for the Jefferson Scale of Patient’s Perceptions of Physician Empa- thy, 5 criterion measures, and 9 for the American Board of Internal Medicine patient rating form) as a part of a quality improvement project with- in the residency program at Thomas Jefferson University Hospital (web-extra material). The resident’s name was printed on the survey that was anonymously completed by the patient. To maintain complete confidentiality, the patients were guided to a private location, away from the physician treatment areas to complete the survey. The research assistant would offer to read and re- cord the patient’s responses if this was requested by patients. Additionally, patients were told that their participation or refusal would in no way in- fluence the care they received. Statistical analyses Principal component factor analysis was used to examine the dimensionality of the Jefferson Scale of Patient’s Perceptions of Physician Empathy. We calculated the Pearson product-moment cor- relation coefficients for the validity study. Results A total of 436 patient rating forms were received. Of these, 225 (52%) were complete with no missing data that were used as the units of anal- yses in this study. In factor analysis of data, only one factor emerged with an eigenvalue greater than one (eigenvalue = 3.7), indicating that the Jefferson Scale of Patient’s Perceptions of Phy- sician Empathy is a uni-dimensional scale mea- suring only one underlying factor interpreted as “empathic engagement.” The factor coefficients are reported in Table 1. The item-total score correlations were all pos- itive and statistically significant (P<0.001), and ranged from a low of 0.77 to a high of 0.90 with Table 1. Factor coefficients, item-total score correlations, and correlations with American Board of Internal Medicine patient rating form for the items of Jefferson Scale of Patient’s Perception of Physician Empathy* Items Factor coefficients Item-total score correlations Correlations with ABIM patient rating form Understands my emotions, feelings and concerns. 0.90 0.90 0.69 Seems concerned about me and my family. 0.89 0.91 0.64 Can view things from my perspective (see things as I see them). 0.81 0.85 0.70 Asks about what is happening in my daily life. 0.76 0.84 0.54 Is an understanding doctor. 0.73 0.77 0.67 *The Jefferson Scale of Patient’s Perceptions of Physician Empathy items were answered on a 5-point Likert-type scale (1 = Strongly Disagree, 5 = Strongly Agree). All correlations were statistically significant (P<0.001). Croat Med J 2007;48:81-86 84 a median correlation of 0.85, indicating that all items contributed substantially to the total score (Table 1). Inter-item correlations ranged from a low of 0.54 to a high of 0.75 with a median of 0.65 (P<0.001). The reliability coefficient (the Cronbach α coefficient of internal consistency) for the Jef- ferson Scale of Patient’s Perceptions of Physician Empathy was 0.58 which is relatively low, but with only five items in the scale it can be consid- ered satisfactory. The score distribution of the Jefferson Scale of Patient’s Perceptions of Physician Empathy was skewed toward the upper tail of the distribu- tion reflected in the mean score of 23.8 on a scale with a maximum score of 25, indicating that pa- tients expressed an extremely positive view of the residents’ empathic engagement (Table 2). Correlations between each item of the Jef- ferson Scale of Patient’s Perceptions of Physi- cian Empathy and the total scores of the Amer- ican Board of Internal Medicine patient rating form ranged from a low of 0.54 to a high of 0.70 (Table 1). All these correlations were statistically significant (P<0.001) with a median of 0.67, in- dicating that the items of the Jefferson Scale of Patient’s Perceptions of Physician Empathy were significantly related to the evaluation of physi- cians’ communication skills, humanistic qual- ities, and professionalism as measured by the American Board of Internal Medicine patient rating form, thus providing support for the valid- ity of the items. Also, correlations between the total scores of the Jefferson Scale of Patient’s Perceptions of Physician Empathy and scores for each item of the American Board of Internal Medicine pa- tient rating form were examined. The highest correlation (r = 0.75) was obtained for the fol- lowing item of the American Board of Internal Medicine patient form: “(this physician) is in- terested in me as a person; does not act bored or ignore what I have to say.” The lowest correla- tion (r = 0.49) was found for the following item: “(this physician) explains what you need to know about your problems and what to expect in plain language.” The median correlation was 0.60, and all correlations were statistically significant (P<0.001). The correlation between the total score of the Jefferson Scale of Patient’s Perceptions of Phy- sician Empathy and the average scores of the American Board of Internal Medicine patient ratings was 0.75 (P<0.001), providing support for the criterion-related validity of the Jefferson Scale of Patient’s Perceptions of Physician Em- pathy (Table 3). Correlations between the total scores of the Jefferson Scale of Patient’s Perceptions of Phy- sician Empathy and the selected items from the Physicians’ Humanistic Behavior Questionnaire (11) and from the patient’s appraisal of physi- cians’ performance (12) were all statistically sig- nificant (P<0.001; Table 3). The correlation be- Table 2. Descriptive statistics for the Jefferson Scale of Patient’s Perception of Physician Empathy Descriptive statistics Mean 23.8 Standard deviation 2.54 Possible range 5-25 Actual range 10-25 Cronbach α reliability 0.58 Table 3. Validity coefficients for the Jefferson Scale of Patient’s Perception of Physician Empathy expressed as correlation coef- ficient between scale result and six criterion measures*. Criterion measures Validity coefficients ABIM Patient Rating Form† 0.75 Shows concerns for my feelings and needs, not just my physical status.‡ 0.86 Asks me how I feel about my problems.‡ 0.79 Arranges for adequate privacy when examining or talking with me.‡ 0.61 Is always in a hurry.‡ -0.50 Takes my wishes into account when making decisions.