needs contribute to patient perception of physician empathy? How does a physician’s accurate understanding of a cancer patient’sunmet Patient Education and Counseling

Communication study

How does a physician’s accurate understanding of a cancer patient’s unmet needs contribute to patient perception of physician empathy?

Sophie Lelorain

^a,b,

*, Anne Bre´dart

^c,d

, Sylvie Dolbeault

^c,e,f

, Alejandra Cano

^c

, Ange´lique Bonnaud-Antignac

^g

, Florence Cousson-Ge´lie

^h,i

, Serge Sultan

^j

aUnivLilleNorddeFrance,DepartmentofPsychology,Lille,France

bUDL3,SCALabUMRCNRS9193,Villeneuved’Ascq,France

cInstitutCurie,Psycho-oncologyUnit,Paris,France

dParisDescartesUniversity,LPPSEA4057—IUPDP,Boulogne-Billancourt,France

eInserm,U669,Paris,France

fUnivParis-SudandUnivParisDescartes,UMR-S0669,Paris,France

gUniversityofNantes,EA4275SPHERE‘bioStatistics,PharmacoepidemiologyandHumansciEncesResearch’,Nantes,France

hUniversityofMontpellier3,LaboratoryEpsylon‘DynamicsofHumanAbilities&HealthBehaviors’,Montpellier,France

iICM,InstitutRe´gionalduCancerdeMontpellier,EpidaurePreventionandEducationCancerCenter,Montpellier,France

jUniversityofMontreal,SainteJustineUniversityHospitalResearchCenter,Montreal,Canada

1. Introduction

Patientperceptionofphysicianempathy(PE)isanimportant factor in cancer care, often associated with positive patient outcomes[1],suchasabetterqualityoflife[2]oradherenceto treatment[3].Inspiteofitsvariousdefinitions[4],empathyina medicalsettingisoftendefinedastheclinician’scognitiveability tounderstandaccuratelytheir patient’sneedsandconcerns[5],

which we willrefer toas accurateunderstanding (AU) in this article¹.Strikingly,fewempiricalstudieshavetestedwhetherAU reallymattersforPE.Infact,thesparsedataavailableinoncology donotrevealanylinkbetweenphysicianAUandconceptscloseto PE,suchaspatienttrustinthephysician[6]orsatisfactionwiththe consultation[7].

Thus, on onehand,it couldbethat thephysician’saccurate perceptionofpatientsisnotsoimportantforPE.Agoodbedside mannerwithoutanaccurateperceptionofthepatient,butwith ARTICLE INFO

Articlehistory:

Received13June2014

Receivedinrevisedform19February2015 Accepted7March2015

Keywords:

Physicianaccurateunderstanding Perceivedempathy

Supportivecareneeds Rapport

Expressivesuppression Oncology

ABSTRACT

Objective:Unmetsupportivecareneedsofpatientsdecreasepatientperceptionofphysicianempathy (PE).Weexploredwhethertheaccuratephysicianunderstandingofagivenpatient’sunmetneeds(AU), couldbuffertheadverseeffectoftheseunmetneedsonPE.

Methods:Inacross-sectionaldesign,28physiciansand201 metastaticcancerpatientsindependently assessedtheunmetsupportivecareneedsofpatients.AUwascalculatedasthesumofitemsforwhich physicianscorrectlyratedthelevelofpatientneeds.PEandcovariateswereassessedusingself-reported questionnaires.Multilevelanalyseswerecarriedout.

Results:AUdidnotdirectlyaffectPEbutactedasamoderator.Whenpatientswerehighlyexpressive andwhenphysiciansperceivedpoorrapportwiththepatient,ahighAUmoderatedtheadverseeffectof patientunmetneedsonPE.

Conclusion:PhysicianAU hasthepowertoprotect thedoctor–patientrelationshipinspite ofhigh patientunmetneeds,butonlyincertainconditions.

Practiceimplications:PhysiciansshouldbeencouragedtowardAUbutwarnedthathighrapportand patientlowemotionalexpressionmayimpedeanaccuratereadingofpatients.Inthislattercase,they shouldrequestaformalassessmentoftheirpatients’needs.

ß2015ElsevierIrelandLtd.Allrightsreserved.

* Correspondingauthorat:SCALabUMRCNRS9193,Universite´ Lille3,UFRde Psychologie,RueduBarreau,BP60149,F-59653Villeneuved’Ascqcedex,France.

Tel.:+33320416968;fax:+330320416036.

E-mailaddress:sophie.lelorain@univ-lille3.fr(S.Lelorain).

