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THE IMPACT OF EMOTIONAL INTELLIGENCE ON PHYSICIANS’ AFFECTIVE DELIVERY IN MEDICAL ENCOUNTER

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THE IMPACT OF EMOTIONAL INTELLIGENCE ON PHYSICIANS’ AFFECTIVE DELIVERY IN MEDICAL ENCOUNTER Powered By Docstoc
					       THE IMPACT OF EMOTIONAL INTELLIGENCE ON
       PHYSICIANS’ AFFECTIVE DELIVERY IN MEDICAL
                       ENCOUNTER

   Hui-Ching Weng, PhD, Hung-Chi Chen* MD, MS, Han-Jung Chen*, MD, PhD,
                          Shu-Ching Chi*, RN, MS,

                Department of Health Management, I-Shou University,
8, Yida Rd., Yanchao Township, KaoHsiung County 824, TAIWAN
                                ami.9691@gmail.com

                         *E-Da Hospital, TAIWAN

                                     ABSTRACT

      Much of the literature pertinent to management indicates that service providers
with high emotional intelligence receive higher customer satisfaction scores. Previous
studies offer limited evidence regarding the impact of physician’s emotional
intelligence on patient-physician relationship. Using a multi-level and multi-source
data approach, the current study aimed to build a model that demonstrated the impact
of a physician’s emotional intelligence on the patient trust and the patient-physician
relationship. The survey sample included 5344 outpatients and 211 physicians
representing 22 specialties. Results of structural equation analysis indicated that
composite EI of physicians (p < .001), physician’s experience (p <.01), ratio of a
patient’s follow-up with the physician (p < .01), had positive effects on patient trust.
Patient trust had a positive impact on the patient-physician relationships (p < .001),
which modulated the effect of trust on patient satisfaction (p < .001). The final model
proved to be valid (chi square/df = 49.23/39, p =0.13), showing a sound fit (GFI =
0.91 and RMSEA = 0.001). The model explained 35% of the variance of trust, 42% of
patient-physician relationships and 55% satisfaction. Multi-sources for assessment of
physician performance and an interdisplinary collaboration among clinicians are
needed to optimize the efficient and therapeutic function of the patient-physician
relationships for patients.

Keyword: emotional intelligence, patient-physician relationship




                                           1
                                  INTRODUCTION
    Emotional intelligence is recognized as an important personal attribute involved in
nurturing the patient-physician relationship and is thus increasingly included in the
medical education curriculum. Goleman (1998) has pointed out, that at a time of
heightened competition for patient loyalty, those physicians who are more aware of
their patient’s emotions are more successful in treating them than their less perceptive
colleagues. Studies involving some 2800 physician “star performers” have shown that
75% of a high achiever’s success is a function of emotional intelligence, while 25% of
success reflects technical competency (Harvard & Rutgers, 2002). As a result,
interpersonal communication skills have been designated as one of the six areas of
professional competence for physicians by the Accreditation Council for Graduate
Medical Education (2001). Emotional intelligence is included as one of the
assessment items under affective and moral domains (Epstein & Hundert, 2002). The
other five domains encompass cognitive abilities, technical skills, integrative abilities,
relationship skills, and habits of mind. Accordingly, medical professionals have begun
to recognize that some physicians are trained to be clinically competent, but have
inadequate social skills for practice. Indeed, assessment of emotional intelligence is
now used as part of the selection process for medical school applicants in an effort to
consider an applicant’s competency in interpersonal skills (Carrathers et al., 2000;
Elan, 2000). However, recent studies (Stratton et al., 2005; Wagner et al., 2002) offer
limited evidence regarding the association between a physician’s emotional
intelligence, the patient-physician relationship, and patient satisfaction. Studies
regarding the factors which influence the patient-physician relationship have focused
mainly on a physician’s demographic characteristics (Duberstein, Meldrum, &
Fiscella, 2006), whether or not a patient sees the same physician on a regular basis
(Kearley et al., 2001), and the physician’s interview style (Paasche-Orlow & Roter,
2003; Graugaard, Holgersen, & Finset, 2006); the literature focusing on a physician’s
characteristics is scant.
      The current study explored the association between a physician’s emotional
intelligence, patient trust, and the patient-physician relationship through the use of a
multi-level and multi-source data approach. Elucidation of this association will be
helpful in assisting physicians to provide care that is emotionally responsive, in
addition to being clinical sound. The current study is unique in the following ways: 1)
most reported studies have been based on the self-ratings of physicians, while our
study used multiple sources, such as nursing directors and senior staff, to explore the
association between a physician’s emotional intelligence, patient trust, the
patient-physician relationship, and patient satisfaction, 2) most reported studies have


