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RESEARCH ARTICLE
Physicians’ self-assessed empathy levels do
not correlate with patients’ assessments
Monica Oliveira Bernardo
1
, Dario Cecı
´lio-Fernandes
2
, Patrı
´cio Costa
3
, Thelma A. Quince
4
,
Manuel João Costa
5
, Marco Antonio Carvalho-Filho
6,7
*
1Radiology Department–Faculty of Medicine—Catholic University of São Paulo–Sorocaba–São Paulo—
Brazil, 2Center for Educational Development Innovation and Research–University Medical Center–
University of Groningen–Groningen–The Netherlands, 3Life and Health Sciences Research Institute—
School of Health Sciences—University of Minho–Braga–Portugal, 4Department of Public Health and Primary
Care–University of Cambridge–Cambridge—United Kingdom, 5Life and Health Sciences Research Institute
—School of Health Sciences—University of Minho–Braga–Portugal, 6Emergency Department–School of
Medical Sciences–University of Campinas–Campinas–São Paulo–Brazil, 7Center for Educational
Development Innovation and Research–University Medical Center–University of Groningen–Groningen–The
Netherlands
*macarval@fcm.unicamp.br,macarvalhofilho@gmail.com
Abstract
Background
Empathy is a fundamental humanistic component of patient care which facilitates efficient
and patient-centered clinical encounters. Despite being the principal recipient of physician
empathy little work on how patients perceive/report receiving empathy from their physicians
has been undertaken. In the context of doctor-patient interactions, knowledge about empa-
thy has mostly originated from physicians’ perspectives and has been developed from stud-
ies using self-assessment instruments. In general, self-assessment may not correlate well
with the reality observed by others.
Objectives
To investigate: 1—the relationship between physicians’ self-assessed empathy and
patients’ measures of physicians’ empathy; 2 –Environmental factors that could influence
patients’ perceptions; and 3 –the correlation between two widely used psychometric scales
to measure empathy from the perspective of patients.
Methods
This is an observational study which enrolled 945 patients and 51 physicians from radiology,
clinical, and surgical specialties. The physicians completed the Jefferson Scale of Physician
Empathy (JSE) and the International Reactivity Index (IRI), and patients completed the Con-
sultation and Relational Empathy scale (CARE), and the Jefferson Scale of Patient’s Per-
ceptions of Physician Empathy (JSPPPE).
Results
We did not observe any significant correlation between total self-assessed empathy and
patients’ perceptions. We observed a small correlation (r = 0,3, P<0,05) between the sub-
PLOS ONE | https://doi.org/10.1371/journal.pone.0198488 May 31, 2018 1 / 13
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OPEN ACCESS
Citation: Bernardo MO, Cecı´lio-Fernandes D, Costa
P, Quince TA, Costa MJ, Carvalho-Filho MA (2018)
Physicians’ self-assessed empathy levels do not
correlate with patients’ assessments. PLoS ONE 13
(5): e0198488. https://doi.org/10.1371/journal.
pone.0198488
Editor: Alejandro Arrieta, Florida International
University, UNITED STATES
Received: February 12, 2018
Accepted: May 20, 2018
Published: May 31, 2018
Copyright: ©2018 Bernardo et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: Funding was provided by Fapesp -
Fundac¸ão de Amparo a Pesquisa do Estado de São
Paulo (2016/11908-1) to Dr Marco Antonio
Carvalho-Filho. The funder had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
dimension Perspective Taking-JSE and JSPPPE. JSPPPE and CARE had a positive and
moderate correlation (0,56; p<0,001). Physicians’ gender and sector influenced the
JSPPPE score. Sector, medical specialty and the nature of the appointment (initial versus
subsequent) influenced the CARE measure.
Conclusions
The lack of correlation between self-assessed empathy levels and patients’ perceptions
suggests patients be included in the process of empathy evaluation.
Practice implications
Training strategies aiming the development of empathy should include patients’ evaluations
and perspectives.
