Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences
Introduction
The interlocked
relationship between mind and body has increasingly resulted in modern medical
practices’ use of biopsycho- social and patient-centered models that emphasize
various psychological and environmental factors [1-3]. In particular,
patientcentered approaches are characterized by a serious consideration of
patients’ views, preferences, values, and economic resources [4]. In addition
to positively affecting various medical outcomes and patient satisfaction
levels, patient-centered approaches have been shown to reduce the use of
healthcare services, diagnostic tests, prescription, referral, and
hospitalization, along with total annual healthcare expenses [5,6]. Given that
visiting a physician may in itself induce considerable worry and anxiety in patients
[7], physicians’ interpersonal communication competencies and styles can
directly influence patients’ self-expression by providing them with a sense of
being listened to and understood, which in turn acts on several factors such as
patients’ anxieties about their illness, hope for a cure, and adherence to the
treatment [8]. In the treatment of somatic diseases, talking about disease
perception reveals the therapeutic effect of talking [9]. In this regard,
empathy refers to a “cognitive quality” that by its interpersonal nature
involves a physician’s capacity to understand and communicate about patients’
experiences, anxieties, and viewpoints [10,11]. Empathy has been reported to
reduce patients’ anxiety and stress levels and to considerably influence positive
health outcomes [12]. More specifically, physicians’ empathy has been shown to
be significantly associated with diabetes patients’ clinical outcomes and
result in shorter periods of the common cold [13-16].
As these studies point
to a concrete and measurable effect in the immune system induced by a
positively experienced subjective feeling, they further substantiate the strong
relationship between mind and body. Among the factors that have transformed the
physician-patient relationship from Emanuel’s paternalistic model to a
conciliatory model are the rising socioeconomic level with social development,
medical technologies that improve the quality of life, the development of
patients’ rights, patients’ greater knowledge of their rights, developments in
the concept of seeking rights, physicians and patients putting more value on
human rights, the widespread implementation of legal responsibilities and
sanctions on physicians and patients, legal obligations, the application and
dissemination of the understanding of quality in healthcare, rising health
literacy, and the existence of complaint mechanisms through communication
centers of public institutions [17]. Studies supporting patients’ empathy
expectations in Turkey [18-23] as well as focusing on patient-physician
communication show that empathy stands out as a very important element,
sometimes alone and sometimes together with other variables [24-26].
There are many studies
that evaluate empathy education and empathetic attitudes of students in the basic
medical education process in medical schools and investigate how empathy can be
developed [27-33]. As another significant variable of this study, cognitive
flexibility is regarded as a form of fluid intelligence marked by the skill of
providing alternative solutions to different situations [34]. This construct is
closely related to the neuro-psychological concepts of role- and
perspective-taking, which entail numerous cognitive flexibility dimensions such
as understanding others, selecting appropriate behavior, thinking about and
generating different ideas, possessing a repertoire for different responses,
and exchanging ideas with others in decision-making [35]. Literature on
cognitive flexibility related to personnel working in the healthcare field is quite
limited. A study on nurses found that coping skills and flexibility were
positively correlated with psychological adjustment [36]. A study of medical
students and residents showed that incorporating cognitive flexibility and
perspective-taking skill instruction has implications for reducing conflict and
stress, as well as improving wellness levels [37]. Empirical studies
demonstrate that increased cognitive flexibility is linked to reduced levels of
experiencing social difficulties, stress, depression, anxiety, and rage
[38-42]. Conversely, cognitive flexibility has been found to be related to
positive personal outcomes such as critical thinking, selfesteem, social
skills, self-competence, and coping with stress [43- 45].
Although limited amount
of evidence exists in the literature, there are several empirical studies that
substantiate the relationship between empathy and cognitive flexibility. In one
major example, neurological patients with various etiologies and cerebral
lesions were found to manifest significantly lower empathy than healthy normal
adults. The same study found significant correlations, ranging from 0.5 to 0.6,
between cognitive flexibility and empathy scores [46]. These data support the
idea that cognitive thinking may be closely linked to empathic behavior either
via granting a precognitive skill or by being part of another common basic
process. The present study is designed to make comparisons between Turkish
practitioner and specialist physicians in terms of empathy, cognitive flexibility,
and interpersonal relations styles. In so doing, it tests the question of
whether practitioners’ long-term interactions with their enrolled patients
(i.e. spending more time with them, knowing them better) or specialists’ longer
training histories are correlated with increased empathy and cognitive
flexibility levels.