1Inthepresentstudy,wewilluse‘accurateunderstanding’(AU)todescribethe accuracywithwhichaphysicianperceivestheneedsandconcernsofaspecific patient.

ContentslistsavailableatScienceDirect

Patient Education and Counseling

j ou rna l hom e pa ge : ww w. e l s e v i e r. c om/ l o ca t e / pa t e duc ou

http://dx.doi.org/10.1016/j.pec.2015.03.002

0738-3991/ß2015ElsevierIrelandLtd.Allrightsreserved.

active listening and warmth [8,9], as well as sufficient time devoted to the patient [10–14], seems sufficient for patient satisfaction. Consistent with this idea, in a vignette study responded tobyanalogue patients, Blanch-Hartiganfoundthat

‘patients’weresatisfiedwith‘physicians’whowereabletodetect theoccurrenceofpatientemotions,even iftheywerewrongat determiningthenature ofthe detectedemotions [15].Thus, as someauthorsargue,accuracymaynotbeasfunctionallyimportant asmightaprioribethought[16].

On theother hand,an accurateperceptionof patient needs shouldbenecessaryforclinicianstoaddresstheseneedsandthus beperceivedasempathic.Findingsthatpatients’unmetinforma- tionneedsarestronglyrelatedtolowPE[17–19]supportthisline ofreasoning.

Wereasonedthatpreviousstudieshavefailedtodemonstrate theassociationofAUwithPE[6,7]becauseofthetwofollowing methodologicaldrawbacks.

First,ratherthaninfluencingPEdirectly,AUcouldmoderatethe linkbetween patientunmetneedsandPE.Aspreviouslystated, thereisastrong linkbetweenpatientunmetneeds andlowPE [17–19]. However, somewhat surprisingly, PE depends on ele- mentsthatgobeyondtheactionscopeofphysicians,suchasthe hospital’s organization of care [20–22]. Dysfunctional hospital organizationcouldcreatepatientunmetsupportivecareneeds,for whichphysiciansarenotresponsible,butwhichdostillimpactPE.

However,itcouldbeexpectedthat,althoughphysiciansarenot responsibleforandperhapsunabletomeetthesepatientneeds, theiraccurateawarenessoftheseconcernscouldatleastlessenthe strongnegativeimpactofunmetneedsonPE.Wethusexpecteda moderatingeffectofAUonthelinkbetweenpatientunmetneeds andPE.Althoughthereisnoempiricalstudytodatetosupportthis hypothesis,fromatheoreticalpointofview,itisconceivablethat AU,asanacknowledgementofpatientsuffering,couldbufferthe negativeimpactofunmetneedsonPE.Nevertheless,asdeveloped inthefollowingtwoparagraphs,themoderatingeffectcouldbe possibleonlyundercertainconditions.

Second, according to some authors’ point of view [16,23], perspective-taking(i.e.adoptinganother’sperspective)couldbe oneway,amongothers,toachieveAU.Therefore,itmightbethat previousstudiesdidnotassesstheAUstemmingfromphysician perspective-taking[24,25],whichrecallsthedistinctiveaccuracyof social psychology [26,27], but rather a normative or stereotype accuracyresultingfromphysicianheuristicstoobtainanideaof thepatient’ssituationrapidlyandeffortlessly.Theseheuristicsare typicallystereotypes(e.g.‘Alladvancedcancerpatientsmusthave a lot of unmetneeds’) or egocentric perspectives (e.g. ‘If, as a physician,Ihave doneall that canbedone for a patient,(s)he should not have unmet needs’) [16,23,25]. If, for example, a physician then assumes that cancer patients always have numerousunmetneeds, (s)hewillbeaccuratewithallpatients thatdohavemanyunmetneeds.However,althoughthisstereotype AUcanbehigh,sinceitisnotbasedonasoundknowledgeofa specific patientby taking his/her perspective,it shouldnot be related to PE. We therefore propose that AU could have the speculated moderating effect (i.e. AU moderating the negative impactofunmetneedsonPE)butonlyforadistinctiveAU.