Introduction
Empathy is a fundamental humanistic component of patient care [1] which facilitates efficient
and patient-centered clinical encounters [2,3]. Positive associations have been found between
physicians’ self-measured empathy and patients’ outcomes, for example in LDL control and
the incidence of metabolic complications of diabetes [4,5]. Moreover, empathetic doctors are
more satisfied with their jobs and less susceptible to burnout and depression [6–9]. However, a
number of problems surround the definition, components, and measurement of empathy [10].
Empathy is multidimensional, involving affective, cognitive and behavioral components
[11]. The affective component refers to one’s ability to perceive subjectively another person’s
inner experiences and natural feelings [12]. The cognitive component of empathy relates to
the capacity to understand and view the outside world from the other person’s perspective
[12]. The behavioral component includes the predisposition and competency to adequately
create a bond with the other person together with the ability to communicate these under-
standings and feelings to reassure and comfort the other [13,14].
Despite being the principal recipient of physician empathy little work on how patients per-
ceive/report receiving empathy from their physicians has been undertaken [15]. Indeed, in the
context of doctor-patient interactions, knowledge about empathy has mostly originated from
physicians’ perspectives and has been developed from studies using self-assessment instru-
ments [16,17]. Very few studies have compared standardized patients’ measures of physicians’
empathy with physicians’ or medical students’ self-assessed empathy. Those undertaken have
reported no significant correlations [18,19]. In general, self-assessment may not correlate well
with the reality observed by others [20,21]. Measuring physician empathy is also fraught by the
variety of instruments employed which research suggests may measure differing constructs
[22,23].
Therefore, physicians’ view of their own empathy may be at worst incorrect and at best
biased. For instance, social expectations about what is considered a desirable attitude for doc-
tors may influence the way physicians appreciate themselves [22]. It would seem crucial, there-
fore, that any evaluation of physician empathy should consider patients’ perspectives. This
would allow a more concrete understanding of physician/patient interaction [23].
However, empowering patients to measure physicians’ empathy is not simple nor easy.
There are constraints related to time, and logistics to fit patients’ assessment on routine clinical
Patients’ assessment of physicians’ empathy
PLOS ONE | https://doi.org/10.1371/journal.pone.0198488 May 31, 2018 2 / 13
activities [24]. Moreover, a cultural change is needed to make doctors aware of the need to
consolidate the role of the patient as a legitimate evaluator of physicians’ behaviors and atti-
tudes [25].
In addition, patients’ perspectives can also be influenced by different factors beyond the
direct interaction with their doctors. These factors include the prevailing physical ambiance,
the patient’s or physician’s gender, and the duration or context of the consultation [26,27]. A
recent Argentinean study showed that age, education level, South American ascendancy and
type of hospital influenced patients’ perceptions of physicians’ empathy [28].
Despite the importance of their views, to the authors’ knowledge, only three studies directly
compared physicians’ perceptions of their own empathy and patients’ perceptions of physicians’
empathy, using validated psychometric scales. [29–31]. Two studies reported no significant cor-
relation, but both studies had small samples of physicians (n = 27 and n = 29), and the number
of patients was not reported [29,30]. A third study found a positive and significant correlation,
but the samples of physicians and patients were small (36 physicians and 90 patients) [31]. Since
medical training at both graduate and post-graduate levels relies heavily on self-assessed mea-
sures of physicians’ empathy, more studies are needed to understand in what extent self-
assessed empathy matches with patients’ perspectives. This understanding would be particularly
relevant to guide feedback and further professional development of doctors.
Our study set out to investigate the relationship between physicians’ self-assessed empathy
levels and patients’ measures of physicians’ empathy. We also investigated whether patients’
assessments could be influenced by patient socio-demographics and consultation contextual
factors in the physician-patient interaction. These factors included gender, medical specialty,
and aspects of the consultation, such as location and whether this was an initial or subsequent
consultation. This work was undertaken in public and private hospital settings in Brazil.
