This multi-center cross-sectional study explored whether work-related perception mediated the relationship between empathy and clinical performance. The results indicated that the SEM produced a good fit to the sample data. When work-related perception was added as a mediating variable, this study found a significant its positive indirect effect on the relationship between empathy and clinical performance, whereas the direct effect of empathy on clinical performance decreased, indicating a partial mediating effect of work-related perception.
Findings from this study indicate that there is a positive correlation between empathy and clinical performance, with the factor load of 0.29. As important elements of clinical performance, accurate diagnosis and correct treatment plan are positively correlated with residents’ empathy, with item loads of 0.74 and 0.71, respectively. These findings are consistent with previous studies that have shown a positive relationship between empathy and clinical competence among medical students and residents (Casas et al., 2017; Ogle et al., 2013; Hojat et al., 2002). However, the study by West et al. showed that empathy and clinical competence may be independent; they found that the clinical competence of residents assessed by structured examination improved after a year of training, whereas empathy declined (West et al., 2007). One possible reason for this phenomenon is that with increasing contact between residents and patients, some situations may increase the residents' feelings of vulnerability, and they may not be able to provide humane healthcare with empathy to protect themselves (Neumann et al., 2011). This phenomenon was also consistent with the results of a study on physicians' brains, which showed that with an increase in medical expertise, physicians down-regulated their pain empathy response (Decety et al., 2010). In fact, residents' empathy may affect their clinical performance to a certain level. In a systematic review, Neumann et al. suggested that empathic behavior may improve diagnostic accuracy of physicians and adherence and satisfaction of patients (Neumann et al., 2011). In the real world, residents' clinical performance needs to be evaluated based on the actual physician–patient therapeutic relationship, rather than just measuring their clinical knowledge. It has been proven that high levels of empathy improve the therapeutic relationship of healthcare providers with their patients and leads to better outcomes (Moudatsou et al., 2020). In addition, this therapeutic relationship reinforces their cooperation in decision-making and formulation of intervention measures, further improving patient satisfaction with the treatment process (Ogle et al., 2013). Further, empathy skills of professionals have been proven to improve through training. Riess et al. showed significant improvement in empathy of residents as assessed by patients through an innovative empathy training based on neuroscience, which showed that the clinical performance of residents could be improved by some intervention for improving empathy (Riess et al., 2012). Administrators could improve the empathy of residents by establishing some clinical theory and practice curriculum and continuing medical education to improve their clinical performance in the future (Pohontsch et al., 2018).
In this study, work-related perception had a significant positive predictive effect on clinical performance, confirming H3, demonstrated by many previous studies (Losier et al., 2021; Gunawan et al., 2020; Liss et al., 2018; Hou et al., 2013). The major component of work-related perception is the resident's work-related intrinsic and extrinsic satisfaction. Intrinsic satisfaction is associated with the stress, intrinsic motivation, and self-efficacy of the professional, whereas extrinsic satisfaction is dependent on the work environment and compensation (Peng, 2014). Previous studies have indicated that only intrinsic satisfaction is a predictor of clinical performance of residents in China (Hou et al., 2020). However, although an effect of compensation on the clinical performance of residents was not found in this study, a significant effect of extrinsic factors such as satisfaction with work environment, satisfaction with health policy, and satisfaction with patient–physician relationship was found. Although intrinsic work satisfaction is dependent on self-efficacy and internal motivation of residents, extrinsic work satisfaction depends on some realistic and tangible factors, such as working environment and conditions. Thus, residents may be more motivated by the extrinsic factors, and such external factors may be more important for residents' clinical performance. Dodson et al. conducted a survey on some otolaryngology residents, and found that improving the clinical learning environment may help improve the performance of residents in in-service training and tests (Dodson et al., 2019). Moreover, this study’s findings were consistent with the study by Willman et al. who reported that establishing a positive work environment is critical for optimized performance of residents and successful clinical outcomes (Willman & Lucke-Wold, 2021). In the young SRTP system of China, an external safeguard system for residents is insufficient, and residents still face problems such as uncertain career development, economic pressure, and huge workload (Wu et al., 2016; Xiao & Wang, 2017). Therefore, from the perspective of clinical work, SRTP administrators should pay attention to the importance of external work satisfaction of residents. More specifically, SRTP administrators should pay more attention to developing institutional educational resources (e.g., resident library, electronic educational resources, and computer room) (Dodson et al., 2019), providing institutional well-being activities (such as gym memberships, social activities outside of work, and vocational guidance) (Patro et al., 2021), and other support related to more convenient work and better resident well-being (e.g., a computerized medical record system with high standard configuration and more optimized time allocation and personnel scheduling) (Lee et al., 2017).
