The influence of patient perception of physician empathy on patient satisfaction among attending physicians working with residents in an emergent care setting

Abstract Background It is unclear whether the patient's perception of attending physician empathy and the patient's satisfaction can be affected when attending physicians work alongside residents. We aim to determine the influence residents may have on (1) patient perception of attending physician empathy and (2) patient satisfaction as it relates to their respective attending physicians. Methods This is a prospective single‐center observational study. Patient perception of physician empathy was measured using Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE) in both attendings and residents in the Emergency Department. Patient satisfaction with attending physicians and residents was measured by real‐time patient satisfaction survey. Multivariate logistic regressions were performed to determine the association between patient satisfaction and JSPPPE after patient demographics, attending physician different experience, and residents with different years of training were adjusted. Results A total of 351 patients were enrolled. Mean JSPPPE scores were 30.1 among attending working alone, 30.1 in attending working with PGY‐1 EM residents, 29.6 in attending working with PGY‐2, and 27.8 in attending working with PGY‐3 (p < 0.05). Strong correlation occurred between attending JSPPPE score and patient satisfaction to attending physicians (ρ > 0.5). The adjusted odds ratio was 1.32 (95% CI 1.23‐1.41, p < 0.001) on attending's JSPPPE score predicting patient satisfaction to the attending physicians. However, there were no significant differences on patient satisfaction among four different groups. Conclusion Empathy has strong correlation with patient satisfaction. Decreased patient perception of attending physician empathy was found when working with senior residents in comparison to working alone or with junior residents.


| INTRODUCTION
Empathy is the ability to understand or feel what other persons' are experiencing and becomes an important indicator of building up provider-patient rapport in clinical practice. 1,2 Better patient-centered care with improved clinical outcomes have been associated with positive perception of empathy among health care providers. 3,4 Empathy can be measured either by health care providers themselves or by their patients. 5,6 High consistency has been reported between patient perception of provider empathy and patient satisfaction to the providers. 7,8 By far, one of the commonly used empathy measures is the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE). 5,9 JSPPPE is a well validated tool to measure health care providers' empathy consistent findings. [10][11][12] However, the use of JSPPPE in the field of Emergency Medicine (EM) has been less studied. Previous studies have considered that inconsistent findings in measuring empathy among health care providers working in the Emergency Department (ED) might be due to providers having less time to spend with the patients, resulting in suboptimal patient-provider rapport. 13 In addition, ED providers rarely follow up with their patients and this lack of patient engagement could further prevent them from building up routine patient-provider rapport. 14 On the other hand, the common practice model of an academic teaching hospital ED will have attending physicians working with residents of different training levels. Attending physicians have responsibilities of taking care of their patients while educating residents. By far, we are uncertain of whether working with residents will affect patient perception of attending physicians' empathy, thus subsequently affecting patient satisfactions to the attending physicians. It is also largely unknown whether residents' empathy and patient satisfaction toward residents can directly affect patient satisfaction toward attendings.
Determining the association and interaction of patient perception of provider empathy and patient satisfaction among attending physicians and residents is very important because it provides evidence of improving patient centered care while also helping improve resident education. A better understanding of the attending-resident practice pattern and how it affects patient centered care can provide guidance to contribute building an optimal clinical practice curriculum among different specialties with residency programs.
In this study, we aim to (1) investigate the association between patient perception of provider empathy when the EM attending physicians worked with residents of different training years; and (2) to determine whether attending physician empathy and satisfaction is affected by working with residents.

| Study design and setting
This is a secondary data analysis derived from a single-center prospective observational study in an urban hospital ED. 13 The study hospital is a Level-1 trauma center, a comprehensive stroke center, chest pain center, and tertiary referral center. The study ED sponsors an ACGME (Accreditation Council for Graduate Medical Education) accredited 3-year EM residency program and has an annual patient volume of more than 125 000. This study was approved by the local Institutional Review Board (IRB#1352504-6) and was performed under the Helsinki research ethics statement. All the participants signed the informed consent form.

| Study participants
ED attending physicians, EM residents, and ED patients who consented and agreed to participate in this study were included. From January 2019 to August 2019, patient perception of physician empathy and patient satisfaction surveys were given to all patient participants who agreed to participate, using either paper-or tablet-based platform, before they were discharged from ED. We excluded subjects who: (1) declined to participate; (2) completed less than 20% of study survey questions; (3) were evaluated by a physician (either attending physician or resident) who did not participate in this study; and (4) were unable to identify their attending physician/residents in order to complete the surveys.