Based on the assumption that self-assessment is frequently not accurate [20], we hypothe-
sized that self-assessed empathy levels would be poorly correlated with patients’ perceptions.
Empathy has several dimensions which may not be fully covered by one instrument. There-
fore, we used two instruments that capture different constructs of empathy [22] to measure
self-assessed physician empathy and two instruments to measure patients’ perspectives of phy-
sicians’ empathy.
For physicians’ self-assessment we used the Jefferson Scale of Empathy (JSE) and the Inter-
personal Reactivity Index (IRI). These instruments were developed with different perspectives
[32]. The JSE was specifically designed to measure empathy in the healthcare context and
focuses on the cognitive aspects of physician empathy [29]. IRI was developed to measure
empathy in the general population and assesses both the affective and cognitive components of
empathy [27]. An international study demonstrated that these two instruments capture differ-
ent constructs of empathy [22].
The instruments to evaluate patients’ perspectives of physician empathy were the Jefferson
Scale of Patient’s Perceptions of Physician Empathy (JSPPPE) and the Consultation and Rela-
tional Empathy Scale (CARE). The JSPPPE was developed assuming empathy to be a “predom-
inantly cognitive attribute” [33].
The CARE measure was developed to capture patients’ expectations of clinical encounters
[34,35]. Both instruments were based on extensive literature reviews, and the latter was also
based on in-depth interviews with a group of ambulatory patients. We hypothesized that
JSPPPE and CARE could also reflect patients’ views of the different components of empathy.
To explore the relationship between patients’ and physicians’ assessments of physician
empathy we asked the following research questions:
1. How do scores on patient scales (JSPPPE and CARE) relate to each other?
Patients’ assessment of physicians’ empathy
PLOS ONE | https://doi.org/10.1371/journal.pone.0198488 May 31, 2018 3 / 13
2. Do the patients’ scores vary according to contextual aspects of the consultation (gender,
location, specialty or initial versus subsequent consultations) beyond the specific doctor/
patient interaction?
3. Do self-assessed physicians’ scores on the IRI and the JSPE scales correlate with patients’
scores obtained with the JSPPPE and CARE scales?
Methods
Participants
Physicians. All physicians in two clinics (one private, one public) located in the same
multi-specialty medical center in Sorocaba, São Paulo, Brazil (n = 60) were invited to partici-
pate, and 51 agreed to do so. Those who declined to participate mentioned time constraints
(n = 6) and not feeling comfortable taking part (n = 3). All participants were experienced phy-
sicians with an average of 18,8 years (±11,7/range 3–43) years of practice and comprised inter-
nists (n = 24), surgeons (n = 10) and radiologists (n = 17). Table 1 present physician’s
demographic information, local of work, their specialties, and self-assessed empathy levels
(Table 1).
Patients. Adult patients (n = 1100) under the supervision of the participating physicians
were randomly invited to join the study and 1050 decided to participate. Fig 1 gives the patient
flow chart: 50 patients declined because time constraints and feeling uncomfortable comment-
ing on their doctors. A further 105 were excluded because they were under 18 years-old, not
able to complete the instrument, or illiterate. The total number of patients was 945, of whom
639 were females (average age 50,5 years-old ±14,1/range 19–84) and 306 males (average age
50,4 years-old ±14,8/range 18–94). Between 18 and 25 patients of each of the participating
doctors took part in the study. (The primary objective was to have 25 patients per doctor.)
Administration procedures
Paper questionnaires were used and patients were approached by an independent researcher,
with no responsibility or connection to their care. The patients were instructed to fill the scales
and to hand them back to the researcher in a closed envelope. All forms were anonymized.
Patients and physicians had access only to their own aggregate results at the end of the study.
The questionnaires were returned directly to the researchers in closed envelopes and the
results were inserted into a data system by a designated person, who did not have access to
patients’ names.
Table 1. Descriptive and comparative statistics for physicians’ characteristics.