§ 0.76 *The Jefferson Scale of Patient’s Perceptions of Physician Empathy items were answered on a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree). All correlations were statistically significant (P<0.001) †Total scores on the American Board of Internal Medicine (ABIM) patient rating form (10). ‡Adapted from the Physicians’ Humanistic Behavior Questionnaire (11). §Adapted from Patients’ Appraisal of Physicians’ Performance (12). Kane et al: Patient’s Perception of Physician Empathy 85 tween scores of the Jefferson Scale of Patient’s Perceptions of Physician Empathy and the item that describes physician as being always in a hur- ry was expectedly negative, indicating that being in rush is not conducive to empathic engagement in the patient care context. These findings fur- ther support the criterion-related validity of the Jefferson Scale of Patient’s Perceptions of Physi- cian Empathy. Data for both the Jefferson Scale of Patient’s Perceptions of Physician Empathy and the Jef- ferson Scale of Physician Empathy were available for a small number of residents (n = 27). Correla- tion coefficient of the two scales for this group of residents was 0.24, which did not reach the level of statistical significance (P = 0.223). Discussion Several conclusions can be drawn from the find- ings of the present study. First, the results of fac- tor analysis suggest that the Jefferson Scale of Patient’s Perceptions of Physician Empathy mea- sures a single factor that can be entitled physi- cian’s empathic engagement as perceived by the patient. Second, findings that each item of the Jefferson Scale of Patient’s Perceptions of Phy- sician Empathy and its total scale score were sig- nificantly correlated with the responses on the selected criterion measures, including the total scores of the American Board of Internal Medi- cine patient rating form provide evidence for the criterion-related validity of the Jefferson Scale of Patient’s Perceptions of Physician Empathy. Third, a lack of significant correlation between patient’s perceptions of physician’s empathic en- gagement and the resident’s self-reported empa- thy deserve further clarification. A lack of rela- tionship on empathic understanding between therapists and patients has been reported (16) and explained by factors such as residents’ inabil- ity to communicate their empathic understand- ing to their patients, or patients’ viewing em- pathic engagement differently from physicians. In another study with residents in a family med- icine program, a significant correlation (r = 0.48, P<0.050) was observed between the Jefferson Scale of Physician Empathy and the Jefferson Scale of Patient’s Perceptions of Physician Em- pathy scores (data not shown). We expected to find a significant overlap between scores of the Jefferson Scale of Patient’s Perceptions of Phy- sician Empathy and the Jefferson Scale of Physi- cian Empathy in the present study. The non-sig- nificant correlation we observed between these two measures could be due to the skewed score distribution of the Jefferson Scale of Patient’s Perceptions of Physician Empathy, restriction of range, and the ceiling effect. We examined the distribution of scores of the Jefferson Scale of Pa- tient’s Perceptions of Physician Empathy for the residents who completed the Jefferson Scale of Physician Empathy and found that a great ma- jority (78%) of them obtained the maximum score on the Jefferson Scale of Patient’s Percep- tions of Physician Empathy, leading to a severe skewed distribution and an extreme ceiling ef- fect. The true relationship between variables can- not be fully captured with such an extreme ceil- ing effect. More empirical research is needed to examine factors that contribute to the relation- ships between physicians’ self-reported empathy and patients’ perceptions of their physicians’ em- pathy in clinical encounters. It is generally believed that patient’s percep- tions of a caregiver’s empathy is associated with a positive treatment outcome (8,16), but empirical evidence in support of this proposition is rarely available. One reason for the scarcity of empiri- cal evidence is the absence of a psychometrically sound instrument for measuring patients’ per- ceptions of their physicians’ empathic engage- ment when rendering care. Although additional studies are needed to further examine different aspects of psychometrics of the Jefferson Scale of Patient’s Perceptions of Physician Empathy in groups of physicians in different specialties and patients in different settings (outpatient, hospi- Croat Med J 2007;48:81-86 86 talized), our preliminary findings suggest that it is feasible to use this scale to study predictors and outcomes of patients’ perceptions of physician empathy. The external validity (generalization of the findings) of this study is limited because of the convenient sampling that included only residents in one residency training program who were not necessarily the primary caregivers of the patients. In this study, we used patients rather than the residents, as the unit of observation. Some of the residents were evaluated by more than one pa- tient. Our analyses showed that the pattern of findings remained generally unchanged when residents were used as the unit of observation. Despite the study limitations, the findings generally suggest that it is feasible to use patients’ ratings of residents’ humanistic attributes in a residency clinic setting. This is important for the Accreditation Counsel for Graduate Medical Education outcome project that emphasizes the centrality of the patient in the evaluation of resi- dents. We believe that greater use of the patients’ assessments of their care provider’s empathy as part of the evaluation of residents could have a significant impact upon the enhancement of pro- fessionalism in medicine. Acknowledgments We would like to acknowledge the following individu- als for their contributions to this project: Kaye Maxwell from the Center for Research in Medical Education for supplying data analysis; Linda Brooks from the Jefferson Hospital Ambulatory Practice for assisting with the fa- cilitation of survey completion in the resident’s clinic; and Deborah Tuitt for formatting and distributing pa- tients’ surveys. Dorissa Bolinski assisted us in editorial polishing. This project was supported in part by a grant (to Dr Hojat) from Pfizer Medical Humanities Initia- tive, Pfizer Inc. New York. References 1 Hojat M. Empathy in patient care: antecedents, development, measurement, and outcomes. New York (NY): Springer; 2007. 2 Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med. 2002;77:502-15. Medline: 12063194 3 Veloski JJ, Hojat M. Measuring specific elements of professionalism: empathy, teamwork, and lifelong learning. In: Stern DT, editor. 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