                                            2
used medical students as research targets, while our study used physicians as research
targets, 3) most reported studies have focused on physicians board-certified in family
medicine or psychiatry, while our sample included physicians representing 11
different specialties and included 39 physicians, 12 of whom were surgeons, and 4)
most reported studies have ignored methodological issues by using individual patients
as the unit of analysis, while we used physicians as the unit of analysis, which
allowed us to observe the contextual effects of the same physicians in encounters with
patients in a similar way at the macro level, and the variations among patient
perceptions of their trust and the patient-physician relationship toward the same
physician at the micro (i.e., individual) level.


                           LITERATURE REVIEW
Emotional Intelligence: Nature and Debates
      Emotional intelligence has been historically rooted within the rubric of social
intelligence, which is defined as the ability to understand and manage people, thereby
guiding adaptive and purposive behavior (Thorndike, 1920). According to Thorndike
(1920), the model of social intelligence incorporates work from the disciplines of
personality and social psychology, focusing on individuals in their social contexts
(Zirkel, 2000). There is a preponderance of literature that examines the areas of
multiple and emotional intelligence given that a person’s behavior is best understood
in terms of its adaptability and functionality (Gardner, 1983; Goleman, 1994; Saarni,
1999). Some empirical evidence form neuroscience also enriches the emotional
intelligence construct in understanding the role of emotion in cognition. Based on the
neurobiological basis of impaired decision-making in patients with bilateral lesions of
the ventromedial prefrontal cortex, Damasio (1994) advanced the somatic marker
hypothesis which posits that decision-making is a process that depends on emotional
signals; only patients with lesions in the somatic marker circuitry have significantly
lower emotional intelligence and poor judgment in decision-making as well as
evidence of social dysfunction, in spite of normal levels of cognitive intelligence
(Bar-On, Tranel, Denburg et al., 2003).
        There have been serious academic debates on whether or not emotional
intelligence is a construct that is distinct from personality traits (Law & Wong, 2004;
Mayer, Caruso, & Salovey, 2000) or a mixed model which combines both (Bar-On,
2000; Goleman, 1995). Salovey and Mayer originally used the term “emotional
intelligence” in 1990, by defining emotional intelligence as the ability to monitor
his/her own and other’s feelings and emotions in order to guide one’s thinking and
actions. In 1997, the definition of emotional intelligence was further refined as “the
ability to perceive emotion, integrate emotion to facilitate thought, understand


                                             3
emotions, and to regulate emotions to promote personal growth” (Mayer, Caruso, &
Salovey, 1997). Davis, Stankow, and Roberts (1998) argued that emotional
intelligence seemed to be an elusive and fluid construct. They offered a
four-dimensional definition to further clarify the emotional intelligence construct: 1)
appraisal and expression of emotion in oneself, 2) appraisal and recognition of
emotion in others, 3) regulation of emotion in oneself, and 4) use of emotion to
facilitate performance. Adapting the definition of Davis et al. (1998), Wong and Law
(2002, 2004) confirmed the arguments of Mayer et al. (1997, 2000) as follows: 1)
emotional intelligence is an attribute which is distinct from the Big Five personality
dimensions, 2) emotional intelligence is a facet of intelligence which is mildly
correlated with general mental abilities, and 3) emotional intelligence is
developmental in nature, which allows emotional intelligence to increase with age and
life experiences.