Physicians’ characteristics N (%) JSE IRI
Gender Male 35 (69%) 116,3 ±16,5 57 ±10,1
Female 16 (31%) 123,3 ±9,0 61,6 ±9,1
Sector Private 39 (76%) 119,2 ±12,7 58,3 ±9,6
Public 12 (24%) 116,2 ±20,9 58,9 ±11,5
Specialty Internal Medicine 24 (47%) 120,4 ±11,8 58 ±10,9
Surgery 10 (20%) 117,4 ±23,2 57,3 ±10,2
Radiology 17 (33%) 116,4 ±13,3 59,7 ±8,8
Total 51 118,5 ±14,9 58,4 ±9,9
JSE = Jefferson Scale of Physician Empathy; IRI = Interpersonal Relative Index.
https://doi.org/10.1371/journal.pone.0198488.t001
Patients’ assessment of physicians’ empathy
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Instruments
Physicians. We used the Portuguese versions of the Jefferson Scale of Empathy (JSE) and
the Interpersonal Reactivity Index (IRI assess physicians’ self-assessment of their empathy.
Both self-assessment instruments have a mixture of positive and negative items and both ask
respondents to rate the extent to which they agree or disagree with statements. JSE has 20
items each rated on a 7-point Likert scale and comprises three subdimensions, Perspective
Taking, Compassionate Care and Standing on the Patients’ shoes [36]. The IRI has 28 items
each rated on a 5-point Likert scale and comprises four distinct dimensions: Perspective Tak-
ing, Empathic Concern, Personal distress and Fantasy [37].
Patients. We used the Jefferson Scale of Patient’s Perceptions of Physician Empathy
(JSPPPE) and the Consultation and Relational Empathy scale (CARE) to measure physicians’
Fig 1. Patient´s flowchart.
https://doi.org/10.1371/journal.pone.0198488.g001
Patients’ assessment of physicians’ empathy
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empathy as perceived by their patients. Both instruments ask patients to rate the extent they
agree or with statements and both are administered at the end of the clinical consultation. The
JSPPPE has 5-items rated on a 7-point Likert scale [29,30]. As no Portuguese version was avail-
able it was translated into Portuguese by four bilingual physicians and checked for accuracy by
a professional translator. The developers of the original English version supervised the process
[38,39]. Researchers interviewed voluntary patients (n = 100) to verify whether the final ver-
sion was understandable. The CARE instrument has 10 items which address different compo-
nents of empathy (affective, cognitive and behavioral). Each item is measured on a 6-point
Likert scale. We used the Portuguese version of CARE scale, which was translated by Scarpel-
lini in 2014 [40]. We performed an analysis of the structure of the scale, as this has not done
before.
Empathy scores. The total score of JSPPPE and CARE is the sum of all item scores and all
the items must be answered to be included. The overall score for the JSE is the sum of all items
scores, but the negative items are transformed into positive ones for analyses; the higher the
total score, the higher the levels of empathy. Similarly, negative items on the IRI were trans-
formed into positive scores. We used the subscale scores for both the JSE and IRI. In accor-
dance with other studies of physician empathy we used the total score for the JSE. For the
purposes of consistency in the analysis we also used the total score for the IRI.
Statistical analyses
We investigated the psychometric properties of the JSPPPE and CARE instruments. The abso-
lute values of skewness and kurtosis for all items were within the acceptable range of the nor-
mal distribution (between -2 and 2) for both JSPPPE and CARE scales, with the exception of
item number 5 of the JSPPPE scale. Subsequent analyses demonstrated that there was no dif-
ference when using the raw and transformed data in the outcome of the analysis. Therefore,
we only present the outcomes of parametric analyses using the raw data. Cross-validation of
the JSPPPE and CARE was assessed using a holdout method with Principal Component Anal-
ysis and Confirmatory Factor Analysis, applied to two sub-samples (A and B), obtained from
randomization of the full sample. An exploratory principal component analysis with Principal
Axis Factoring was applied to sub-sample A (n = 474). A confirmatory factor analysis with
Maximum Likelihood estimation was applied to sub-sample B (n = 471). To assess the best
confirmatory factor model, we used the following goodness of fit: Chi-square statistics, Com-
parative Fit Index (CFI), Tucker-Lewis Index (TLI) and Root Mean Square Error of Approxi-
mation (RMSEA). The Chi-square statistics was used to assess the overall fit and discrepancy
between the sample and the model. Both CFI and TLI were considered optimal with values
above 0,90. Optimal RMSEA is close to zero. Reliability was calculated using Cronbach Alpha.
