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Research ArticleOriginal Research

General Practitioners’ Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation

Stewart W. Mercer, Maria Higgins, Annemieke M. Bikker, Bridie Fitzpatrick, Alex McConnachie, Suzanne M. Lloyd, Paul Little and Graham C.M. Watt
The Annals of Family Medicine March 2016, 14 (2) 117-124; DOI: https://doi.org/10.1370/afm.1910
Stewart W. Mercer
1Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
PhD
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  • For correspondence: Stewart.Mercer@glasgow.ac.uk
Maria Higgins
1Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
MSc
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Annemieke M. Bikker
1Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
MSc
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Bridie Fitzpatrick
1Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
PhD
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Alex McConnachie
2Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
PhD
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Suzanne M. Lloyd
2Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland
BSc
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Paul Little
3Primary Medical Care, Aldermoor Health Centre, University of Southampton, Southampton, England
FMedSci
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Graham C.M. Watt
1Academic Unit of General Practice and Primary Care, Institute of Health and Well-Being, University of Glasgow, Glasgow, Scotland
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    Figure 1

    Patients’ desire for involvement in management decision making.

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    • View popup
    Table 1

    Patient Demographic and Baseline Characteristics

    CharacteristicDeprivation Area P Value
    LowHigh
    Age in y, mean (SD)50.50 (19.13)51.45 (17.07).60
    Female, No. (%)199 (66.3)223 (62.6).50
    Married/living with partner, No. (%)174 (58.6)140 (39.8)<.001
    Chronic conditions, No. (SD)1.6 (1.4)2.2 (1.9)<.001
    ≥3 Chronic conditions, No. (%)68 (22.4)131 (36.8)<.001
    Disabled by condition, No. (%)102 (34.1)182 (51.7)<.001
    Good or better rating of health, No. (%)185 (62.3)142 (40.5)<.001
    Anxiety score, mean (SD)a10.82 (3.00)11.59 (3.32).003
    Depression score, mean (SD)a5.46 (5.45)7.28 (6.59)<.001
    ≥2 Problems to discuss, No. (%)129 (42.9)192 (54.1).01
    Desire for involvement in decision making, mean (SD)a2.43 (0.61)2.05 (0.65)<.001
    • Note: P values for differences between areas of deprivation are extracted from multi-level linear or logistic regression models that include fixed effects for age and sex and a random effect for GP level.

    • ↵a Possible anxiety scores ranged from 6 to 24 (higher meaning worse anxiety), depression scores from 0 to 27 (higher meaning worse depression), and desire for involvement from 1 to 5 (where 1 means doctor alone should decide and 5 means patient alone should decide).

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    Table 2

    Characteristics of the Clinical Encounters

    VariableLevel of Deprivation Effect Size (Cohen’s d)P Value
    Low Mean (SD)High Mean (SD)
    GP verbal communication
    Patient-centered score total1.42 (0.45)1.27 (0.49)0.319.02
     Component 1: Exploring both disease and illness experience0.28 (0.13)0.25 (0.13)0.231.08
     Component 3: Understanding of the whole person0.34 (0.38)0.29 (0.38)0.132.22
     Component 3: Finding common ground0.81 (0.14)0.72 (0.18)0.559<.001
    GP nonverbal communication
    Smiles0.38 (.65)0.29 (0.58)0.146.20
    Supportive facial expressions1.78 (1.76)1.27 (1.41)0.357.04
    GP Head nods6.05 (5.53)4.05 (5.88)0.350.08
    GP seconds looking at patient21.51 (9.10)17.94 (10.23)0.369.01
    GP seconds looking at computer6.18 (8.81)9.63 (10.62)−0.353.02
    Consultation length and continuity
    Length of consultation (minutes)9.24 (4.17)9.17 (4.11)0.017.90
    How well patient knows GP3.48 (1.29)4.04 (1.03)−0.085.001
    Empathy and enablement
    Patients’ score of GP empathy (CARE Measure)4.50 (0.62)4.34 (0.66)0.250.02
    Patient enablement (PEI)4.62 (3.29)4.28 (3.45)0.101.20
    • CARE = consultation and relational empathy; GP = general practitioner; PEI = patient enablement instrument.

    • Note: P values for differences between areas of deprivation are extracted from multi-level linear regression models that include fixed effects for age and sex and a random effect for GP level.

    • View popup
    Table 3

    Outcome Measures by Level of Deprivation

    VariableLevel of Deprivation Effect Size (Cohen’s d)P Value
    Low Mean (SD)High Mean (SD)
    MYMOP symptom scorea
     Baseline4.58 (1.50)
    n = 266
    4.90 (1.56)
    n = 310
    −0.209.01
     1 Month after baseline2.79 (1.78)
    n = 221
    3.48 (2.01)
    n = 211
    −0.363<.001
     Change from baseline−1.76 (2.10)
    n = 200
    −1.21 (2.13)
    n = 188
    −0.260.01
    MYMOP well-being scorea
     Baseline3.29 (1.63)
    n = 287
    3.74 (1.78)
    n = 340
    −0.264.005
     1 Month after baseline2.78 (1.62)
    n = 225
    3.53 (1.91)
    n = 211
    −0.424<.001
     Change from baseline−0.49 (1.90)
    n = 217
    −0.20 (2.09)
    n = 203
    −0.145.15
    • GP = general practitioner; MYMOP = Measure Yourself Medical Outcome Profile.