Becauseofphysicianexternalconstraints[8],suchaslackof time,and since perspective-takingis anenergy-consuming and demandingtask,itcanbeassumedthat,bydefault,physiciansdo not take patient perspectives but use heuristics instead. A distinctiveAU ought tooccur ifphysicians have a goodreason toengageactivelyintheinteractionwithpatientsandtaketheir perspectives[28].Amongothermotivations,perspective-takingis triggeredindifficultsituationstocopewithrelationshipthreats [29]orlackofpersonalcontrol[30].Thismayexplainwhymedical studentselicitmorepatientperspectivesinthecaseofanunclear

diagnosis, which can be challenging for the doctor–patient relationship,comparedtoacleardiagnosis[31].Therefore,although itmaynotseemintuitive,weassumedthatdistinctiveAUwould bemorelikelywithpatientsforwhom physiciansperceivepoor rapportratherthanwith‘easy’patients.Moreover,distinctiveAU can only occur with patients who disclose information/cueson whichphysicianscandrawinordertounderstandthemaccurately [32–34].Withoutclearavailableinformation,physicianshaveno otherchoicebuttouseheuristics.

To summarize, our primary goal was to investigate the unresolved issue of how AU could contributeto PE. Clarifying this issueis vital todemonstrate theimportance of AU in the doctor–patientrelationship.Basedonatheoreticalreasoning,we hypothesizedthatAUwouldbufferthenegativeimpactofunmet patientneedsonPE,butonlyforanassumeddistinctiveAU,which, in this study, is either with expressive patients providing diagnosticinformationabouttheirneedsorwhenphysicianshave poorrapportwithapatient.Highpatientexpressivenessandpoor rapportwillbeusedas‘proxies’foranassumeddistinctiveAU,as our study does not allow distinctive AU to be empirically disentangledfromstereotypeAU.

Asubsidiarygoalwastoexplorewhetherclassicalcovariatesof PE, i.e. physician self-reported empathy [14,35,36], length of consultations[10,11,22,37],andphysicianexperienceinoncology inareversesense[35,38,39],wouldalsocorrelatewithPEinthe contextofadvancedcancercare.

Advanced metastatic cancer patients were chosen to reach thoselikelytoreportunmetsupportivecareneedsandbecausethe doctor–patientrelationshipwasdeemedparticularlyimportantin thisphaseofthediseasetrajectory.

2. Methods

Fulldetailsofthestudymaybefoundinanotherreport[32]so onlythemaininformationisgivenhere.

2.1. Procedure

EligiblephysiciansfromfourFrenchhospitalswereinvitedto participate in the study. Upon acceptance, they completed a questionnaireassessingtheirself-reportedempathyandproviding theirsocio-professionalcharacteristics.Theythenhadtoinclude 10consecutivepatientsmeetingtheinclusioncriteria.Attheend ofaconsultationwiththephysician,patientsweregivenadetailed written study description, a written consent form and the questionnaires to fill in. Within one day of each inclusion, physicians had to fill in a short questionnaire assessing their understandingofthepatient’sunmetsupportive careneeds(i.e.

theAUtask,seeSection2.3).

2.2. Participants

The sample was composed of 28 clinicians, mostly medical oncologists with19 yearsofexperience inoncologyonaverage (SD=8.4), and 201 adult advanced metastatic cancer patients.

Mostpatientswerefemaleandlivedwithsomeone,theirmeanage was62yearsandtheprimarycancersiteswerebreast,colorectal andlungcancers.Inallcases,patientshadalreadyconsultedthe physicianatleast3 timesbeforejoiningthestudysothatthey alreadyhadaminimalknowledgeofeachother.

2.3. Measures

Patientperceptionofphysicianempathy(PE)wasmeasuredusing theConsultationAndRelationalEmpathymeasure(CARE),a10- item5-pointLikertscaleprovidinganoverallscoreofPE[40,41],

withahigherscoremeaningahigherPE.Itemsofthescaledeal with patient perception of physician listening, respect, clear explanations and information provision, whether thephysician (from the patient point of view) fully understands his/her concerns,andshowscareandcompassion.Cronbach’salpha(

a

) was0.97inoursample.

Physicianself-reportedempathywasmeasuredusingtheJefferson ScaleofPhysicianEmpathy(JSPE),a20-item7-pointLikertresponse scale [42] with good psychometric properties [42,43]. In these validation articles, the scale provides scores for 3 dimensions:

perspective-taking(e.g.‘Itrytounderstandwhatisgoingoninmy patients’mindsbypayingattentiontotheirnonverbalcuesandbody language’or‘Itrytothinklikemypatientsinordertorenderbetter care’),compassionatecare(e.g.‘Ibelievethatemotionhasnoplacein thetreatmentofmedicalillness’,reverseditem)andinthepatients’

shoes(e.g.‘Itisdifficultformetoviewthingsfrommypatients’

perspectives’,reversed).Higherscoresindicatehigherself-reported empathy.Inoursample,

a

was0.64,0.57and0.85,respectively,for thethreedimensions.