We used Pearson correlation to investigate the relation between physicians’ self-report
empathy and the empathy perceived by their patients. Since the Jefferson Scale of Empathy
(JSE) and the Jefferson Scale of Patient’s Perceptions of Physician Empathy (JSPPPE) were
developed by the same researchers using similar words in many questions, we also have ana-
lyzed the intra-class correlation between the items of the JSPPPE and JSP. We have analyzed
the four from the JSPPPE with items 2 and 10 from JSE; the item 3 from the JSPPPE with item
16 from JSE; and the item 1 from JSPPPE with items 3, 6 and 9 from JSE. We compared
patients’ assessments in respect of their gender and sector (public vs. private) using t-tests and
we investigated differences between medical specialty by means of an analysis of variance
(ANOVA).
Data were analyzed using IBM-SPSS 21.0 and AMOS 18. The latter was only used for the
confirmatory factor analysis.
Patients’ assessment of physicians’ empathy
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Ethical approval
We obtained ethical approval for this study from the Research Ethics Committee of the Faculty
of Medical Sciences–São Paulo Catholic University in June 2015 (CAAE = 46056115.0.0000.
5373). All participants gave written informed consent before data collection began.
Results
Cross-validation of instruments
There are no validation studies in the respective contexts of the instruments used in this study
to assess physician empathy as perceived by the patient participants. Therefore, we included a
validation step.
JSPPPE
The necessary assumption of Principal Component Analysis (PCA) was met with a
KMO = 0,781, and Bartlett’s Test of Sphericity was significant (p <0,001). The PCA demon-
strated a unidimensional factorial structure with an eigenvalue of 3,42, explaining 68,9% of the
variance; factor coefficients ranged from 0,84 to 0,87.
Confirmatory Factor Analysis (CFA) revealed that the base model (model A) for the
JSPPPE demonstrated poor fit index values, based on the χ2/df ratio, the Comparative Fit
Index (CFI) and Root Mean Square Error of Approximation (RMSEA). When the correlation
between the items’ errors was added (model B), the model achieved a satisfactory level of
model fit (Table 2).
Cronbach’s Alpha for the total sample was 0,88, indicating that the instrument is reliable.
CARE
The necessary assumptions of PCA were meet with a KMO = 0,849, and Bartlett’s Test of Sphe-
ricity was significant (p <0,001). The Principal Component Analysis demonstrated a unidi-
mensional factorial structure with an eigenvalue of 7,66, explaining 76,7% of the variance;
factor coefficients ranged from 0,77 to 0,91.
Confirmatory Factor Analysis (CFA) revealed that the base model for the CARE scale
(model A) displayed poor fit index values, based on the χ2/df ratio, the Comparative Fit Index
(CFI) and Root Mean Square Error of Approximation (RMSEA). When the correlation
between the items’ errors was added (model B), the model achieved a satisfactory level of
model fit (Table 3).
Table 3. Fit indices for the CARE scale.
χ
2
(df) Sig. Ratio χ
2
/df TLI CFI RMSEA (HI90)
Model A χ
2
(35) = 307; p<0,001 8,771 0,940 0,954 0,129 (0,142)
Model B χ
2
(30) = 126; p<0,001 4,200 0,975 0,984 0,083 (0,098)
https://doi.org/10.1371/journal.pone.0198488.t003
Table 2. Fit indices for the JSPPE.