Emotional Intelligence, the Patient-Physician Relationship, and Patient
Satisfaction
     Much of the literature pertinent to management supports the notion that service
providers with high emotional intelligence receive higher customer satisfaction scores
(Kernback & Schutte, 2005; Lernmink & Mattsson, 2002; Winssted, 2000).
Individuals with high emotional intelligence have self-reported satisfaction with
social relationships, as well as a perception of more social support, and are less likely
to report negative interactions with others (Lopes, Salovey, & Straus, 2003). Among
the variety of social relationships valued by people, Magee (1999) has argued that the
patient-physician relationship is more important than it is given credit for. He
indicated that second only to family relationships, the patient-physician relationship is
considered to be extremely or very important by 67% of those surveyed, surpassing
the relationship with spiritual advisors (52%), pharmacists (45%), and co-workers
(44%). However, there is little literature in the medical field that explores these issues,
although there is considerable interest in exploring the predictors of the
patient-physician relationship. Using the Bar-On Emotional Quotient Inventory as an
assessment of emotional intelligence, Wagner, Moseley, Grant et al. (2002) published
the first study that focused on a physician’s emotional intelligence and the
patient-physician relationship. They found that only one sub-scale of emotional
intelligence (i.e., happiness) was related to higher patient satisfaction; the other
sub-scales (i.e., interpersonal skills, adaptability, stress, and mood [happiness is an
indicator under the sub-dimension of mood]) were unrelated.
        Stratton, Elam, Murphy-Spencer et al. (2005) found that the emotional
intelligence of medical students, as assessed by attention to feelings, empathic


                                             4
concern, and perspective, were positively correlated with communication skills, while
the latter two measures (empathic concern and perspective) were negatively
associated with physical examination skills. Given the limited evidence for an
association between a physician’s emotional intelligence and the patient-physician
relationship, these findings should be considered preliminary.
         Though these studies did not utilize a specific assessment of a physician’s
emotional intelligence, the traits, characteristics, and behaviors they described for
physicians were relevant or overlapping with the emotional intelligence construct.
Affirming the therapeutic effectiveness of the effect of the patient-physician
relationship, Blasi, Harkness, Ernst et al. (2001) conducted a systematic review of 25
studies and found that physicians who exuded a warm, friendly, and reassuring
manner were more effective than those who kept consultations formal, yet there was
considerable inconsistency regarding emotional and cognitive care. Berrios-Rivera,
Street, Garcia et al. (2006) have argued that a physician’s sensitivity to concerns,
reassurance and support, and patient-centeredness are positively related to the
patient-physician relationship. Again, by its tradition and very nature, medicine is a
unique form of social interaction that cannot be achieved effectively without the
virtues of humility, honesty, intellectual integrity, compassion, and effacement of
excessive self-interests (Crawshaw, Rogers, Pellegrino et al., 1995). Accordingly, the
physician is assumed to be a key figure in facilitating and managing the
patient-physician relationship by influencing the way patients perceive and feel about
their treatment and illness.


Trust, the Patient-Physician Relationship, and Satisfaction
        The designation of medicine as a “covenant of trust” Crawshaw et al. (1995)
echoes Putnam’s argument(1995) of claiming that a successful encounter is the
accumulation of social capital, that being the value that accrues between two
individuals who share a relationship marked by commitment, trust, and willingness.
Many studies have demonstrated a positive correlation between trust, the
patient-physician relationship, and patient satisfaction (Duberstein, Meldrum, &
Fiscella, 2006; Shenolikar, Balkrishnan, & Hall et al., 2004; Thom, Hall, & Pawlson,
2004). Given the importance of trust in the patient-physician encounter, we have
also included patient trust with the emotional intelligence of the physician as
predictors of the patient-physician relationship.


Hypothesis
        In line with the aforementioned reasoning, our hypothesis comprises a model
that includes antecedents and consequences of a physician’s emotional intelligence


                                            5
and the patient-physician relationship (Figure 1). First, we have hypothesized that the
physician’s experience, the differences between specialties (i.e., internal medicine and
surgery), the patient’s compliance, and the physician’s emotional intelligence, would
explain the variance in trust toward physicians. Second, the magnitude of the
patient-physician relationship was hypothesized to be affected by the patient’s trust
toward physicians, and mediated by the patient’s satisfaction.




                      Physician                                                                       Hospital       MD
                     Experience
                                     .17                                                                  1.00   1.07***
                                           **


                     PT Follow-up                  Patient                  Patient Physician   .20
                                                                                                           Patient
                                    .16**                         1.05***
                        Ratio                       Trust                     Relationship               Satisfaction

  SEA
              1
                                            ***
  OEA     1.07***     Physician       .93
                      Emotional
  UOE     1.10***
                     Intellgence
  ROE       .98***




                                      X2/df = 49.23/39   P=0.13   RMSEA=0.083 GFI=0.82


                                        Figure 1
Results of Structural Equation Modeling of the Impacts Physician’s Characteristics on
         the Patient’s Trust, Patient-Physician Relationship, and Satisfaction.