Methods
Participants
It is included family
physicians, who have completed 6 years of medical training and specialists who
have completed an additional 5 years. Family physicians see the patients
registered with them and specialists see patients who can make an appointment
anytime and anywhere. Inclusion criteria for data collection were determined as
for specialists who work as clinician. Branches of specialists: 5 orthopedics, 8
chest diseases, 1 neurology, 4 obstetrics, 3 infectious diseases, 2 internal
medicine, 1 physical therapy, 1 pediatric, 3 ENT, 2 urology. General
practitioner work as clinician. Thus, the sample of the present study comprises
60 participants, i.e. 30 practitioners and 30 specialists. Demographically, 40%
of the practitioners and 47% of the specialists were women. Additionally, 90%
of the practitioners and 97% of the specialists were married. The age average
for practitioners and specialists was 45.5 and 43.2, respectively. As mentioned
above, participants’ working posts involved family health centers and state or
training and research hospitals. Paper-and-pencil questionnaires were filled
out by volunteer participants themselves in the major cities of Istanbul and
Ankara between January and April 2019.
The questions that the
study aims to measure in terms of the variables included are as follows:
Do long-term interaction
and being familiar affect physicians’ interpersonal relationship styles?
Does residency training
affect specialist’ relationship styles?
Assessment Instruments
To address its research
questions, this research employed the Jefferson Scale of Physician Empathy, the
Cognitive Flexibility Inventor, the Interpersonal Relationship Scale, and a
sociodemographic form.
Jefferson scale of physician empathy
The Jefferson Scale of
Physician Empathy (JSPE) is a 20-item, 7-point Likert-type scale. In a sample
of medical doctors, its internal consistency was found to be around .80. In the
Turkish context, this scale was adapted by Malkondu in 2006 and its validity-reliability
study was done on a sample of dentists [47].
Cognitive flexibility inventory
Developed by Dennis and
Vander, the Cognitive Flexibility Inventory involves 20 questions and two
subscales entitled “alternatives” and “control” [28]. The alternatives subscale
comprises 13 items that tap into the extent to which an individual is able to
find alternative solutions to difficult conditions or can form alternative
explanations for life situations and people’s behaviors. The control subscale
is constituted by items that measure to what extent these predicaments can be
controlled [48]. The Cronbach’s alpha values for alternatives and control
subscale were reported as .91 and .84, respectively. Higher scores are
indicative of increased cognitive flexibility [28]. Validity and reliability
research for the scale’s Turkish version was undertaken, who found Cronbach’s
alpha values of .90 for the whole scale, .89 for the alternatives subscale, and
.85 for the control subscale.
Interpersonal relationship scale
Developed by this
31-item, 3-point Likert-type scale assesses individuals’ interaction styles
with others. Two subscales measure nurturing and restraining styles,
respectively. Nurturing relations involve skills such as expressing one’s needs
in an open manner, treating the other person with a respectful and accepting
style, and employing a constructivist discourse. Conversely, restraining
communication styles are marked by behaviors such as selfrighteousness,
condescension, short temper, verbal abuse, and mockery. The scale has been used
in many studies and evidence has been obtained that it is valid and reliable
[49-52] Subscales for nurturing styles, in turn, tap into open and respective
styles, while the restraining styles subscale further comprises egocentric and
condescending styles. The internal consistency coefficient for the whole scale
was measured as .79. Cronbach’s alpha values for open, respectful, egocentric,
and condescending styles were .73, .70, .56, and .78, respectively.
Results
As reassessed from the
data, the Cronbach’s alpha coefficient for the empathy scale turned out to be
.847, while the cognitive flexibility subscales of control and alternatives had
internal consistency values of .653 and .749, respectively. The interpersonal
relationship subscales’ alpha coefficients ranged from 0.653 to 0.749. In terms
of between-group comparisons, Mann-Whitney U tests indicated that, although
specialists’ empathy level was higher than practitioners, the difference was
not statistically significant. With respect to cognitive flexibility
comparisons, Mann-Whitney U and t-tests substantiated that only the cognitive
flexibilityalternatives subscale was significantly higher in specialists than
practitioners. The associated values for these comparisons are shown in Tables
1,2. Interpersonal relationship style comparisons centered on nurturing
(open-respectful) and restraining (ego centric-condescending) styles. As scores
for open and egocentric styles were normally distributed for both groups,
t-tests were employed for comparisons. Conversely, distributions for respectful
and condescending styles were not normally distributed. Thus, the Mann-Whitney
U test was preferred for comparisons in these domains. Accordingly, results
indicated that specialists received significantly higher scores than
practitioners in nurturing styles and significantly lower scores in restraining
styles [Table 3].
