Doctors' and Patients' Perceptions of Impacts of Doctors' Communication and Empathy Skills on Doctor-Patient Relationships During COVID-19.

BACKGROUND: During the COVID-19 pandemic, the performance of Chinese doctors may have led to improved doctor-patient relationships (DPRs). However, it is unclear how doctors and patients perceived the impact of doctors' communication and empathy skills on DPRs during the COVID-19 pandemic.
OBJECTIVE: To examine the perceptions of doctors and patients on how doctors' communication skills and empathy skills influence DPRs during COVID-19. MAIN MEASURES: Doctors' and patients' perceptions of doctors' communication skills were measured using the Chinese version of the SEGUE Framework. To measure empathy skills and DPRs, the Jefferson Scale of Empathy and Difficult Doctor-Patient Relationship Questionnaire were administered to doctors, and the Consultation and Relational Empathy Measure and Patient-Doctor Relationship Questionnaire were administered to patients.
RESULTS: A total of 902 doctors and 1432 patients in China were recruited during the pandemic via online or offline surveys (overall response rate of 69.8%). Both doctors and patients rated doctors' empathy skills as more impactful on DPRs than communication skills. Doctors believed that only their empathy skills influenced DPRs. But patients believed that there was a significant bi-directional relationship between doctors' communication and empathy skills and these two skills interacted to directly and indirectly influence DPRs, and doctors' empathy had a greater mediating effect than their communication.
CONCLUSIONS: During COVID-19, there were both similarities and differences between Chinese doctors' and patients' views on how doctors' communication and empathy skills influenced DPRs. The greater effect of doctors' empathy skills suggests that both doctors and patients attach more importance to doctors' empathy in doctor-patient interactions. The bi-directional effect on patient outcomes suggests that both doctors' communication and empathy skills are important to patients' perceptions of DPRs.

INTRODUCTION

Doctors’ interpersonal skills, such as communication ability[1] and empathy,[2,3] are key factors in the doctor–patient relationship (DPR). According to the communication accommodation theory (CAT), [4,5] and the Russian doll model of empathy,[6] the quality of this relationship is enhanced when a doctor’s communication skills[7,8] and empathic ability[9,10] improve. However, patients’ and doctors’ perspectives on doctors’ communication[11,12] and empathy skills[13,14] differ. While doctors may believe that they express empathy, patients often disagree.[15] In addition, the reciprocal relationship between doctors’ communication and empathy skills is supported by theoretical models, including empathic neural responses,[16] and empathic communication.[17] There is also empirical evidence for this relationship. Norfolk et al.[18] conducted a study using semi-structured interviews and found a significant relationship between doctors’ communication ability and empathy skills: patient-centered communication is based on an understanding of the patients’ viewpoint. Appropriate summaries and responses to patients’ feelings can improve doctors’ empathic understanding. Schrooten and de Jong[19] also found that doctor’s communication skills and empathic abilities complemented each other. Doctors’ empathic responses to patients can promote increased patient communication and positive communication behavior can enhance doctors’ empathy. Intervention studies have found that improving doctors’ empathy improves communication,[6] and training in communication skills enhances empathy.[20,21] It follows then that the complementary effects that doctors’ communication abilities and empathy skills have on each other are a mechanism for improving patient satisfaction and the DPR.[18,19] Thus, this study aimed to investigate the impact of doctors’ communication skills and empathic abilities on the DPR during the coronavirus disease of 2019 (COVID-19) pandemic.

METHODS

The study is primarily based on research by Wang et al.,[22] and Norfolk et al.’s model and viewpoint[18]: In doctor–patient interactions, the relationship between doctors’ communication and empathy skills is mutual. We propose a bi-directional model (Fig. 1), testing the hypothesis that there is a bi-directional relationship between doctors’ communication and empathy skills.

Figure 1

Bidirectional relationship.

Study Design and Participants

This study utilized a cross-sectional design with a convenience sample taken from the Chinese population. Doctor and patient data were collected through online and offline surveys. Participating doctors filled out questionnaires online and patient participants completed written surveys before their appointments with their doctors. We included patients (1) that were older than 18 years, (2) that could consent to participation, and (3) who could read Chinese. None of the participants received any compensation. The surveys were conducted between January and April 2020. The study was approved by the Ethics Committee of the Shanghai Normal University.

Measures

Doctors’ Communication Skills

Doctors’ evaluation of their own communication abilities was measured using the 25-item Chinese version of SEGUE Framework. This scale was developed by Makoul[23] and was revised in China in 2017.[24] It has five dimensions: preparation, requesting information, providing information, understanding the patient, and ending the consultation. Each item is scored on a 5-point scale where 1 = never and 5 = all the time. The patients’ evaluation of the doctors’ communication skills was consistent with doctors’ communication scale in terms of content and scoring. Higher scores represented higher ratings of doctors’ communication skills by patient participants. In our study, Cronbach’s alpha coefficients for the two scales were .95 and .96, respectively.