Patient expressive suppression was assessed with the 4-item 7-point Likert expressive suppression scale from the Emotion Regulation Questionnaire (ERQ) [44]. Expressive suppression describestowhatextent peoplegenerally inhibitongoingemo- tion-expressivebehavior(e.g.‘WhenIamfeelingnegativeemotions, ImakesureIdon’texpressthem’).Theexpressivesuppressionscore rangesfrom4to28.Inoursample,

a

was0.83.

Rapport was evaluated by a single question assessing the physician-perceived quality of the relationship with a given patienton a 7-pointLikert scale: ‘Whatis thequality of your relationshipwiththispatient?’from1‘verydifficultrelationship’

to7‘veryeasyrelationship’.

Patientunmetsupportivecareneedswereassessedusinganad- hocadaptationoftheSupportiveCareNeedsSurvey-ShortForm34 (SCNS-SF34) [45,46]. This contains 34 items grouped into five domainsofneeds:physical,psychological,sexual,informational, and care/support. Because physicians should also fill in this questionnairetakingthepatientperspective(seebelow),it was deemedtoo long for this purpose. So, we shortened the scale

further,keepingfromthe5originaldimensionsthe13itemsthat patients had rated as the most important in a previous study [47].Foreachitem,patientswereaskedtorate,ona7-pointLikert scale,theextenttowhichtheyhadneededsomehelpoverthelast month,from1‘noneedatall’to7‘atotalneedofhelp’.Dueto frequentmissingdata,theretaineditemaboutunmetsexualneeds wasdiscarded.Withtheexceptionofonecross-loadeditem(about pain),thusalsodiscarded,anexploratoryfactoranalysis(principal components,varimaxrotation,andscreetest)extractedtwoclear factorslabeled‘psychological’and‘staff-related’dimensionswith

a

of0.87and0.91,respectively(seeTable1fordetailsofitems).

AccurateUnderstanding(AU) ofpatientunmetneeds.Indepen- dentlyofthepatient,thephysicianhadtoratethepatient’sunmet needs on the abridged SCNS-SF34. Physicians were clearly instructedtotakethepatient’sperspectiveandnotindicatetheir own view of the situation. For each item, the physician was consideredaccurateif(s)hegavethesameratingasthepatientto withinonepoint.Thischoicewasmadetofindabalancebetweena too stringent and a too permissive criterion, from both a probabilisticand a clinicalpoint of view.Then,a physician AU scorewasgeneratedbysummingthephysician’saccurateitems foreachofthetwodimensions:psychological(possiblerangefrom 0to5)andstaff-relatedneeds(possiblerangefrom0to6).

2.4. Statisticalanalyses

Torespectthetwo-levelhierarchicalstructureofpatients(level 1) nested within doctors (level 2), multilevel analyses were performed[48,49]withMLwiNsoftware2.30[50,51].

Westartedfromtheemptymodel(M0),whichcontainsonly theinterceptandresidualsforbothpatientorsituational(

s

²e)and physician (

s

²phy) levels. This model enabled the intraclass correlation(ICC)tobecalculated,whichhere isthevariancein PEduetophysicians,i.e.

s

²phy/(

s

²phy+

s

²e).

Next,theassociationsofthepotentialcovariateswithPEwere tested one by one in bivariate analyses. Those significantly associated withPE enteredModel 1. Then, ourhypothesis was specifiedin two differentmodels (2a and 2b)according tothe

Table1

Patientunmetneedsasratedbypatientsandphysicians.

Patient’srating Physician’srating Difference^y AU^z ICC

Mean SD Mean SD

Dimension/item Psychologicaldimension

Lackofenergy,tiredness 3.32 1.92 4.09 1.73 0.77^*** 49 0.37^***

Uncertaintyaboutthefuture 3.64 2.11 4.11 1.78 0.48^** 43 0.25^*

Keepingapositiveoutlook 3.11 2.05 3.91 1.66 0.79^*** 43 0.36^***

Feelingsaboutdeathanddying 3.08 2.17 3.89 1.68 0.81^*** 42 0.34^***

Beinginformedaboutthingsyoucandotohelpyourself togetwell

3.83 2.24 3.42 1.55 0.41^* 41 0.17

Dimensionscore 3.40 1.69 3.89 1.39 0.49^*** 2.17(1.47) 0.29^***

Staff-relateddimension

Beinggivenexplanationsofthosetestsforwhichyou wouldlikeexplanations

3.05 2.05 3.03 1.50 0.02 43 0.01

Beinginformedaboutyourtestresultsassoonasfeasible 3.44 2.27 3.31 1.67 0.13 43 0.24^*

