February 5, 2014

Healthcare Provider Empathy and Clinical Outcomes in Diabetes

Study examines the relationship between physicians' empathy and reducing complications from diabetes
This retrospective correlational study finds physician empathy to help in reducing serious metabolic complications from diabetes. Groups whose physicians had high empathy scores had significantly fewer patients with acute metabolic complications.


Canale SD, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med. 2012;87(9):1243-1249.


A retrospective correlational study


20,961 participants from a population of 284,298 adults in Parma, Italy, whom were enrolled with 1 of 242 primary care physicians in 2009. Participants were aged 18 years or older and diagnosed with diabetes mellitus, type 1 or 2, either by ICD-9-CM code on hospitalization or having a prescription for a diabetes medication. Sixty-one percent of the participants were older than 65 years of age, and 51% of the participants were male.

Study Parameters Assessed

The association between a Jefferson Scale of Empathy (JSE) score and clinical outcomes for patients with diabetes mellitus

Primary Outcome Measures

The JSE consisted of 20 items answered on a 7-point scale with 1 meaning “strongly disagree” and 7 meaning “strongly agree.” Points measured included perspective-taking, compassionate care, and walking in the patient’s shoes. Clinical outcomes focused on acute metabolic complications including hyperosmolar state, diabetic ketoacidosis, and coma.

Key Findings

Based on empathy scores, physicians were classified into three groups whose mean JSE scores were significantly different (P<0.001): high (n=81, JES score 119.4±5.4), moderate (n=84, 105.1±4.3), and low (n=77, 85.2±15.4). Physicians with high empathy scores had significantly fewer patients with acute metabolic complications (4.0/1,000 patients) compared with moderate (7.1/1,000 patients; z=2.51, P<0.01) and low empathy scores (6.5/1,000 patients) (z=2.04, P<0.05). Switching from a low to high JES-scoring physician reduced the odds of metabolic complications in diabetic patients by 40% (OR 0.59, [95% CI: 0.37–0.95]). Being older (aged ≥69 years) increased the odds of metabolic complications in patients by 70% (OR 1.70, [95% CI: 1.2–1.4]).

Practice Implications

Physician empathy in this study was shown to help in reducing serious metabolic complications from diabetes. In an earlier study published in 2011, Hojat et al reported that “patients of physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy scores (40%, P<0.001).”1
These improvements in outcomes may have been associated with increased patient compliance. In other research, empathy and patient-centered communication have been shown to be associated with improved clinician-to-patient relationships, patient satisfaction, and compliance.6–9 It is likely that empathy from other members of the multidisciplinary healthcare team is helpful as well. Therefore, practitioners other than primary care MDs, such as PharmDs, RNs, and RDs, may play a vital role in patient care and satisfaction. Including complementary and alternative medicine (CAM) providers such as NDs in the patient care team may add even more value, thus further improving outcomes.
Physicians with high empathy scores had significantly fewer patients with acute metabolic complications.
Some CAM therapies and dietary supplements and the additional attention case managers bring may also improve outcomes in diabetes or reduce complications associated with it. Alpha-lipoic acid and konjac glucomannan have strong scientific evidence for efficacy in diabetes.2 Beta-glucan, fenugreek (Trigonella foenum-graecum; DM-2), ivy gourd (Coccinia indica), guar gum, Gymnema (Gymnema sylvestre), and whey protein have good scientific evidence for efficacy in diabetes.2 Many other herbs and supplements, such as barley (Hordeum vulgare), beet (Beta vulgaris), chromium, ginseng (Panax spp), psyllium (Plantago ovata, Plantago ispaghula), and seaweed may affect glucose levels when taken alone or concurrently with other supplements.2 However, just like prescription drugs, some integrative therapies may not be safe in certain patient populations; therefore, appropriate monitoring parameters and screening for interactions/depletions is important. However, just like prescription drugs, some integrative therapies may not be safe in certain patient populations, therefore, appropriate monitoring parameters and screening for interactions/depletions is important.
Apart from CAM therapies potentially being effective prevention or treatment options for many disease states, CAM practitioners work to empower patients and encourage them to take responsibility for their own health. These practitioners’ treatment recommendations often take into consideration patient beliefs and preferences. CAM practitioners also have been shown to be more open-minded,3,4 spend more time with their patients,3,4 offer choices,3 share their knowledge and vision with patients,3 and form stronger bonds with their patients.4 Other research shows that CAM practitioners’ increased time spent with patients led to more general problems being diagnosed than in mainstream practitioners’ offices.5
Preliminary research has shown naturopathic care to result in improved outcomes in patients with type 2 diabetes. A small prospective observational pilot study (N=12) published in 2011 investigated changes in outcome measures in patients with type 2 diabetes after a 3-month dietary education program delivered in naturopathic primary care.10 It was reported that hemoglobin A1c improved significantly (P=0.02), adherence to healthy eating increased (P=0.05), and measures of physical activity, self-efficacy, and self-management improved significantly. In another prospective study published in 2012, 40 patients with inadequately controlled type 2 diabetes recruited from a large integrated healthcare system received on average 3.9 adjunctive naturopathic care (ANC) visits during the year of the study.11 At 6 months, significant improvements were noted in glucose testing (P=0.001), mood (P=0.001), self-efficacy (P=0.0001), and motivation to change lifestyle (P=0.003), all of which persisted at 12 months (P<0.005). At 6 months, mean hemoglobin A1c was also reported to have decreased by 0.90% (P=0.02) in patients receiving ANC; however, at 12 months, reductions were not statistically significant (P=0.14).
The following question has been raised: Can CAM practitioners be successful in managing or treating diabetes given their emphasis on overall mind-body wellness and the empathy upon which this approach depends, the specific therapies they recommend, or a combination of both? While research has been conducted on clinical algorithms for nutritional and botanical medicines in the treatment of type 2 diabetes,12 similar models specifically involving the use of empathy in naturopathic treatment of diabetes are lacking. It is generally accepted that a healthy lifestyle and diet are central to diabetes management and treatment, but in many cases this is not adequately communicated to patients or it is challenging for patients to comply. Thus it has been suggested that empathy may play a role in improving compliance and outcomes in patients with diabetes.
This information should stimulate a collaborative effort among practitioners to have empathy and encourage increased patient interaction with the goal of improving healthcare outcomes in diabetes and other indications.

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