Implementation, results and face validity of the Consultation and Relational Empathy measure in a Canadian department of surgery

Discussion

This study describes the successful implementation of the validated CARE Measure to assess empathy and communication skills in single academic surgical department. Surgeons in our department had a mean CARE score of 46.9, which is above average8 and shows that patients perceived them to have great empathy and communication skills. We observed variability among surgeon- and division-level scores, and higher scores among female surgeons than male surgeons.

Importantly, a large majority of surgeons found the assessment applicable and useful to their practice, and 34% planned on making changes based on participation in this intervention. In contrast, a 2017 review of 64 independent CARE studies showed that the average physician score was 39.68.7 All divisions in our study had a higher average CARE score than this. Compared to normative values published by the creators of the CARE Measure,8 our department scored in the 90th percentile overall, with the lowest-scoring division still in the 70th percentile.

We found 2 prior studies in which the CARE Measure was applied in a surgical setting. Steinhausen and colleagues2 compared assessments by 120 patients who had undergone trauma surgery of their physician’s empathy (using the CARE Measure) to their assessment of medical treatment outcome (using the Cologne Patient Questionnaire). They found that patients who rated their physician’s empathy higher tended to rate their medical outcome better. They reported an average CARE score of 38.0 (standard deviation [SD] 9.75). However, they did not report the number of surgeons assessed or individual surgeon scores. Dekker and colleagues9 compared 6 orthopedic surgeons’ self-assessment of their own empathy with their patients’ assessment using the CARE Measure and found that the two do not necessarily correlate. The average CARE score overall was 47 (SD 5); individual surgeon’s CARE scores were not reported.

To our knowledge, our study is the first to describe the logistics of implementing the CARE Measure in surgical clinics, the results of the measure at the surgeon, division and department level, and the attitudes of surgeons toward the measure. Several authors have suggested that surgeons have different personality types from their colleagues in medical specialties. Surgeons are at times portrayed as exhibiting ambition, leadership and guile, but often lacking in compassion, empathy and communication skills.10^–13 Some authors have made direct comparisons, reporting that medical specialists have greater levels of empathy than surgeons.14^,15 The present study refutes those findings, showing high communication and empathy scores across multiple surgical specialties. The cause of this discrepancy is not clear. Studies that directly compare patient satisfaction with communication skills between surgical and medical or primary care encounters are lacking; they should be performed to better understand the differences observed. White and colleagues16 performed an analysis of the structure of communication between surgeons and patients in the outpatient clinical setting and found that it differs from that in primary care encounters in subtle but important ways. Specifically, surgical encounters are unique in that they tend to start with establishing a mutual understanding of the referral and achieving alignment of goals between the surgeon and patient. This may explain some portion of the discrepancy in communication and empathy scores between our study and other reports.

We noted a statistically significant difference in CARE scores between male and female surgeons, with females scoring higher than males by about 1 point. However, it is difficult to assess whether this difference was perceptible by patients. The minimal clinically important difference has not been studied for the CARE Measure. It remains unclear whether this represents a true difference in male and female empathy, or a gender-based difference in empathy perceived by patients. In any case, this finding is consistently borne out in the literature. The review of 64 independent CARE studies, for example, showed that the 6 studies with a majority (> 50%) of female practitioners showed mean empathy scores that were 16% higher than those of the 6 studies with a majority of male practitioners (42.77 v. 34.85).7 This difference in empathy has been described in numerous other sociologic, psychologic, behavioural and neurodevelopmental studies.17

The finding that patients seeing their surgeon for a follow-up visit rated them higher, by 1 point on average, than those meeting their surgeon for an initial consultation was unexpected, as consultation visits typically last longer than follow-up visits and involve more in-depth discussion of diagnosis, treatment and prognosis. One possible explanation is that patients have higher expectations for initial visits than for follow-up visits, which are not entirely met. Alternatively, patients in follow-up are more familiar with their surgeon and may be more likely to score them higher. Another explanation is that consultations are often initially performed by a fellow, resident or medical student, who then reviews with the attending surgeon before the surgeon sees the patient to review the plan and answer any questions. Our instructions to the patients were to complete the survey based only on their interaction with the attending surgeon, not with the fellow or resident. As such, their interaction with the surgeon may be relatively brief and unsatisfying. This finding suggests that surgeons may want to allocate more time to new consultations.

The assessment and training of physician empathy has important consequences. Breakdowns in communication are a major cause of malpractice litigation in the United States, Canada and elsewhere.18^–20 A recent review by Shouhed and colleagues21 suggests an inverse relation between a surgeon’s emotional intelligence — defined as his or her ability to monitor and regulate his or her emotions as well as the emotions of others — and litigation rates. Other investigators have shown that communication training for physicians leads to improved patient satisfaction.22 This underscores the importance of assessing and teaching these skills like any other medical or surgical technique. Although most surgeons are extremely committed to the care of their patients, there appear to have been minimal efforts made to objectively measure surgeons’ empathy as judged by their patients.

Our results may provide valuable insights into the applicability of the CARE Measure in surgical practice. One finding was that surgeons and patients alike agreed that item 9 (“Helping you to take control”) was not particularly suitable: when asked which item was least useful, surgeons selected this question most frequently, and it received the greatest number of “Does not apply” responses by patients. Interestingly, this directly mirrors the findings of Mercer and Murphy23 in a study of CARE Measure validity in a secondary care population, where they also found the highest “Does not apply” rate (9.1%) for question 9. Perhaps this finding reflects the nature of surgical treatments, where patients often relinquish control to their surgeons.

A large majority of surgeons (69%) in the present study felt that the feedback they received was useful to them, and half of these reported that they intended to make changes in response to the feedback. As such, we appear to have demonstrated face validity of the CARE Measure in this population. We plan to readminister the study to assess for changes in our results and to formally assess relevance, performance, reliability and construct validity. We are also exploring hospital-wide implementation of the CARE Measure in all departments.