χ
2
(df) Sig. Ratio χ
2
/df TLI CFI RMSEA (HI90)
Model A χ
2
(5) = 61,38; p<0,001 12,276 0,932 0,966 0,155 (0,191)
Model B χ
2
(3) = 5,66;
p = 0,129
1,888 0,995 0,998 0,043 (0,098)
https://doi.org/10.1371/journal.pone.0198488.t002
Patients’ assessment of physicians’ empathy
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Cronbach’s Alpha for the total sample was 0,97, indicating that the instrument is reliable.
Concurrent validity
The correlation between the JSPPPE and CARE latent variables was moderate (0,56) and sig-
nificant (p<0,001), indicating that both scales share 32% of the same measurement.
Contextual elements influencing patients’ perspectives (Table 4)
Patients’ gender did not affect their assessments on either the CARE or the JSPPPE scales.
However, patients’ assessments of female physicians were higher on the JSPPPE scale but not
on the CARE scale.
Patients in the private sector perceived their physicians’ empathy to be significantly higher
than those in the public sector on both scales.
There was a significant difference regarding medical specialty for the CARE measure (F
(2,942) = 7,426 –p<0,005), but not for the JSPPPE (F (2,942) = 2,904 –P>0,05).
Subsequent consultations resulted in a higher score for empathy on the CARE measure, but
no difference was observed with the JSPPPE scale when compared to initial consultations.
Associations between the patients’ and the physician self-assessed empathy
measures
As the number of patients per doctor differed we averaged the patients’ responses to their par-
ticular physician before conducting the Pearson correlation analysis. All correlations between
patients’ and physicians’ perspectives were not significant, with one exception (Table 5). The
score of the JSPPPE positively and significantly correlated with the sub-score of the Perspective
Taking dimension of the JSE. Also, the outcomes regarding the intra-class analyses showed a
low agreement between the empathy perception of the physician and the patient (ranging
from 0,151 to 0,197). The exception was item 1 from JSPPPE with items 3, 6 and 9 from JSE in
which the analyses did not have enough variance.
There were no significant correlations between the total scores and the sub-scores of IRI
and JSE.
Table 4. Descriptive and comparative statistics for patient’s characteristics and measurements.
N % JSPPPE
a
P CARE
b
P
Patient’s Gender . Male 306 32% 30,1 ±5,8 p = 0,064 43,1 ±7,5 p = 0,302
. Female 639 68% 30,8 ±5,4 42,6 ±7,8
Physician’s Gender . Male 692 73% 30,2 ±5,7 p<0,001 42,5 ±7,7 p = 0,124
. Female 253 27% 31,6 ±5,2 43,4 ±7,8
Sector . Private 810 86% 31,0 ±5,1 p<0,001 43,5 ±7,3 p<0,001
. Public 135 14% 28,2 ±7,4 38,2 ±8,5
Specialty . Internal Medicine 437 31,1 ±5,3 p = 0,055 43,8 ±7,5 p<0,001
. Surgery 177 30,0 ±6,0 42,3 ±7,8
. Radiology 331 30,1 ±5,7 41,5 ±7,8
Appointment . Initial 543 57% 30,4 ±5,5 p = 0,266 42,3 ±7,6 p = 0,031
. Subsequent 402 43% 30,8 ±5,7 43,4 ±7,8
Total 945 100% 30,6 ±5,6 42,8 ±7,7
JSSPPE = Jefferson Scale of Patients Perceptions of Physician Empathy; CARE = Consultation and Relational Empathy Scale.
https://doi.org/10.1371/journal.pone.0198488.t004
Patients’ assessment of physicians’ empathy
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Discussion and conclusion
Discussion
The present study was developed with the underlying premise that patient involvement is vital
to evaluate physician’s empathy. Our study indicates that the JSPPPE and CARE scales may
capture different aspects of how patients perceive their physician’s empathy but that they share
a common element. Both are validated measures which should be more widely employed.