Note:
MD Experience = The number of years since the physician got medical license
PT Follow-up Ratio = The ration of patient’s follow-up for the physician
SEA = A summative ratings from the physician, the senior staff, and the nursing director for the
        physician’s emotional intelligence of self emotion appraisal
OEA = A summative ratings from the physician, the senior staff, and the nursing director for the
        physician’s emotional intelligence of other emotional appraisal
UOE = A summative ratings from the physician, the senior staff, and the nursing director for the
        physician’s emotional intelligence of use of emotion
ROE = A summative ratings from the physician, the senior staff, and the nursing director for the
        physician’s emotional intelligence of regulation of emotion
Hospital = Patient satisfaction on the health care provided by the hospital
MD = Patient satisfaction on the health care provided by the physician




                                                         6
                                       METHODS
Research Sample and Data Collection
      The study was reviewed and approved by the Institution Review Board of E-Dah
Hospital. Consent was obtained from the 211 participating physicians. Patient consent
was obtained in the outpatient department by nurse practitioners. To avoid common
methods of variance due to self-reported research (Podsakoff, MacKenzie, &
Podsakoff, 2003), this study collected data from multiple sources. At the individual
level, in which the patient was nested under each physician, data regarding patient
trust, the patient-physician relationship, and patient satisfaction with the hospital’s and
physician’s services, were obtained from patient’s questionnaires by face-to-face
interviews conducted by nurse practitioners. The patient response rate was 72.5%.
Questionnaires were checked for proper completion and plausibility. Data regarding
the patient-physician relationship and emotional intelligence were obtained from the
physician’s self-ratings. At the group level, patient trust, the patient-physician
relationship, and emotional intelligence for each physician, were assessed from three
external sources: 1) two nurse practitioners who worked with the physician in the
examining rooms within the outpatient department, 2) three nursing directors, and 3) a
senior staff member who handled malpractice claims within the hospital. The analytic
assessment of the physician’s performance differed between the three external sources.
The ratings of the two nurse practitioners were averaged. Unlike the three nursing
directors and the senior staff member, the nurse practitioners did not know all of the
39 physicians. The ratings by the three nursing directors were combined into a single
measure derived from a consensus following a brief discussion about the 39
physicians. The rating for the senior staff member represented the staff member’s
assessment alone.


Measures and Instruments
    As shown in Table 1, the physician’s emotional intelligence was assessed by an
ability-based measure designed by the Wong and Law emotional intelligence scale
(WLEIS; 2002). Based on further work by Davies et al. (1998), George (2000), and
Mayer and Salovey (1997), emotional intelligence was defined as a four-dimensional
construct, comprising the ability to understand one’s own and other’s emotions, how
one’s emotions are regulated, and the use of one’s emotions, which is conceptually
distinct from the Big Five personality dimensions (Wong & Law, 2004).




                                            7
Table 1 Respondent Level, Variables, and Questionnaire Sources and Reliability
                                                                 Item
   Variable                           Respondent / Source                  Reliability
                                                                number
   Patient Level
   Trust                             Patients                     11          .819
   Patient physician relationship    Patients                      9          .898
   Physician satisfaction            Patients                      2          .883
   Hospital satisfaction             Patients                      2          .795
   Physician Level
   Trust                             (1) Physician peers           9          .802
                                     (2) Nurse directors           9            --
                                     (3) Nurse practitioners       9          .760
                                     in the examining room
                                     (4) Senior staffs             9          .677
   Patient physician relationship    (1) Physicians               11          .949
                                     (2) Physician peers
                                     (3) Nurse directors          11            --
                                     (4) Nurse practitioners      11          .914
                                     in the examining room
                                     (5) Senior staffs            11          .630
   Health care climate               Observers                     6          .736
   Demographic variables             Physicians                    5            --
   Patient follow-up ratio           Claim data                    1            --