    • ↵a MYMOP scores are generated by the patient on a 7 point scale from 0 (“as good as it could be”) to 6 (“as bad as it could be”). Thus high mean scores at baseline or follow-up reflect worse symptoms and well-being. Change scores are calculated as score at 1 month minus score at baseline.

    • Note: P values for differences between areas of deprivation are extracted from multi-level linear regression models that include fixed effects for age and sex and a random effect for GP level.

    • View popup
    Table 4

    Baseline Factors Predicting Outcomes at 1 Month After Consultation

    Covariate (n)Adjusted Parameter Estimate Value (95% CI)P Value
    Predictors of MYMOP symptom scores at 1 month
     Baseline MYMOP score (388)−0.71 (−0.83 to −0.59)<.001
     High deprivation level (432)0.16 (−0.24 to 0.56).43
     10-y Increase in age (430)−0.03 (−0.14 to .08).61
     Male sex (430)−0.08 (−0.49 to .31).68
     Multiple morbidity count (432).13 (0.01 to 0.26).03
     Rating of health (423).25 (0.02 to 0.47).03
     GP Visits in past year (401).05 (0.01 to 0.08).01
     Duration of symptoms >4 wk (378).53 (0.15 to 0.92).006
     PHQ-9 Baseline score (417).05 (0.02 to 0.09).003
     Minutes spent with GP (423).06 (0.02 to 0.11).008
     CARE Measure score (432)−0.40 (−0.70 to −0.10).01
    Predictors of MYMOP well-being scores at 1 month
     Baseline MYMOP score (420)−0.83 (−0.94 to −0.72)<.001
     High deprivation (436)0.24 (−0.11 to 0.59).18
     10-y Increase in age (434)−0.01 (−0.11 to 0.09).80
     Male sex (434)−0.18 (−0.53 to 0.17).31
     Rating of health (428)0.38 (0.19 to 0.58)<.001
     Duration of symptoms >4 wk (376)0.42 (0.09 to 0.75).01
     GP visits in past year (406)0.04 (0.01 to 0.07).01
     PHQ-9 baseline score (421)0.06 (0.03 to 0.09)<.001
     CARE measure score (436)−0.27 (−0.53 to −0.02).04
    • CARE = consultation and relational empathy; GP = general practitioner; PHQ-9 = patient health questionnaire.

    • Note: For both outcome measures, the baseline MYMOP score, age, sex, and deprivation level were included in the adjusted regardless of significance. The full unadjusted and adjusted results are shown in the Supplemental Appendix, available at http://annfammed.org/content/14/2/117/suppl/DC1. A negative score in the parameter estimate (eg, baseline MYMOP scores) indicates a positive effect of that variable on outcomes at 1 month (because higher MYMOP scores represent worse symptoms and worse well-being). Depending on the nature of the covariate measured, the parameter estimate can be interpreted as the mean difference in the outcome variable associated with a 10-year increase in age, a 1-point increase in other continuous or ordinal predictors, or being in the specified subgroup (compared with the other) for binary predictors.

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  • The Article in Brief

    General Practitioners' Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation

    Stewart W. Mercer , and colleagues

    Background Primary care has the potential to help reduce health inequalities but there has been little research on patients' expectations and the characteristics of doctor visits in differing socioeconomic areas. This study compares general practitioner visits in areas of high and low deprivation in Scotland and analyzes factors that predict poorer or better outcomes in both low and high socioeconomic groups.

    What This Study Found Compared with affluent areas, patients in deprived areas have higher rates of ill health, psychosocial problems, and multimorbidity; more problems to discuss within the same visit time yet less desire for shared decision making; perceive their GPs as less empathetic; and have worse outcomes at one month. Physicians in deprived areas display verbal and nonverbal behaviors that are less patient-centered. Perceived physician empathy is the only visit factor that predicts better outcomes in patient symptoms and wellbeing in both high- and low-deprivation groups.

    Implications

    • To improve health in deprived areas, the authors call for policies that address wider social determinants of health and improve consultation quality.
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The Annals of Family Medicine: 14 (2)
The Annals of Family Medicine: 14 (2)
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March/April 2016
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General Practitioners’ Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation
Stewart W. Mercer, Maria Higgins, Annemieke M. Bikker, Bridie Fitzpatrick, Alex McConnachie, Suzanne M. Lloyd, Paul Little, Graham C.M. Watt
The Annals of Family Medicine Mar 2016, 14 (2) 117-124; DOI: 10.1370/afm.1910

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General Practitioners’ Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation
Stewart W. Mercer, Maria Higgins, Annemieke M. Bikker, Bridie Fitzpatrick, Alex McConnachie, Suzanne M. Lloyd, Paul Little, Graham C.M. Watt
The Annals of Family Medicine Mar 2016, 14 (2) 117-124; DOI: 10.1370/afm.1910
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