Background
Empathy is regarded as a core aspect of effective consultations in general practice [
1]. In the context of patient care, Hojat et al. proposes that empathy is primarily a cognitive attribute, not an affective or emotional one. Thus, for a doctor, empathy requires understanding of patients’ experience, concerns and perspectives, as well as the ability to communicate their understanding and their intention to help [
2]. Mercer and Reynolds defined empathy in the clinical context as an ability to (i) understand the patient’s situation, perspective, and feelings (and their corresponding meanings), (ii) to communicate that understanding and check its accuracy, and (iii) to act on that understanding with the patient in a helpful and therapeutic way [
1]. Empathy has been linked to a number of benefits in health-care encounters, including improved patient satisfaction, better medication adherence, higher patient enablement, and better clinical outcomes [
3‐
6].
Although several tools have been developed to assess physicians’ empathy using self-reported or observer-reported measures [
7‐
9], these methods are limited by doctors’ conceptual structures of empathy, which change with their experiences [
10]. Thus, it is ultimately the patient’s perception of empathy that determines the interpersonal effectiveness of the clinical encounter [
11]. The Consultation and Relational Empathy (CARE) Measure is a widely used patient-reported measure that has been extensively validated [
12]. The CARE Measure was originally developed in English, in the United Kingdom (UK) [
13,
14]. It has been translated and validated in other languages, and is currently used by researchers in various countries, including China, Holland, Sweden and Croatia [
15‐
18]. A preliminary study of the validity and internal reliability of a Japanese version of the CARE Measure has been published [
19]. However, unlike the English and Chinese versions, the ability of the Japanese version of the measure to effectively discriminate between individual doctors has not yet been established [
14,
20,
21].
The current study sought to determine whether the Japanese version of the CARE Measure can reliably differentiate between doctors, and how many patients are required per doctor to provide a high level of reliability.
Discussion
We conducted ICC analysis of data from the Japanese CARE Measure to examine its ability to discriminate effectively between doctors. The current results suggest that the Japanese CARE Measure can effectively differentiate between doctors with 38 or more patient ratings per doctor (average ICC > 0.8). These findings suggest that the measure is feasible for use in routine practice.
Our findings are in accord with previous studies of the reliability of the CARE Measure in languages other than Japanese. A study of the Chinese version of the CARE Measure reported that an average reliability of 0.8 of GPs was achieved with approximately 30 patients per doctor [
20]. Similarly, a study of the original English version of the measure tested on GPs in Scotland reported that, for the GP requiring the largest number of patients among attending GPs, 50 patients per doctor resulted in a reliability above 0.8 [
14]. We applied the same analysis method to the current data, revealing that the largest patient number required by any GP in our sample was 53, similar to the results of the previous study in Scotland [
14].
The heterogeneity of the Chinese version of the mean CARE Measure of GPs was higher (mean score: 34.58; standard deviation: 4.861 in the Chinese version) [
20], whereas the heterogeneity in the current study was lower (mean score: 38.6; standard deviation: 3.2). This difference in the required number of patient ratings is likely to be related to studies examining doctors at different stages of training in general practice, resulting in greater variation between doctors. The current study only included GPs who were trained in the same hospital. Thus, the variation between doctors would be expected to be more aligned with the UK study [
14] than the Chinese study [
20].
A key strength of the current study is its contribution to the development of the Japanese version of the CARE Measure and its future utility. However, the study involved several limitations that should be considered. First, for pragmatic reasons, patients were recruited on a consecutive basis rather than randomly selected. The selection of suitable patients was determined by the attending physician, which may have introduced sample bias. In addition, patients with specific diseases (e.g., anxiety, dementia) were excluded from the study. Because the study was conducted in a single setting, the feasibility of carrying out such research in other settings, such as rural or private clinics, was not tested. The setting used may have been atypical in terms of consultation length and continuity of care. Finally, only nine doctors at the same hospital took part in this study, which was a smaller sample of doctors than in previous studies of the CARE Measure [
14,
20].
In our analysis, we chose the outpatient clinic of the university hospital because it provides a primary care facility run by qualified and experienced GPs. GP certification in Japan only began in 2009 and few well-qualified GPs existed in 2011 when the data in the current study were obtained [
25]. However, the number of GPs in Japan has increased rapidly since then. Thus, further large multicenter studies including both GPs and non-GPs working as family doctors in Japan would provide valuable insight.
Based on the current results, we believe that the Japanese version of the CARE Measure is useful for evaluating GPs in terms of relational empathy in Japan. Our findings suggest that the Measure is feasible, even within busy clinics. As Japan develops and grows its general practice workforce, ensuring that empathic, patient-centered care is at the heart of the system will aid the acceptability of care for patients, and its future sustainability.
Conclusion
We validated the reliability of the Japanese version of the CARE Measure in differentiating between doctors. The Measure provides a reliable estimate of perceived GP empathy, if 38 or more completed questionnaires are included. Further comprehensive investigations with larger samples would be valuable for confirming and extending these findings.
Acknowledgments
The authors would like to thank all the GPs and patients who participated in this study.
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