Hospitalstaffattendingpromptlytoyourphysicalneeds 2.43 1.85 3.25 1.61 0.82^*** 51 0.36^***

Reassurancebymedicalstaffthatthewayyoufeelisnormal 3.02 2.08 3.68 1.66 0.66^*** 48 0.30^**

Beingtreatedlikeapersonnotjustanothercase 2.60 2.07 2.44 1.41 0.16 57 0.20^*

Beingadequatelyinformedaboutthebenefitsandside effectsoftreatmentsbeforeyouchoosetohavethem

3.38 2.24 3.19 1.59 0.19 42 0.17

Dimensionscore 2.99 1.73 3.15 1.27 0.16 2.83(1.85) 0.24^***

Foreachitem,AUisthepercentageofphysicianswhowereaccurateonthisitem(i.e.sameratingasthepatienttowithinonepoint).Foreachdimension,AUisthemeanscore ofaccurateitemsperphysician,withstandarddeviationinbrackets;ICC=IntraClassCorrelationCoefficient.

*** p<.001.

** p<.01.

* p<.05.

y Differencewastestedusingpairedttests.

z AU=accurateunderstandingofpatient’sunmetneeds.

dimensionofneeds,andusingathree-wayinteraction:2a)patient unmetstaff-relatedneedsAUrapport;and2b)patientunmet psychological needsAUpatient expressive suppression. In fact, patient expressive suppression was deemed particularly relevantforphysiciandistinctiveAUonpsychologicalneeds,while rapportwasthoughtmorerelevantforstaff-relatedneeds.Indeed, as expressive suppression is really about the expression of emotions,itseemedmorerelevantforpsychologicalneeds,which arepreciselyaboutemotions.Moreover,asapoorrapportprobably reflects the patient’s dissatisfaction withinformation and staff care,it seemedmorerelevantforstaff-related needs,whichtap preciselytheseissuesratherthanemotions.

Thetestofathree-wayinteractionrequirestheintroductionof thethreetermsplusthethreetwo-wayinteractionsinthemodel before entering the final interaction [52]. Models 2a and 2b thereforecontainsevennewparameters.

Finally,model fit wasevaluatedwiththe2Log Likelihood (2LL). The smaller the 2LL is, the better the model is. The differencein 2LLbetween two modelswastestedusinga chi squaretest.Lastly,althoughmultilevelanalysesdonotprovidean R²fortheexplainedvariance,apseudoR²canbecomputedasthe reductioninvariancebetweentwomodels,forexample:(

s

²Model 1

s

²Model2)/

s

²Model1.

3. Results

3.1. Descriptiveresults

ThemeanforPEwasratherhigh:38.4(SD=8.9;possibleand sample range: 10–50). Consultations lasted on average 26min (SD=14;range:5–90).Physicianself-reportedempathywas48.9 (SD=6.5;possiblerange:10–70)onthe‘perspective-taking’factor, 41.2(SD=5.4;possiblerange:8–56)onthe‘compassionatecare’

factor, and 7.7 (SD=3.3; possible range: 2–14) for the ‘in the patients’shoes’factor.Meanrapportwithpatientswashigh,5.7 (SD=1.1, possiblerange: 1–7,sample range:2–7), and patient expressivesuppressionwasmoderate:15.0(SD=6.4;possibleand samplerange:4–28).

PatientunmetneedsandAUarereportedinTable1.Withthe exception of the item about ‘things patients coulddo to help themselvestogetwell’,forwhichphysiciansunderestimatedtheir

patients’ needs,physicians eitheroverestimatedor equivalently ratedtheirpatients’needs.Onaverage,physicianswereaccurate for2.17outofthe5itemsofthepsychologicaldimension,andfor 2.83outofthe6itemsofthestaff-relateddimension.

3.2. Physicianeffectsandcovariates

TheICCcomputedfromtheemptymodel(M0, Table2)was 18%. This means that PE was significantly different between physicians.

In bivariate analyses, physician‘compassionate care’ and ‘in the patients’ shoes’ empathy were not related toPE (

b

=0.21, standard error (SE)=0.17, p=0.22, and

b

=0.10, SE=0.28, p=0.72, respectively), whereas ‘perspective-taking’ empathy was positively related (

b

=0.32, SE=0.13, p=0.01). Length of consultations positively correlated with PE (

b

=0.18, SE=0.05, p<0.001), while physician experience in oncology negatively correlatedwithPE(

b

=0.23,SE=0.10,p=0.02).Thethreelatter variablesenteredModel1,whichwassignificantlybetterthanthe emptymodel(

D

2LL=17.5,p<.001,seeTable2).Inparticular, thecovariatesenabledareductionof39.8%inphysicianvariance (from 14.06to8.47).When thecovariatesweretogetherinthe model,onlythelengthofconsultationremainedsignificantlyand positivelylinkedtoPE.