Our study also revealed that contextual factors influenced patients’ perspectives of the
empathy they received. We found a small but significant difference in CARE measures among
different medical specialties, which was not found with the JSPPPE. CARE was also able to
capture differences between empathy measurements from initial and subsequent consulta-
tions. It suggests that the CARE measure can capture more subtle nuances of patients’ interac-
tions with their doctors, confirming its value to address relational components of empathy.
Another interesting aspect of our results is the influence the sector (public vs private) had on
patients’ scores. In Brazil, the Health System is divided into a public sector, supported by the
government, and a private sector, maintained by private profit-driven Health Insurance Com-
panies. Our results show that patients in the private sector tend to give higher empathy scores
to their doctors. Two interpretations are possible: the doctors are consciously or unconsciously
modulating their behavior, or there are other elements influencing patients scores beyond the
direct interaction with their doctors. Regarding the first possible interpretation, a study with
German doctors showed a positive impact of financial incentives on patients’ perceptions of
physicians’ empathy measured by the CARE scale, which is aligned with our findings [26].
Considering the second possibility, a similar survey in Argentina showed opposite results, with
patients scoring higher physicians from the public sector. The authors of this second study
hypothesized that patients were expecting less from the doctors working in the public sector
[28]. It could suggest that different cultural expectations regarding the public or private health
systems can interfere in patient’s perceptions.
This study involved patients and doctors exclusively from one institution and nationality.
Extrapolations of findings to other cultures need to be cautious, as patient definitions and clas-
sifications of empathy are culturally sensitive. Indeed, patients from different cultures can have
disparate expectations regarding an empathetic doctor and doctors themselves can vary their
understandings about how to demonstrate empathic concern or shared understanding [41]. In
Table 5. Pearson correlations between empathy measurements: Physicians’ and patients’ perspectives.
Physicians’ Perceptions (n = 51) Patients’ Perceptions’ (n = 945)
JSPPE CARE
JSE Perspective Taking 0,3010,04
Compassionate care 0,07 0,03
Standing in the Patient’s Shoes 0,10 -0,07
Jefferson Total 0,23 0,01
IRI Perspective Taking 0,14 -0,09
Empathic concern 0,06 0,14
Personal Distress -0,02 -0,04
Fantasy 0,08 0,04
IRI Total 0,12 0,02
p<0.05. Note: Perspective Taking and Empathic concern are other-oriented dimensions of IRI, while Personal
Distress and Fantasy are self-oriented.
https://doi.org/10.1371/journal.pone.0198488.t005
Patients’ assessment of physicians’ empathy
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addition, the interpretation of the instrument items may have cultural nuances that the study
did not expose, as that went beyond the predetermined goals. For instance, the item “How was
the doctor showing care or compassion” (CARE scale) can be differently understood by a
European, South American or Asian patient. Subsequent research should clarify the influence
of cultural specificities in our findings.
An important objective of our study was to evaluate associations between widely used phy-
sician self-assessed empathy measures (JSE and IRI) and patient measures (JSPPPE and
CARE) collected from the respective patients. The main finding was that there were no corre-
lations between physician and patient measures. Overall, this study confirmed that self-
assessed physician measures: JSE and the IRI, did not accord with the perceptions of their
patients about their empathy as collected with the CARE and the JSPPPE. The main implica-
tion of this study is the confirmation that inferences about physician empathy based on self-
assessment measures should not be taken as representative of patient perceptions.
The correlation of JSPPPE with the Perspective Taking dimension of JSE is in accordance
with its development, which aimed the cognitive aspect of empathy [33]. Both instruments
were developed by Hojat et al and use similar wording [29]. On the other hand, the CARE
items were developed based on in-depth interviews with patients and further refined through
interviews with patients, physicians and experts [34,35]. The CARE items aim to capture the
internal atmosphere of the consultation; valuing empathy in the context of listening, reassur-
ing and planning, from a patient perspective [34]. The lack of correlation of CARE and self-
assessed measures of empathy gives insight into how inefficient self-assessment could be in
capturing patients’ subjective experiences.
