The relationship between empathy and Self-Management Support in general practice consultations in areas of high and low socio-economic deprivation

Mullen, J-M (2013) The relationship between empathy and Self-Management Support in general practice consultations in areas of high and low socio-economic deprivation. PhD thesis, University of Glasgow.

Abstract

Aim:

Empathy is widely regarded as an important attribute of healthcare professionals, and has been linked to higher patient satisfaction, enablement, and some health outcomes. The ‘mechanism of action’ of clinical empathy is not well understood. An ‘effect model’ of empathic communication in the clinical encounter has been proposed by Neumann et al (2009). In this model, clinician empathy is seen as having a positive effect in encouraging patients to tell more about their symptoms and concerns (for example, by picking up on emotional cues and responding in an encouraging way). This can result in ‘affective-oriented effects’ (such as the patient feeling listened to and understood) or ‘cognitive/action-oriented effects’ which include the clinician collecting more detailed information (medical and psychosocial), gaining a more accurate perception of the problem (and possible diagnosis) and enhanced understanding and responses to the patients’ individual needs. Such responses may include Self-Management Support of various kinds, which help enable the patients to better manage their condition(s), leading to improved outcomes.

Recent Government policy in Scotland has focused on Self-Management Support and Anticipatory Care as key priorities in primary care, in response to the rise in chronic disease and health inequalities. However, the amount and type of Self-Management Support and Anticipatory Care that occurs in routine consultations in primary care is not known, nor their relationship with empathy and patient enablement. Thus the ‘effect model’ of empathy as proposed by Neumann, which postulates a relationship between empathy, Self-Management Support, and outcomes in the consultation remains largely theoretical.

The aim of this thesis was to examine the relationships between patients’ perceptions of doctors’ empathy, patient enablement, health outcomes and the amount and the type of Self-Management Support (including Anticipatory Care) in general practice consultations. Due to the wide health inequalities that exist in Scotland, and the continuing operation of the ‘inverse care law’, a comparison was made between consultations in areas of high or low socio-economic deprivation to establish whether the relationships varied by deprivation.

The thesis had the following research objectives;

• To assess the nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups

• To determine whether patients’ perceptions of GP empathy is related to Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation groups

• To explore the effects of Self-Management Support (including Anticipatory Care) on patient enablement and health outcomes in high and low deprivation groups

• To assess patients’ perception of empathy in terms of the nature, type, and frequency of emotional Cues and responses by GPs rated as high or low in empathy by their patients in consultations in high and low deprivation groups

Methods:

The research objectives were investigated by a secondary analysis of data collected between 2006-2008 by Mercer and colleagues in the Section of General Practice and Primary Care at the University of Glasgow. These data were collected as part of a research project in general practice in areas of high and low deprivation funded by the Chief Scientist Office of the Scottish Government. The research produced database, includes 659 videoed baseline consultations, with patient rated experience measures, including the Consultation and Relational Empathy (CARE) Measure, the Patient Enablement Instrument (PEI) and outcomes (self-reported symptom change and well-being) at 1 month post-consultation available on 499 patients.

An observer-rated method of assessing Self-Management Support and Anticipatory Care was sought from the literature to answer objectives 1-3. However, there were a lack of validated observer-rated tools available that were specifically designed to measure these constructs. As such, the Davis Observation Code was identified as a validated system of coding primary care consultations across a broad range of consultation components which included items deemed to relate to Self-Management Support and Anticipatory Care. The process of selecting the Davis coding system, and the rejection of alternative coding systems is discussed in detail in Chapter 5. The Davis coding system was also considered feasible given the large size of the database. Self-Management Support and Anticipatory Care were then measured by using combinations of seven codes deemed relevant to Self-Management Support within the consultation setting.

Four additional codes were added to the Davis system, in order to include tasks relevant to UK general practice consultations. These additional codes were not part of Self-Management Support or Anticipatory Care but were added to achieve a complete coding system of activities within the consultations.

The Verona coding system measured emotional cues, concerns and health provider responses that were observed within the consultations. As such, this system was used to answer objective 4. The choice of this system reflected a desire to use an observer-rated measure to help ‘validate’ the patient-rated empathy measure (the CARE Measure) in terms of the first part of the Neumann et al (2009) model, i.e. eliciting concerns and symptoms, separate from the cognitive/action oriented effects relating to Self-Management Support.

Results:

Reliability of the objective coding systems
Preliminary work was carried out on both coding systems in order to establish reliability in the application of the codes. This was a lengthy process, involving several cycles of coding by two coders (the author and one of her supervisors) but resulted in acceptably high levels of inter-rater reliability (kappa > 0.7 for the Davis coding system, and > 0.9 for the Verona coding system).

Objective 1: The nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups
In both the high and low deprivation groups, time was predominantly allocated to gaining information about the patient’s complaint, conducting physical examinations and planning treatment.

There was no difference observed in the amount of Self-Management Support overall in the consultations between high and low deprivation areas. However, there were significant differences in the nature, type and frequency of certain aspects of Self-Management Support, with significantly more Anticipatory Care in the consultations in the high deprivation areas.