   Using multi-trait and multi-method analyses, data from other’s ratings of
emotional intelligence has established the convergent and discriminate validity of
emotional intelligence. Trust was assessed using the scales of Hall et al. (2002).
Cronbach’s alpha for patient trust was 0.92. Patients were instructed to answer 11
items using a 5-point response set as it applied to their diabetes (i.e., 1 = strongly
disagree to 5 = strongly agree). Higher scores on the scales indicated higher levels of
trust towards the physician. The patient-physician relationship was measured by Van
der Feltz-Cornelis’s patient-physician relationship (PPR-9; 2004) on a 5-point scale
(i.e., 1 = strongly disagree to 5 = strongly agree) scale, which included 9 items.
Cronbach’s alphas for the patient towards the physician and the physician’s self-rating
were 0.91 and 0.86, respectively. Many studies that have inquired about patient
satisfaction at different time points have yielded different outcomes, which may
reflect the measurement of different domains (Jacksone et al., 2001; Jutalis et al.,
1997). Immediately following a physician visit, satisfaction was most strongly


                                            8
related to measures of the patient-physician relationship; by 2 weeks or more
following a physician visit, satisfaction was related to an improvement in the patient’s
symptoms or functioning. Since our aim was to measure satisfaction with specific
physician behaviors, patient satisfaction was assessed immediately following the visit.


Statistical Analysis
     Descriptive analyses were performed using the Statistical Package for Social
Sciences (SPSS 12). The causal model predicting the patient-physician relationship
was tested by structural equation modeling using the LISREL 8.71.


                                   RESULTS
       Patient demographics are shown in Table 2. The gender of the patients was
nearly equally divided. The mean age of the subjects was 47.77  21.63 years. The
majority of the patients had follow-up visits (82.6 %) to a same doctor. Most subjects
(67.8 %) were married and the educational level was at the senior high school level
(30.1 %). The majority of subjects were almost equally recruited from the clinic of
internal medicine (50.6%) and surgery (49.4 %). Physician demographics are shown
in Table 3. The doctors were predominantly male (91.5 %), with a mean age of 42.55
 6.75 years, a bachelor degree of medicine from medical school (83.9%), and board
certification in internal medicine (52.1 %) and in surgery (47.9 %).
      The relationships between the ratings of multiple sources for the physician’s
emotional intelligence and patient trust, the patient-physician relationship, and patient
satisfaction toward the hospital and physicians are shown in Table 4. The relationships
were examined using Pearson correlation coefficients with two-tailed tests of
significance. The results indicate, from the patient’s perspective, patient trust, the
patient-physician relationship, and patient satisfaction toward the hospital and the
physicians were positively correlated. Patients who were older, less educated, and
more compliant with follow-up evaluations gave higher ratings on patient trust, the
patient-physician relationship, and patient satisfaction with the hospital and the
physician. Among the four sources of ratings for the patient-physician relationship,
only the rating by the nursing director was positively associated with patient trust
(.348*, p<.05). None of the four dimensions pertaining to emotional intelligence
ratings from the physician were significantly correlated with any variables rated by
the patients. The other emotions appraisal of emotional intelligence for the physician
rated by the senior staff member was shown to be significantly associated (.375*,
p<.05) with patient trust. Three dimensions of a physician’s emotional intelligence
(i.e., other emotions appraisal, use of emotions, and regulation of emotions) rated by
the nursing directors were positively correlated with patient trust (.286, p<.10, .358*,


                                            9
p<.05, and .270, p<.10, respectively).


Table 2 Patient Demographics (n=5344)
Variable                                  n         %
Gender
    Male                                 2980      55.8
    Female                               2364      44.2


Mean age (years): 47.77                  SD:       21.63
    Min: 1                               Max:       99


Follow-up visits
    Yes                                  4414      82.6
    No                                   930       17.4


Marital Status
    Single                               1610      30.1
    Married                              3624      67.8
    Other                                110        2.1


Education
    Elementary school                    1506      28.2
    High school                          780       14.6
    Senior high school                   1610      30.1
    College or higher                    1448      27.1


Category of Department
    Internal Medicine                    2702      50.6
    Surgery                              2642      49.4




                                              10
Table 3 Physician Demographics (n=211)
 Variable                                      n      %


 Gender                                       18     8.5
      Male                                    193    91.5
      Female
 Mean age (years): 42.55                      SD:    6.75
      Min: 28                                 Max:   61
 Education