Conclusion
Patients’ assessment of physicians’ empathy must be valued in empathy research and also in
clinical care evaluation. More research is needed to investigate better how the different compo-
nents of empathy and the various elements of the clinical encounter influence patient care and
satisfaction. Physicians’ self-assessment of their own empathy is insufficient to evaluate the
complexity of the interaction between doctors and patients. Insights from the empowerment
of patients can give opportunities to develop training strategies to physicians willing to
improve their clinical interactions with patients. Health care providers can also use this data to
bring the multi-professional team together to discuss how to implement changes in patient
care that could foster a patient-centered approach. Future research should explore what
patients demand for their physicians’ behaviors and attitudes to acknowledge them as
empathic doctors.
Practice implications
Our data corroborate the understanding that empathy is a complex construct that should be
evaluated through different lenses, depending on the goal of the evaluation process. If the
intention is to create awareness among clinical doctors or medical students about the clinical
value of empathy, self-assessment may represent a good strategy, providing there is awareness
of the advantages and disadvantages of the instruments used. If, however, the purpose is to
improve clinical care, then education and other interventions based on self-assessment instru-
ments may not be enough because self-assessment cannot capture the reality as perceived by
patients. As such, the curricular design for teaching and learning empathy and the interna-
tional studies about medical students’ empathy development should be revisited, and there are
implications for curricula and for teaching and learning empathy, of international studies
about the development of undergraduate medical students’ empathy [42] and of studies
Patients’ assessment of physicians’ empathy
PLOS ONE | https://doi.org/10.1371/journal.pone.0198488 May 31, 2018 10 / 13
evaluating the impact of programs to enhance empathy [43] should be revisited. Not only is
selecting and applying the appropriate instrument to the research or practical question under
investigation important but also, where ever possible, including patients is crucial.
Our contribution to the field is to show that the patient scales JSPPPE and CARE could be
measuring different components of empathy and that other elements of the clinical encounter
affects patients’ perceptions of their physicians’ empathy.
Limitations
Unfortunately, our study was not designed to identify and to discriminate all the possible ele-
ments that could interfere with patients’ perceptions. However, we could hypothesize that
time spent on consultation, time waiting for consultation, the general comfort of the environ-
ment, interactions with other health care professionals, the sense of the dignity of the process
of care, and also heuristic bias related to the act of paying for the consultations are all possible
factors. Further research is necessary to clarify these relations and how they can affect patients’
perceptions of physicians’ empathy, so allowing a more meaningful interpretation of data orig-
inated from these measurements. Also, our data were collected in a single center which can
prevent generalization of the results. Although the number of interviewed patients was ade-
quate, the number of doctors participating was small.
Supporting information
S1 Data.
(XLSX)
Acknowledgments
The authors would like to thank all the patients and physicians who contributed to this work.
Author Contributions
Conceptualization: Monica Oliveira Bernardo, Manuel João Costa, Marco Antonio Carvalho-
Filho.
Formal analysis: Dario Cecı
´lio-Fernandes, Patrı
´cio Costa, Manuel João Costa.
Investigation: Monica Oliveira Bernardo, Marco Antonio Carvalho-Filho.
Methodology: Monica Oliveira Bernardo, Dario Cecı
´lio-Fernandes, Patrı
´cio Costa, Manuel
João Costa, Marco Antonio Carvalho-Filho.
Project administration: Monica Oliveira Bernardo, Marco Antonio Carvalho-Filho.
Supervision: Thelma A. Quince, Manuel João Costa, Marco Antonio Carvalho-Filho.
Validation: Monica Oliveira Bernardo, Thelma A. Quince, Marco Antonio Carvalho-Filho.
Writing – original draft: Marco Antonio Carvalho-Filho.
Writing – review & editing: Monica Oliveira Bernardo, Dario Cecı
´lio-Fernandes, Thelma A.
Quince, Manuel João Costa, Marco Antonio Carvalho-Filho.
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