The results also showed that patients in the high deprivation group tended to experience a more direct biomedical focused consultation that featured practical tasks such as physical examinations and discussion of substance misuse. In the low deprivation group, a biopsychosocial approach was more common, which involved more time spent within the consultation discussing treatment effects, compliance or discussing how previous interventions had impacted on the patient’s health. For both groups, little time was allocated to gathering family information or counselling, answering patient questions or discussing health knowledge.

Objective 2: Patients’ perception of GP empathy and relationship with Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation areas.
The relationship between empathy and Self-Management Support was explored using the Consultation and Relational Empathy Measure (CARE) and the Davis observation code respectively. Potential confounding variables were taken into account. Patients' perceptions of their GP's empathy were significantly associated with Self-Management Support in the low deprivation group, but not the high deprivation group. Anticipatory Care was not associated with patients' perceptions of their GP's empathy in either high or low deprivation groups.

Objective 3: Effects of Self-Management Support (including Anticipatory Care) on patient enablement and health outcomes in high and low deprivation groups
The effects of Self-Management Support on patient enablement and health outcomes were explored. Patient Enablement was not related to the amount of Self-Management Support or Anticipatory Care in the consultations in either high or low deprivation settings, nor were Davis codes associated with enablement in the high deprivation group. However, enablement was positively and significantly associated with discussions around patient questions in the low deprivation group. The amount of time spent on procedures (such as taking blood) had a negative association with enablement in the low deprivation group.

Changes in health outcome in terms of symptom severity at 1 month post-consultation were not related to overall Self-Management Support in the consultation in either high or low deprivation settings. However, Anticipatory Care in the consultation was related positively with symptom improvement in the low deprivation group but not high deprivation group.

Changes in health outcome in terms of well-being improvement at 1 month post-consultation were not related to overall Self-Management Support or Anticipatory Care in the consultation in either high or low deprivation settings.

Objective 4: Patients’ perception of empathy in terms of the nature, type, and frequency of emotional Cues and responses by GPs rated as high or low in empathy by their patients in consultations in high and low deprivation groups
Patient perception of GP empathy within the consultation, as measured by the CARE Measure, was compared with the type and frequency of patients’ emotional cues and concerns and GP responses using the Verona coding system. Because of the lengthy process that this coding system entails, coding was undertaken on a sub-group of the full data set. 112 consultations were coded, from the highest and lowest empathy GPs, (based on GPs’ mean CARE Measure scores) in the dataset, in both high and low deprivation areas.

The results showed that in areas of high deprivation, patients who consulted GPs with high empathy (high CARE measure scores) expressed more emotional cues and concerns and the GPs had more encouraging responses, compared with consultations with practitioners with low patient ratings of empathy. These associations between Verona codes and GP empathy were not observed in consultations in low deprivation areas. These findings suggest that the way in which patients judge their GPs to be empathic or not differ according to deprivation level.
Conclusions

The thesis findings are based on one of the largest databases of general practice consultation content linked to health outcomes in the world. New findings on the relationships between patients’ perceptions of doctors’ empathy, patient enablement, health outcomes and the amount and the type of Self-Management Support (including Anticipatory Care) in general practice consultations have been identified.

Objective measurement of Self-Management Support showed similar amounts of Self-Management Support overall in consultations in high or low deprivation areas, though more Anticipatory Care (involving more health promotion) was observed in the high deprivation group, possibly as a reactive response to the higher levels of unhealthy behaviours (such as smoking and substance misuse) in deprived areas. However, the amount of Self-Management Support shown in consultations in both deprivation areas was generally low.

In agreement with theoretical cognitive/action-oriented effects of the Neumann model, perceived GP empathy was positively related to the amount of Self-Management Support in the consultations in the low deprivation areas. However, this was not found in the high deprivation consultations, suggesting that patients judge their GPs empathy on different criteria depending on their deprivation levels and that affect-oriented effects may be more important in consultations in deprived areas. Symptom improvement was related to the amount of Anticipatory Care in the low deprivation group, which would again fit with the cognitive/action-oriented effects of the Neumann model. However, in the high deprivation group such an association was not found.

Collectively, the results of this thesis indicate that the relationships between perceived GP empathy, Self-Management Support (including Anticipatory Care), patient enablement, and health outcomes are complex and differ depending on the deprivation level of the patient. The findings provide some support for the utility of the ‘effect model’ of empathy but mainly in the low deprivation setting. These findings have implications for how consultations are best conducted in high or low deprivation areas, and possibly for medical student and GP training in communication and consultation skills.

• Item Type: Thesis (PhD)
• Qualification Level: Doctoral
• Keywords: empathy, Self-Management Support, Anticipatory Care, Verona-CoDES-CC, Davis Observation Code, Deprivation, General Practice & Primary Care, Greater Glasgow and Clyde, Inter-Rater Reliability, patient-practitioner relationship, patient-enablement and health outcomes
• Subjects: R Medicine > RA Public aspects of medicine; R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
• Colleges/Schools: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > General Practice and Primary Care
• Supervisor's Name: Mercer, Prof. S.W. and Watt, Prof. G.C.M.
• Date of Award: 2013
• Depositing User: Miss Jenna-Marie Mullen
• Unique ID: glathesis:2013-4533
• Copyright: Copyright of this thesis is held by the author.
• Date Deposited: 03 Sep 2013 15:11
• Last Modified: 11 Aug 2015 10:52
• URI: https://theses.gla.ac.uk/id/eprint/4533