Table 1: Comparison
of empathy levels between specialists and practitioners.
According to the
Mann-Whitney U test, although specialists’ empathy levels were higher than
practitioners’, this difference was not statistically significant, (p>0.05).
Table 2: Comparison
of cognitive flexibility levels between specialists and practitioners.
*p<0.05
According to the
Mann-Whitney U and t-tests, alternatives subscale was the only statistically
significant difference, and scores were higher for specialists, (p<0.05).
Table 3: Comparison
of interpersonal relationship styles between practitioners and specialists.
*p<0.05
According to
Mann-Whitney U and t-tests, significant differences were found in terms of
open, respectful, and condescending styles between practitioners and
specialists. Specifically, specialists displayed higher open and respectful
style scores and lower condescending style scores.
Spearman-Brown
correlational analyses revealed a significant positive association between
empathy and cognitive flexibility for practitioners. Similarly, for this group,
the relationship between empathy and respectful relationship styles was also
significantly positive, while the correlation between empathy and condescending
styles was significantly negative [Table 4]. Specialists’ correlations between
empathy and cognitive flexibility and relationship styles were not significant
[Table 5]. Regarding correlations between cognitive flexibility and
relationship styles, for practitioners, control and alternatives subscales were
moderately associated with respectful styles. For specialists, cognitive and
alternatives subscales were significantly related to open styles. For this
group, an alternatives subscale was also moderately related to respectful
styles. These significant positive associations are shown in Tables 6 and 7,
respectively. Gender and marital status were not significantly related to
specialists’ or practitioners’ empathy tendencies, relationship styles,
cognitive flexibility total, or subscale scores. For practitioners, having
longer careers contributed significantly to increased empathy, cognitive
flexibility levels, and nurturing styles. For this group, age and cognitive
flexibility was also positively related. For specialists, age and working
duration were not significantly correlated with empathy levels, relationship
styles, or cognitive flexibility levels. These results are shown in Table 8. According
to the Spearman-Brown analysis, significant moderate associations were found
between cognitive flexibility alternatives and respectful and condescending
styles that were positive and negative in nature, respectively. There was also
a positive moderate correlation between cognitive flexibility control and
respectful style.
Table 4: Correlations
between empathy and cognitive flexibility and empathy and interpersonal
relationship styles in practitioners.
*p<0.05
According to the
Spearman-Brown analysis, positive significant correlations were found between
empathy and cognitive flexibility control and alternatives subscales. Empathy
was also positively related to respectful styles. The sizes of these relations
were moderate. Another moderate correlation was found between empathy and
condescending styles that was negative in nature.
Table 5: Correlations
between empathy and cognitive flexibility and empathy and interpersonal
relationship styles in specialists.
Table 6: Correlation
between cognitive flexibility and interpersonal relationship style in
practitioners.
*p<0.05
According to the
Spearman-Brown analysis, significant moderate associations were found between
cognitive flexibility alternatives and respectful and condescending styles that
were positive and negative in nature, respectively. There was also a positive
moderate correlation between cognitive flexibility control and respectful
style.
Table 7: Correlation
between cognitive flexibility and interpersonal relationship style in
specialists.
*p<0.05
According to
Spearman-Brown correlation, the cognitive flexibility alternatives subscale was
positively and moderately related to open and respectful styles. The cognitive
flexibility-control subscale was positively correlated to open style.
Table 8: Associations
between Empathy/Cognitive Flexibility and Age/Working Duration.
*p<0.05s
Discussion and Conclusion
Discussion
Findings revealed
specialists’ empathy and cognitive flexibility scores were generally higher
than practitioners’, yet the only statistically significant dimension was
cognitive flexibilityalternatives in specialists.
In interpersonal
relations, significant differences in terms of open, respectful, and
condescending communication styles demonstrated that, compared to
practitioners, specialist physicians were again more competent in these areas.
These findings do not corroborate our tentative assumption when undertaking the
study, namely that due to familiarity and longer interactions with their
patients, practitioners should exhibit higher empathy, cognitive flexibility,
and communication competence. Our particular pattern may have stemmed from
various factors: First, with respect to cognitive flexibility, due to certain
preexisting cognitive skills, individuals who become specialists may be
predisposed to more competently assess alternatives in particular situations
and problems. Indeed, [53] proposed that the predominant characteristic of
experts is the ability to manipulate versatile mental representations, which in
turn enables them to adapt better to environmental changes and use their
knowledge more efficiently among different tasks. Alternatively, one may
consider the effect of specialists’ education in terms of both different
cognitive skills acquired and being exposed to courses on patient-doctor
interactions. It is conceivable that different specialist branches, the
cultures of hospitals and medical schools, socioeconomic status, or even cities
of residence may play a role in augmenting or hindering cognitive flexibility,
empathy, and interpersonal relationship style. In this regard, future studies
may include these variables to determine both their unique and interactive
effects for various professionals in the medical field.