Doctors’ Empathy Skills

Doctors’ evaluation of their own empathic abilities was measured using the 20-item Chinese version of the Jefferson empathy scale.[25] Patients’ evaluation of doctors’ empathic abilities was measured using the 10-item Chinese version of the Consultation and Relational Empathy Scale.[26] For both scales, higher scores represented better ratings of doctors’ empathy skills. In this study, Cronbach’s alpha coefficients for the two scales were .82 and .92, respectively.

Doctor–Patient Relationship

The doctors’ evaluation of the doctor–patient relationship was measured using the 10-item Chinese version of the Difficult Doctor Patient Relationship Questionnaire.[27] It comprised three dimensions, namely doctors’ subjective perceptions, objective manifestations of patient behavior, and combining patient behavior and doctors’ subjective responses to patients’ symptoms. The patients’ evaluation of the doctor–patient relationship was measured using the 15-item Patient-Doctor Relationship Questionnaire.[27] Its three dimensions are patients’ satisfaction, doctors’ approachability, and doctors’ attitude. Both scales indicated that higher scores represented better quality doctor–patient relationships. In our study, Cronbach’s alpha coefficients for the two scales were .77 and .94, respectively.

Statistical Analysis

Data analysis progressed with SPSS Version 25.0 in three stages. First, we examined demographic characteristics of participants, and descriptive and correlational analyses of main study variables. Second, to yield standardized coefficients, the original data of all variables were normalized as z-scores. After controlling for demographic variables, we conducted two mediation analysis to test whether doctors’ communication skills mediated the relationship between doctors’ empathy skills and DPRs (model 1), and doctors’ empathy skills mediated the relationship between doctors’ communication skills and DPRs (model 2). Thus, the two mediation models were fitted with DPRs as the dependent variable. Third, we further verified the mediated effect of the two models. PROCESS macro for the Statistical Package for the Social Sciences (SPSS)[28] was used to calculate a bias-corrected and accelerate bootstrapped confidence interval (CI) (5000 resamples) for the size of each models’ direct effect of independent variables on the outcome (label c), the effect of the independent variable on mediator (label a), and the effect of the mediator on outcome (label b), total effect (label a*b+c) and the indirect effect (label a*b). Significant mediation was indicated by CI of indirect effect that does not contain zero.

RESULTS

Participant Characteristics.

We enrolled 903 doctors, with a mean age of 33.51 years old (SD = 6.22, range =20–79 years), and 1432 patients, with a mean age of 36.09 years old (SD = 7.03, range =18–99 years, Table 1).

Table 1

Demographic Characteristics of Doctors ( = 902) and Patients ( = 1432)

	Doctors N (%)	Patients N (%)	χ2
Gender			13***
Male	482 (53%)	656 (46%)
Female	420 (47%)	776 (56%)
Age			200***
18–30	347 (38%)	604 (42%)
31–40	470 (52%)	414 (29%)
41–50	75 (8%)	212 (15%)
51–60	8 (1%)	166 (12%)
>60	3 (0.3%)	36 (3%)
Education level			710***
High school/technical secondary school graduation	17 (2%)	443 (31%)
Junior college	70 (8%)	324 (23%)
Undergraduate	407 (45%)	577 (40%)
Graduate	409 (45%)	89 (6%)
Medical institution grade			50***
Tertiary	711 (79%)	1031 (72%)
Secondary	129 (14%)	160 (11%)
Primary	63 (7%)	242 (17%)
Region			202**
East	144 (16%)	622 (43%)
Central	754 (83%)	787 (55%)
West	5 (1%)	24 (2%)

Note: **p < .01, ***p < .001

Descriptive Statistics and Correlations Among Variables

Correlations showed that doctors’ communication skills and doctor–patient relationship were not significantly related to each other in the doctors’ evaluation, while patients’ evaluations showed that all variables are significantly correlated (Table 2).

Table 2

Descriptive and Correlational Analyses of Main Study Variables

Variable	Range	Min	Max	M (SD)	1	2
Doctors
Doctors’ communication skills	0~125	68	125	102.53(11.08)
Doctors’ empathy skills	0~100	24	94	67.76(8.54)	−.08*
Doctor–patient relationship	0~50	17	46	32.57(5.34)	−0.06	.37**
Patients
Doctors’ communication skills	0~125	31	125	94.46 (16.13)	-
Doctors’ empathy skills	0~50	13	50	39.06 (5.60)	0.71**	-
Doctor–patient relationship	0~75	28	75	58.42 (7.47)	0.72**	0.79**

Note. *p < .05, **p < .01, ***p < .001

Mediation Analyses

Figure 2 presents doctors’ and patients’ views on the effects of doctors’ empathic abilities and communication skills on DPR, respectively, and the effect of doctors’ empathy and communication ability on each other.