      Baccalaureate                           177    83.9
      Master’s                                29     13.7
      PhD                                      5     2.4
 Department
      Internal Medicine                       110    52.1
      Surgery                                 101    47.9




                                         11
Table 4 Correlation matrix associated with patients’ ratings
                            PT TRUST                    PT PPR             PT H SAT       PT MD SAT
1       PT TRUST                     1
2       PT PPR                    .773**                    1
3       PT H SAT                  .752**                  .807**                 1
4       PT MD SAT                 .647**                  .761**               .931**          1
5       PT Age                    .121***               .079**               .083**        .128***
6       PT Education              -.092**                -.058†               -.011          -.049
7       PT Follow-up              .132***               .109**                .068*         .075**
8       MD PPR                    .050                   -.077                -.062         -.017
9       SS PPR                    .186                    .017                 .115          .143
10      NR1 PPR                   -.099                  -.172                -.051         -.064
11      NR2 PPR                   .348*                   .215                 .144          .167
12      MD SEA                    -.059                   .017                -.014         -.004
13 MD OEA                         .033                   -.007                 .027          .091
14 MD UOE                         .116                    .102                 .040          .084
15 MD ROE                         .003                    .076                -.038         -.006
16      SS SEA                    .302                   .140                  .228         .236
17      SS OEA                    .375*                  .221                  .258         .257
18      SS UOE                    .172                   .211                  .234         .275
19      SS ROE                    .214                   .106                  .182         .207
20      NR2 SEA                   .137                   .094                  .033         .095
21      NR2 OEA                   .286†                  .207                  .034         .098
22      NR2 UOE                   .358*                  .162                  .135         .046
23      NR2 ROE                   .270†                  .202                  .108         .176
Note:
1PT TRUST= patients’ ratings of trust toward his/her physician
2 PT PPR = patients’ ratings of patient-physician relationship
3 PT H SAT = patients’ satisfaction of hospital
4 PT MD SAT = patients’ satisfaction of physicians
5 MD PPR = physician’s self-ratings of patient-physician relationship
6 SS PPR = a senior staff’s ratings of the physician’s patient-physician relationship
7 NR1 PPR = ratings of patient-physician relationship from nurses in the examining room
8 NR2 PPR = ratings of patient-physician relationship from three nursing directors
9 MD SEA = MDs’ self ratings of self emotion appraisal
10 MD OEA = MDs’ self ratings of other emotion appraisal
11 MD UOE = MDs’ self ratings of use of emotion
12 MD ROE = MDs’ self-rating of regulation of emotion


                                                   12
13 SS SEA = senior staff’s ratings of the physician’s emotion appraisal
14 SS OEA = senior staff s ratings of the physician’s other emotion appraisal
15 SS UOE = senior staff s ratings of the physician’s use of emotion
16 SS ROE = senior staff s rating of the physician’s regulation of emotion
17 NR2 SEA = ratings from three nursing directors’ ratings of the physician’s self emotion appraisal
18 NR2 OEA =ratings from three nursing directors’ ratings of the physician’s other emotion appraisal
19 NR2 UOE = ratings from three nursing directors’ ratings of the physician’s of use of emotion
20 NR2 ROE = ratings from three nursing directors’ ratings of the physician’s regulation of emotion


† < .10,   * < .05, ** < .01



       Analyses by structural equation modeling are depicted in Figure 1. The
physician’s years of experience ( = .17, p<.01), the ratio of patient follow-up visits (
= .16*), and the physician’s emotional intelligence ( = .93, p<.01), all had a positive
effect on patient trust. Since the multicollinearity caused by highly positive
association among the physician’s age, experience, his/her average number of
outpatients and the ratio of patient follow-up visits (not shown in the table), and the
allowed numbers of parameters to be measured, only the physician experiences, the
ration of patient follow-up visits and the physician emotional intelligence were put in
the model as exogenous variables. The more trust the patient had toward the physician
( = 1.05, p<.001), the better the patient-physician relationship was perceived by the
patient, and in turn, the higher the satisfaction achieved by the patient ( = .20). The
impact of patient trust on patient satisfaction was mediated by the patient-physician
relationship at a significant level. The final model proved to be valid (chi square/df =
49.23/39, p = 0.13), showing a sound fit (GFI = 0.82 and RMSEA = 0.083). The
model accounted for 37% of the variance of patient trust, 48% of the patient-physician
relationship, and 56% of patient satisfaction.