3.3. ModeratingeffectofAUontherelationshipbetweenunmet‘staff- related’needsandPE

Inthefinalmodel(Table2),asexpected,patientunmet‘staff- related’needswerestronglynegativelyrelatedtoPE(p<0.001) whereasAUonthoseneedsdidnotdirectlyaffectPE.However,AU significantlypredictedPEinthethree-wayinteractionincluding both unmet needs and rapport (p<0.05). The interaction was plottedfortheoreticalvaluesoflow(rapport=3;Fig.1a)andhigh rapport (rapport=5; Fig. 1b). Because of the negative skewed distributionofthisvariable,wepreferredtoplottheinteraction withtheoreticalvaluesof3and5ratherthanusingtheclassical criteriaofpercentiles20and80.Whenrapportwaslow(Fig.1a), AUhadastrongeffectontheneeds-PElink.WhenAUwaslow, unmetneedscorrelatedstronglyandnegativelywithPE,whereas whenAUwashigh,unmetneedscorrelatedpositivelywithPE.In

Table2

MultilevelmodelsforthepredictionofPEbyAUonpatientunmet‘staff-related’needs.

Models M0:Emptymodel Model1 Model2a

Parameters Fixedeffects

Intercept 38.70^***(0.94) 38.45^***(0.81) 37.72^***(0.80)

Lengthofconsultation 0.14^**(0.05) 0.19^**(0.04)

Experienceinoncology 0.13(0.09) 0.11(0.09)

Physicianperspective-taking(JSPE) 0.16(0.13) 0.15(0.12)

Patientunmet‘staff-related’needs 2.26^***(0.35)

AUofunmet‘staff-related’needs 0.46(0.31)

Rapport 1.17^**(0.56)

RapportAU 0.22(0.29)

Rapportunmet‘staff-related’needs 0.73^*(0.30)

AUunmet‘staff-related’needs 0.28(0.20)

Unmet‘staff-related’needsAUrapport 0.40^*(0.18)

Randomeffects

Physicianvariances²phy 14.06(6.42) 8.47(4.71) 8.91(4.21)

Patientorsituationalvariances²e 64.42(6.89) 61.01(6.51) 44.46(4.75)

Modelfit:2LogLikelihood(2LL) 1432.83 1415.30 1356.92

Differencein2LLbetween2models(df) 17.5^***(3dfwithM0) 58.38^***(7dfwithM1)

Effectsignificance=estimate/standarderror(inbrackets).Foreachmodel,therandomslopemodel,whichallowstheslopestovaryacrossphysicians,wastested.Norandom slopemodelsweresignificantlybetterthanthemodelwithoutrandomslopeeffects;thesemodelswerethereforediscarded(datanotshown).

* p<.05.

** p<.01.

*** p<.001.

other words, when rapport was low, overlooked unmet ‘staff- related’needswerenegativelylinkedtoPE,whereasaccurately understoodunmet‘staff-related’needswerepositivelylinkedto PE.Incontrast,whenrapportwashigh(Fig.1b),AUnolongerhad anyeffect.

Model2aalsodemonstratedthatrapportpositivelycorrelated withPE(p<0.01).Overall,thismodelwassignificantlybetterthan Model 1 (

D

2LL=58.38, p<0.001, see Table 2). While it had almostnoeffectonphysicianvariance,itreducedvariancedueto patientorsituationalfactorsfrom61.01to44.46,i.e.by27.1%.

3.4. ModeratingeffectofAUontherelationshipbetweenunmet psychologicalneedsandPE

As predicted, patients’ unmet psychological needs were stronglyand negatively correlated withPE(p<0.001) whereas AUoftheseneedsdidnotdirectlyaffectPE(Table3).However,AU significantlypredicted PEinthethree-wayinteractionincluding bothunmetneedsandpatientexpressivesuppression(p<0.05).

Theinteractionwasplottedforlow(atpercentile20;Fig.2a)and

highpatientexpressionsuppression(atpercentile80;Fig.2b).For low patient expressive suppression (i.e. patient is expressive;

Fig.2a),AUhadaneffectontheneeds-PElink.WhenAUwaslow, unmetpsychologicalneedswerestronglynegativelyrelatedtoPE, whereaswhenAUwashigh, unmetneeds almostdidnotaffect PE.Inotherwords,whenpatientswereexpressiveandtheirunmet psychologicalneedsoverlooked,therewasanegativerelationship betweenunmetneedsand PE,whereaswhentheseneedswere accurately understood by the physician(high AU), highunmet needswerenotrelatedtolowerPE.Incontrast,whenpatientswere notexpressive(Fig.2b),AUnolongerhadanyeffect.