Although not displaying
a statistically significant difference, higher empathy levels and interpersonal
relations competence of specialists may be linked to particular predicaments of
the medical system in Turkey. In Turkey, practitioners regularly receive a
burdensome number of registered patients. In this sense, it is reasonable to
suggest that practitioners may have developed certain emotive strategies to
mitigate the emotional burden that accompanies personal interactions with their
patients. Alternatively, the mundane and repetitive tasks of referrals to
specialists and renewing prescriptions may also hamper the tendency to develop
a genuinely empathetic understanding of patients’ problems and emotional
states. Conversely, specialists in Turkey accept additional patients in return
for extra income, which offers them an opportunity to control the overburden
they experience. These points highlight the importance of considering the
significant role that the nature of healthcare systems may play in determining
the quality of interpersonal communication and empathetic interaction. It is
particularly telling that both specialist and practitioner empathy scores in
Turkey are well below those reported by international studies, which lends
support to the idea that predicaments in healthcare systems may greatly
compromise cognitive flexibility and empathy. As compared to our scores of
101.30 for specialists and 97.63 for practitioners. Reported international
physicians’ empathy levels in human-centered and technology-centered specialty
fields as 112.9 and 106.9, respectively. Average physician empathy levels were
found to be 120 in the United States [54-60].
In another major
finding, in a practitioner sample within group analyses, the present study
substantiated empathy’s significant relation to cognitive flexibility and
interpersonal relations. These findings resonate with a prior study on Turkish
university students [52] in which, as in this study too, empathy was found to
be positively associated with open and respectful styles and negatively linked
to condescending styles. Since in our study, empathy in specialists was not
correlated to cognitive flexibility or communication style, one may consider
the idea that, for specialists, the more intermittent and impersonal nature of
doctor-patient interactions in the Turkish healthcare system enables the
acquisition of satisfactory communication skills mainly via cognitive skills.
Conversely, for health professionals such as practitioners and nurses who
interact more closely with patients, communication skills may be induced mainly
along the path of empathy.
Notwithstanding fields
or branches among health professionals, the present study can be considered a
noteworthy contribution to international research that investigates questions
regarding empathy, cognitive skills, communication, and patient outcomes for
healthcare professionals and workers at large. Indeed, a recent upsurge in
international studies started to increasingly point to relations of these
kinds. To give a few examples, prior research found a positive relationship
between empathy and interpersonal relations in nursing students [61,62] and
similarly posited positive relationships among empathy, perspective-taking,
nurturing care, and friendly-harmonious relationship types in medical students
[63]. Recently a strong relationship was suggested between empathic thinking
and perspective-taking [64]. Hence, the present study lends support to the idea
that the empathic and communicational skills of medical professionals should be
one of the major avenues of research for promoting patient outcomes [65- 67].
This study offers ideas
as to why training intervention is needed to improve communication and
interpersonal relationships, and also includes suggestions about what the
training program should cover. Some limitations should also be noted. The
rather small sample sizes, including 30 participants for each group, and
nonrandom, voluntary sampling procedures in this study should be considered
caveats preventing satisfactory representativeness and generalizations around
the globe. Additionally, variables such as doctors’ and patients’ personality
traits and cultural and socioeconomic backgrounds were excluded from analyses.
Lastly, our measuring instruments relied on self-report scales and are thus
subject to biases rooted in the conveyance of subjective experience. These
points should be taken into account by researchers while drawing cautious inferences
for future research studies.
Conclusion
All in all, this study
provides support to bio-psycho-social model patient-centered approaches and
suggests their adoption positively influences patients’ psychological, mental,
and physical health. Hence, the cultivation of an understanding recognizing the
importance of interpersonal relations, communication skills, and interaction
between the mind and body seems to be a worthwhile endeavor in the medical
field. The long-term articulation of costeffective methods in healthcare
systems – primarily training in factors promoting interpersonal relationships
such as empathy and cognitive flexibility – would positively contribute to more
efficient processes of diagnosis and therapy based on fulfilling interactions between
physicians and patients.
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