                                      DISCUSSION
Credibility of the External Assessment of a Physician’s Emotional Intelligence
      The significant association between a physician’s emotional intelligence, patient
trust, the patient-physician relationship, and patient satisfaction found in our study,
but not in other studies, may have resulted from using the external rating sources for
the physician. Our findings showed that there was no significant association between
a physician’s self-reported emotional intelligence and the patient-rated trust, as well as
the patient-physician relationship; however, the patient’s rating of trust and the
patient-physician relationship was significantly correlated with the ratings of the
nursing directors and the senior staff member. A physician’s emotional intelligence,


                                                  13
patient trust, and the patient-physician relationship, as rated by the three nursing
directors, was significantly associated with the patient’s rating of trust and the
patient-physician relationship. Our findings affirm the findings of previous studies
(Bagg, Schmitt, Mushlin et al., 1999; Nembhard & Edmondson, 2006; Shortel et al.,
1991). A systematic review of physician self-assessment indicates that a physician’s
self-assessment has poor or limited accuracy; these findings are independent of the
level of training, the specialty, the domain of self-assessment, or the manner of
comparison (Davis et al., 2006). Further, Davis et al., (2006) have argued that a
physician’s difficulty is particularly serious when assessing the physician’s behavior
or ability in the social-psycho realm, such as interpersonal or communication skills.
They suggest that the evaluation of physician competence may need to focus more on
external assessment. Epstein and Hundert (2000) have suggested that a physician’s
self-assessment may be biased or influenced by their psychological sense of
self-efficacy and self-confidence, rather than more appropriate criteria, even among
bright and motivated individuals. Duff and Holmboe (2006) have also argued that
physicians may confuse confidence with competency. In line with the reasoning from
the literature, the lack of accuracy and validity for a physician’s self-reported
emotional intelligence may be the major reason that there is limited evidence of an
association between a physician’s emotional intelligence, the patient-physician
relationship, and patient satisfaction (Wagner et al., 2002; Stratton et al., 2005), and
not just the result of a small sample or the validity of the emotional intelligence
assessment.
        A nurse’s sensitivity regarding patient thoughts and mindset also merits
serious consideration. Our study indicates that patient trust and the patient-physician
relationship, as rated by both the physician and the senior staff member, had no
significant association with the patient’s rating, in contrast to the ratings by the
nursing directors. In assessing professional competence, Epstein and Hundert (2002)
indicated that a peer may be in the best position to evaluate professionalism,
especially the integration of core knowledge into clinical practice. However, given a
nurse’s observational and intellectual skills, nurses may be more reliable in including
sensitivity within the context of healthcare, (Nembhard & Edmondson, 2006), the
patient’s clinical physiological and psychological status, and family needs and
concerns (Baggs et al., 1999). Though our findings reveal that the nurses’ ratings were
significantly correlated with patient trust toward the physician, not all the ratings from
nurses achieved the validity of external sources. From a methodological standpoint,
the nurse’s ability to assess patient trust may differ between work assignments,
nursing units, and individual experiences. In our study, the nurse practitioners were
not familiar with all 39 participating physicians. For example, some nurse


                                            14
practitioners worked in the internal medicine department and rarely worked with the
surgeons. Therefore, each physician was evaluated by nurse practitioners with whom
they were acquainted. This was in contrast with the ratings from the consensus of the
three nursing directors, who knew all the physicians and had moderate discussions
and exchanged opinions regarding the physicians. Although the senior staff member
knew all the physicians and rated their emotional intelligence equally, the results may
have been affected by personal prejudice and probability bias arising from malpractice
events. For those physicians not involved in malpractice suits, their emotional
intelligence may not have been tested and their limitations in the regulation of
emotions when encountering difficult situations may have been unknown. In some
sense, the assessment standards adopted by the senior staff member may have been
too rigid for assessing patient trust and the patient-physician relationship in question.
In our study, the physician’s emotional intelligence was assessed by an ability-based
instrument, rather than a personality trait-based instrument. In addition, the
patient-physician relationship was an interaction pattern involving at least two
individuals, the patient and the physician. It would not have been appropriate to adopt
only either the patient’s or the physician’s perception of the patient-physician
relationship. Using external sources for emotional intelligence assessment accounted
for the validity and credibility of achieving scrutiny of the methodology.