Overall, Model 2b was significantly better than Model 1 (

D

2LL=36.19,p<0.001, seeTable2).While it hadalmostno effectonphysicianvariance,itreducedvarianceduetopatientor situationalfactorsfrom61.01to50.76,i.e.by16.8%.

4. Discussionandconclusion

Our goalwastotestwhether physicianAUcouldbufferthe adverseeffectofpatientunmetneedsonPE,controllingforusual covariatesofPE.

First,amongthecovariates,inagreementwiththeliterature, theconsultationdurationhadthestrongestpositiverelationship withPE.Withouttime,PEisinevitablylimited.Thiscouldexplain why,althoughcommunicationskillstrainingimprovesempathic behavior,patientperceptionof,andsatisfactionwith,healthcare professionalsisnotbetteraftertheseinterventions[37,53].

Second, ourresult that in bivariate analyses physician self- reported perspective-taking but not compassionate care was positivelyrelatedtoPEechoesthosestudieswhereapersonalized medicalapproachbyphysicians(i.e.physiciansknewtheunique elements of patients’ cases and offered supportabout medical aspects),butnottheirfocusonpatientemotionsorpersonaltopics, wasthecoreelementofPE[54,55].Allthesedatahighlightthe importanceofperspective-takingasa keycomponentofpatient satisfaction [56]. Third, still in bivariate analyses, physician experience in oncology was negatively related to PE. An experimentalstudyhasdemonstratedthattoomuchexperience triggers a desensitization, which decreases perspective-taking abilities[57].Perhapsafteracertaintimeinoncology,physicians alsoexperiencea sortof desensitization,bywhich theyprotect themselves against compassion fatigue, but at the expense of showinganinterestinpatients.Finally,only18%ofthevariancein PEwasexplainedbydifferencesinphysicians.Thisconfirmsthat PEisalsosensitivetopatientandsituationalvariables[58–60].

Fig.1.(a)Interactionplotbetweenpatientunmetstaff-relatedneedsandPEforalowrapportwiththepatient(leftfigure);AU=accurateunderstandingofpatient’sneeds.(b) Interactionplotbetweenpatientunmetstaff-relatedneedsandPEforahighrapportwiththepatient(rightfigure).

Table3

MultilevelmodelsforthepredictionofPEbyAUonpatientunmetpsychological needs.

Model Model2b

Parameters Fixedeffects

Intercept 38.39^***(0.75)

Lengthofconsultation 0.16^**(0.05)

Experienceinoncology 0.17(0.09)

Physicianperspective-taking(JSPE) 0.17(0.12) Patientunmetpsychologicalneeds 1.72^***(0.32)

AUofunmetpsychologicalneeds 0.28(0.36)

Patientexpressivesuppression 0.03(0.08)

PatientexpressivesuppressionAU 0.07(0.05) Patientexpressivesuppressionunmet

psychologicalneeds

0.05(0.05)

AUunmetpsychologicalneeds 0.31(0.21)

UnmetpsychologicalneedsAUpatient expressivesuppression

0.06^*(0.03) Randomeffects

Physicianvariances²phy 7.48(4.03)

Patientorsituationalvariances²e 50.76(5.42)

Modelfit:2LogLikelihood(2LL) 1379.11

Differencein2LLbetween2models(df) 36.19^***

(7dfwithM1)

*p<.05;^**p<.01;^***p<.001.SeeTable2foremptymodel(M0)andModel1.Effect significance=estimate/standarderror(inbrackets).Norandomslopemodelswere significantlybetterthanfixedslopemodels,andwerethusdiscarded.

Asexpected,patientunmetneedswerestronglyandnegatively associatedwithlowPE,andthequalityofrapportwaspositively associated withPE.More importantly, themoderatingeffectof highAUwasobservedinthetwoconditionsthatwereexpectedto preventphysiciansfromheuristics:poorrapportandhighpatient expressiveness. Informalfeedback fromphysicians inthestudy addedcredencetoourargumentthatdistinctiveAUisdifficultto achieve in this context. In fact, in the debriefing interviews followingtheresearch,thephysicianstoldusthattheAUtaskwas difficult and that they sometimes felt they had performed it randomly.Consistentwithpreviousworks[61],theyreportedthat theyrarelyquestionedthemselvesabouttheirpatients’careneeds intheirusualroutine.Althoughthismayseemsurprising,itshould berememberedthattheheavyworkloadandcompassionfatigue oftenfacedbyphysiciansarerealbarrierstotheperspective-taking thatunderliesAU[8,62,63].