| Patient perception of physician empathy and physician satisfaction measurements
Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE) was used for patient perception of physician empathy. JSPPPE can measure different health care providers' empathy including physician, nurses, residents, and medical students. 12,15,16 It can be applied to physicians of different specialties including orthopedics, family medicine, and internal medicine. 15,17,18 JSPPPE includes five questions, each of which were assessed using a 7-point Likert Scale ("strongly disagree" = 1 to "strongly agree" = 7), with a total score ranging from 5 to 35. Higher JSPPPE scores indicate higher patient perception of physician's empathy. In this study, participating patients completed the JSPPPE on both the attending physicians and the residents separately if an individual patient was cared by both. If patients were cared by multiple attending physicians and residents, patients were offered to complete as many surveys as possible if they were able to differentiate individual providers' names or characteristics. Immediately upon completion of JSPPPE, a patient satisfaction survey was rendered. Patients were asked to score their satisfaction on the surveyed providers. Patient satisfaction was assessed using a 5-point Likert Scale ("very dissatisfied" =1, "dissatisfied" =2, "neither satisfied nor dissatisfied" =3, "satisfied" =4, and "very satisfied" =5).
Similarly, patient satisfaction was surveyed on both the attending physician and resident separately if an individual patient was cared for by both the attending and the resident.

| Study protocol and study variables
For patient selection, a set of 4-hour blocks were randomly generated every 3 months by using the random number generator in STATA (College Station, TX) as previously reported. 13  Patients were also divided into four groups based upon patients who were cared for by (1) the attending physicians only; (2) both the attending physicians and PGY-1 EM residents; (3) both the attending physicians and PGY-2 EM residents; and (4) both the attending physicians and PGY-3 EM residents. JSPPPE and patient satisfaction to both the attending physicians and residents were calculated and analyzed separately. Due to the skew data (>90% of patients rates satisfaction survey as either "5: very satisfied" or "4: satisfied), we further classified patient satisfaction into either "very satisfied" (satisfaction score of 5) or "notvery satisfied" (satisfaction score of 0-4) groups.

| RESULTS
From January 2019 to August 2019, a total of 351 patients were enrolled in the final analysis. A detailed study flow diagram is shown in Figure 1. During the study period, 28  and patient satisfaction to residents. Consistent lower JSPPPE and patient satisfaction scores (differences of the scores and its correlation) were found between attending physicians and EM residents who worked together (Table 3).
A multivariate logistic regression analysis was then performed to determine the risks associated between patient satisfaction to attending physicians and patient perception of attending physicians' empathy after adjustment of the potential confounders (eg, working with residents, years of physicians' practice, patient demographics, to the junior residents (interns). 18 Other studies using different empathy tools showed a similar trend among residents of different training years. 6,21 Though we can still not fully understand the mechanism(s) for why these trends are similar, perhaps different patient illnesses (e. g., different acuity levels), patient trust in physicians or different stress levels, anxiety, or burnout among physicians could all affect physicians' empathy. 6,22 We should also consider that senior residents may have higher stress and burnout levels which could partially attribute to the decreased empathy levels 6 as compared to their junior counterparts. Interestingly, patient perception of attending physicians empathy trended down (decreased) when the attending worked with the senior residents. Perhaps this could be partially explained as the synergistic effect occurred between the attending physicians and the residents (e.g., strong correlation between JSPPPE of attending and resident; Table 2) and that senior EM residents usually require less supervision from the attending physicians. Attending physicians trust the senior residents' performance/clinical judgement more than the junior (e.g., interns, PGY-1) residents, for which the attending physicians may spend less time with the patients to avoid redundancies.
Previous studies indicated that a provider "in-hurry" phenomenon has Patient satisfaction is a core measurement in patient-centered care. 24,25 Though JSPPPE affects patient satisfaction, we found resident empathy and their satisfaction had less influence on patient satisfaction to attending physicians. These findings indirectly proved that patient satisfaction can be affected multifactorially, with empathy being just one contribution. 26,27 Previous studies showed many independent factors could possibly affect patient satisfaction to physicians including patient demographics, patient experience at ED, and patient trust of the physician, to list a few. 26,28,29 Our study was not focused on identifying potential risks affecting patient satisfaction but rather to determine the association between JSPPPE and patient satisfaction with the influence of the attending physicians working with residents.

| Limitations
Our study is not without its limitations. This is a secondary data analysis derived from a single-center prospective observational study with limited sample size. Our study setting is limited to a urban tertiary hospital with an extremely busy ED, which had patient selection bias potentially affecting its generalizability. Secondly, this study only focused on JSPPPE and patient satisfaction; we did not analyze other factors that could affect patient perception of provider empathy and patient satisfaction since these two measures can be affected multifactorially. Third, though the study showed a synergistic effect on patient perception of attending physician empathy and resident empathy and we can only address its association; more investigation is needed to determine the causative effect. Therefore, to further validate our findings, a large-scale multicenter prospective randomized study with different patient cohorts is warranted.

| CONCLUSION
Decreased patient perception of attending empathy was found when working with senior residents in comparison to attending physicians working alone or with junior residents. However, the change of patient perception of attending empathy did not significantly affect patient satisfaction towards the attending physicians.

CONFLICT OF INTEREST
Authors have no conflict of interest.

FUNDING
This study received no funding. Hao Wang had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT
The corresponding author (Hao Wang) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported, that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

ETHICS STATEMENT
This study was approved by the local Institutional Review Board (IRB#1352504-6) and was performed under the Helsinki research ethics statement. All the participants signed the informed consent form.