Managerial Implications
         Our findings highlight the importance of the physician’s emotional
intelligence in patient trust, the patient-physician relationship, and patient satisfaction.
Following Mayer and Salovey’s (1997) theory, emotional intelligence, focused on
ability rather than traits, can be acquired through learning and experience. First, an
underlying capacity for emotional intelligence is necessary for a successful physician,
though not sufficient, to manifest a competency in the medical profession. After a
medical student leaves school, the capacity to learn emotional intelligence may be
enhanced by adjusting interaction styles, attitude, and mindset when encountering
difficult situations, such as malpractice suits. Training a good physician is at the cost
of social capital, while training a physician with a high emotional intelligence is
beneficial to everyone. Offering more emotional intelligence coaching in continuing
medical education is of great necessity. Second, the multi-source ratings or feedback
from the stakeholders, such as the patient, the paramedical associates, and the staff at
the administrative level, is a feasible means of assessing the competencies of
physicians (Claudio & Fidder, 2003). Physicians can be allowed to use such feedback
to contemplate and initiate changes to their daily practice by engaging in lifelong


                                             15
learning by participating in continuing medical education. We believe that a
comprehensive “know-how” in handling the patient-physician relationship cannot be
fully learned in school, nor can be bought in the market place, but must be intrinsic in
the physician’s lifelong learning journey to be informed, to be aware of patient needs,
and to endeavor to enhance their capacity for emotional intelligence.


Limitations of the Study
        Our findings should be viewed as tentative and interpreted with caution, as
there are several limitations to the study: selection bias, context effect, and the
Hawthone effect. First, selection bias may have occurred since the physicians who
agreed to participate may have been nicer and friendlier in handling the
patient-physician relationship while being studied and scrutinized. Patients who
agreed to participate may have been in favor of the physicians. Also, the patients who
valued the patient-physician relationship may have been more likely to respond.
Patients who had malpractice towards certain physicians may have been excluded
from the sample. Given the selection bias, our interpretation of the patient’s higher
rating towards physicians may have been interpreted in a conservative manner.
Second, the findings of the present study lack external generalization to other settings
and other samples. The context effect of inpatient and emergency departments on
patient trust and the patient-physician relationship would differ from that in the
outpatient department. Third, the physicians who agreed to participate may have
pretended to be nicer to patients than usual during the time the study was executed.


                                   CONCLUSION
      This study extends a stream of research on offering evidence that a physician’s
emotional intelligence is associated with patient trust and the patient-physician
relationship, and initiates a discussion about the multi-sources of assessing a
physician’s emotional intelligence and appraising the patient-physician relationship as
perceived by the patient. At a time when considerable attention is centered on how to
advance quality improvement efforts in heath care, this paper offers initial theoretical
and practical insight. Training in emotional intelligence may be as important as
selecting applicants to medical school with high emotional intelligence. Again, it is
critical to nurture the patient-physician relationship and achieve improved patient
satisfaction by providing care that is both clinically sound and emotionally responsive.
Future studies should consider multiple sources of subjective measurement and a
physician’s emotional intelligence and the patient-physician relationship in
conjunction with more highly refined measures of emotional intelligence. Moreover,
more empirical evidence of testing the associations between a physician’s emotional


                                           16
intelligence and the patient-physician relationship would help to clarify the theoretical
basis underlying the emotional dimensions of health care.


                            ACKNOWLEDGEMENTS
     This study was funded in part by a grant of the Taiwan National Science Council
(NSC94-2516-S-214-002). The authors express their thanks for the assistance of
data collection provided by WH Chen, MD, SC Chi, RN, WW Feng, MD, LJ Lin, MD,
YT Liu, MD, LC Hsiao MS, SY Hung MD, K Lu, MD, YT Lu, MD, DS Perng, MD,
YT Su, MD, HB Wu, MD, and CY Yen, MD. The authors also are grateful for helpful
comments from TK Peng, PhD, J Lin, PhD and CC Lin, PhD, HC Kuo, PhD.


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