However,patientopenemotionaldisclosureandlowrapport allowed a different pattern to emerge. Two alternatives may explainhowlowrapportcanfacilitatedistinctiveAUandPE.Low rapport can come from either high patient disclosure of their unmet needs and discontent [64] or, conversely, from patient silenceanddisengagement inmedicalinteractions[59].Inboth cases, those physicians who overcome low rapport to try and understandtheirpatientsandachieveAU,whetherbymaintaining aninterestinthepatientsinspiteoftheirdiscontentorbyeliciting concerns from silentpatients, should logically be perceivedas highlyempathic.ThisisprobablywhywefoundhighPEinspiteof physician-perceivedlowrapport,butonlywhenAUwashigh.This explanationisallthemorelikely since oncologistsusually give littleroomfordisclosure ofpatientimplicitorambiguous cues [65],sothatthosewhomakethiseffortshouldobtainbothhigher AUand,asaresult,higherPE.

Beforeconcluding,weaddressthelimitationsofthisinvestiga- tion.First,thephysiciansamplewaslimited,thecross-sectional design rules out any causal direction, and measurement flaws should be acknowledged: a low Cronbach’s alpha for the

‘compassionatecare’dimensionoftheJSPEandasingleitemto assess rapport. Second, although both the literature and our findings support the idea that AU can result from different processes, thus leading todifferent outcomes, our data do not formallydemonstratethis.Third,wehavenoinsightintophysician empathicbehavior such as paralinguistic expressions or verbal reassurance[66].Therefore,itisstillunknownwhetherAUalone orAUcoupledwithempathicbehavioristhesourceofPE.Although itwasnecessarytoinvestigateAUalonefirst[67],researchinto bothAUandbehaviorsisnowwarranted.

5. Conclusion

Toourknowledge,thisstudyisthefirsttoelucidatehowAU contributestoPEinanaturalisticmedicalsetting.Itshowsthat, underconditionsmaximizingperspective-takingandthusdistinc- tive AU, e.g. when physicians perceive a low rapport withthe patientorwhenthepatientisparticularlyexpressive,AUbuffers theadverseeffectofpatientunmetneedsonPE.

5.1. Practiceimplications

Physiciansshouldalsobewarnedofthepitfallsofhighperceived rapportand/or lessexpressivepatients.Although these typesof patientandrapportmightappearcomfortableforphysicians,they donotenabledistinctiveAU,andthusitsbeneficialeffectonPE.This is whyan assessment ofunmet needs should besystematically offeredtoallcancerpatients,includingthoseforwhom nothing special cameupin consultations.In parallel,patients shouldbe encouragedoreventrainedtocommunicateopenlyandeffectively withdoctorssoastofacilitatephysicianAUandhenceimprovetheir own qualityof life[68]. Ultimately,continuing educationabout empathywouldbenefitfrominformingphysiciansoftheminimal logisticconditions,suchasconsultationduration,whichseemvital for PE,sothattheycan organizethemselves accordingly and/or advocateamodifiedorganizationofthehealthcaresystem.

Conflictofintereststatement Noconflictofinterest.

Acknowledgments

ThisstudywassupportedbyINCASHS2008and2009awarded toSergeSultanandAnneBre´dart.Itwasconductedwhenthefirst authorwasapostdoctoralfellowatUniversite´ ParisDescartesand theInstitutCurie.ThefirstauthoralsothankstheInstitutCurieand the SIRIC ONCOLille Grant INCa-DGOS-Inserm 6041, for their supportduringthewritingofthearticle.

References

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Psychooncology2012;21:1255–64.http://dx.doi.org/10.1002/pon.2115.

[2]FarinE.,NaglM..Thepatient–physicianrelationshipinpatientswithbreast cancer:influenceonchangesinqualityoflifeafterrehabilitation.QualLifeRes 2013;22:283–94.http://dx.doi.org/10.1007/s11136-012-0151-5.

Fig.2.(a)InteractionplotbetweenpatientunmetpsychologicalneedsandPEforalowpatientexpressivesuppression(i.e.patientisexpressive,leftfigure);AU=accurate understandingofpatient’sneeds.(b)InteractionplotbetweenpatientunmetpsychologicalneedsandPEforahighpatientexpressivesuppression(i.e.patientisnot expressive,rightfigure).