Figure 2

Standardized regression coefficients among the three variables from doctors’ (a) and patients’ (b) perspectives. The black solid lines represent significant, and the gray dotted lines represent not significant. *** < .001.

While models based on the doctors’ perspective indicated that only the effect of empathy on DPR was significant (β = 0.37, 95% CI: 0.19–0.47), patients’ evaluations suggested that both empathic ability (β = 0.56, 95% CI: 0.69–0.80) and communication skills (β = 0.33, 95% CI: 0.13–0.17) had an effect on DRP, as well as there being evidence of a relationship between empathy and communication (β = 0.71, 95% CI: 1.9–2.2) and between communication and empathy (β = 0.32, 95% CI: 0.18–0.45).

Table 3 demonstrates the standardized total effects, direct and indirect, associated with each of the three variables. From the doctors’ perspective, we found that empathy had a direct effect on DPR (β =0.37, 95% CI: 0.19–0.47), but there were no indirect effects. In contrast patients reported both direct and indirect effects, including that a doctor’s empathic abilities had a direct effect on DPR (β =0.56, 95% CI: 0.69–0.80) and that a doctor’s communication skills had a direct effect on DPR (β =0.33, 95% CI: 0.18–0.45). We further found that a doctor’s empathic abilities indirectly affected DPR by way of their communication skills and that this effect was significant (a*b =0.23, 95% CI: 0.18–0.28). Doctor’s communication skills were also found to have an indirect effect (a*b = 0.18, 95% CI: 0.16–0.21) on DPR.

Table 3

Total, Direct, and Indirect Effects

Effect	BCBCI
	Label	b	Lower	Upper
Model 1: Doctors’ empathy skills (X) - Doctors’ communication skills (M) - DPR (Y)
Doctors
Total effect	a*b+c	.37	.19	.47
Direct effect	c	.37	.19	.47
Indirect effect	a*b	.002	−.004	.001
Patients
Total effect	a*b+c	.79	.63	.95
Direct effect	c	.56	.69	.80
Indirect effect	a*b	.23	.18	.28
Model 2: Doctors’ communication skills (X) - Doctors’ empathy skills (M) -DPR (Y)
Doctors
Total effect	a*b+c	−.03	−.06	.10
Direct effect	c	−.03	−.07	.01
Indirect effect	a*b	−.003	−.008	.001
Patients
Total effect	a*b+c	.51	.36	.66
Direct effect	c	.33	.27	.39
Indirect effect	a*b	.18	.16	.21

BCBCI bias-corrected bootstrap confidence interval

DISCUSSION

Our findings suggest that both doctors and patients acknowledge that doctors’ empathic abilities are crucial to the DPR. We noted that while doctors presumed that only their empathy skills were important, patients believed that doctors’ empathy skills influenced their communication skills, and vice versa. In addition, we found that patients’ views regarding the DPR were that doctors’ communication skills mediated empathy and vice versa. For patients the mediating effect of doctors’ empathy was more significant than that of the effect of their communication skills, thus highlighting the importance of good empathic abilities for patients.

Our findings are consistent with studies conducted prior to the COVID-19 pandemic[22] and supports both the CAT model as well as the Russian Doll model.[4,5,29] For patients, doctors’ empathic abilities were found to have influenced their medical care experience.[30] Doctors with well-developed empathy skills were able to perceive patients’ emotions accurately[31] and were more likely to generate appropriate emotional responses and to express them in a suitable manner to obtain patients’ feedback. This process served to enhance the DPR.[32] Thus, this study suggests that the patients perceived a better DPR and regarded the doctors’ empathy skills as better when their communication skills were excellent.

We found that Chinese doctors did not believe that there was a bi-directional relationship between communication skills and empathic ability, but that Chinese patients were of the opinion that these two skills influenced each other, which is consistent with previous research.[33,34] Our findings are inconsistent with the results reported by Norfolk et al.[18] who found that doctors also believed in a bi-directional relationship. Norfolk et al.’s study participants were British practitioners and they made use of qualitative methods. Our sample included Chinese practitioners and we utilized surveys to determine the extent and strength of the relationships. It is unclear whether our results differ from those of Norfolk et al. due to a difference in the viewpoints and culture of the doctors or if quantitative exploration would corroborate British doctor’s belief in a bi-directional relationship.

Our study has a number of limitations. First is cross-sectional data and relies on surveys. Longitudinal data would be useful to corroborate this relationship. Second, we did not include variables that have previously been demonstrated to impact perspectives on interactions, including visit duration We also did not directly observe the interactions to corroborate either the patient or provider perception of interaction quality and have no information on specific behaviors that may influence perception.

Despite these limitations, our results supported doctor and patient perceptions that doctors’ empathy skills are important to the DPR and both doctors’ communication and empathy skills influence patients’ perceptions of DPRs. Given that training can improve doctor–patient interactions,[35,36] Chinese medical schools should incorporate training in interpersonal communication skills.