We also found that only 13.1% of residents were satisfied with the health policy, more than 85% felt stressed, and less than a third were satisfied with the patient–physician relationship in this study. Although the health system reform policy has been implemented for many years, healthcare providers in China have faced many challenges over the years. On the one hand, not only has the patient–physician relationship remained poor but the patients' distrust of the current healthcare system and policies is also increasing, and the number of violent incidents against healthcare providers are increasing each year (The Lancet, 2014). On the other hand, because of the huge workload, the proportion of residents experiencing burnout syndrome in China is as high as 61–71% (Li et al., 2020; Huang et al., 2020; Zhang et al., 2019). In addition, as SRTP in China was initiated nationally, residents face increased challenges, such as three years of high-stress training, career uncertainty, and low salary. Because of these challenges, some young doctors lose their enthusiasm in the medical profession and regret their decision to study medicine (Wu et al., 2016). Given the challenges faced by Chinese residents and their dissatisfaction with work environments and policies, policy-makers should develop and maintain supportive work policies for healthcare providers as their professional and ethical responsibility (Xiao et al., 2014; Kuehn, 2010). Several studies suggest that following conditions should be improved for Chinese residents: the equity of residents' rights in SRTP, establishment of supportive working environment, legal protection of residents' rights and interests, and title evaluation system (Cao & Chen, 2019; Sun et al., 2020).
Based on the results of pathway analysis, empathy had a positive correlation with work-related perception with the factor load of 0.26, which provided evidence to support H2. Work-related perception was considered a medium stability factor in the tentative theory of empathy development proposed by Yu et al. A medium stability factor often represents long-standing environmental and personal limitations and may be associated with the level of empathy (Yu et al., 2022). In line with this, a cross-sectional study conducted in India found that dental interns and graduate students showed a positive correlation between empathy score and work satisfaction (Rajput et al., 2020). The findings from a 10-year follow-up study in nurses also showed that long-term work satisfaction was related to the degree of empathy (Sand, 2003). Empathy is a basic parameter for competence among residents in their daily work, but when they face illness and death every day with low level of empathy, they can not establish a good therapeutic relationship with patients, resulting in burnout, stress, and hostile working environment, which ultimately leads to heavy workload and a bad work-related perception (Jia, 2018). Previous studies have found that factors such as negative emotions, work dissatisfaction, and poor work conditions may in turn accelerate the decline of empathy and clinical performance during clinical internships and training (Pohontsch et al., 2018; Wilkinson et al., 2017), forming a “vicious circle”. Han and Pappas indicated in their review that “hidden curriculum” during resident training may be the main reason for this phenomenon (Han & Pappas, 2018). The hidden curriculum could be defined as “a set of influences that function at the level of organizational structure and culture,” and comprise rituals, assumptions, and what is implicitly taught (Lases et al., 2019). The existing technocratic and biomedical paradigm of medicine creates an environment wherein vulnerability is punishable, imperfection is denied, and control is valued (Shapiro, 2008). Poor work–life balance, lack of social support, insufficient role models, and many practical problems in clinical reality have a negative impact on the empathy of residents and aggravate their work-related distress (Han & Pappas, 2018). Therefore, there has been a widespread institutional call for interventions based on “hidden lessons” in clinical learning settings, such as standardized management of the tutors of residents, a series of lectures by role models and supervisors, and self-awareness training for residents (Pohontsch et al., 2018; Arora et al., 2010; Bandini et al., 2017).
Finally, this study found that work-related perception played a mediating role between empathy and clinical performance, which fully supports H4. The indirect effect of work-related perception accounted for 21.9% of the total effect with regard to the relationship between empathy and clinical performance, which indicated that work-related perception had a partial mediating role. The higher the residents' empathy, the better their work-related perception, and the stronger their clinical performance. According to positive psychology, the first possible explanation for the partial mediating role of work-related perception could be that residents with high level of empathy could enhance their confidence in communicating with patients in clinical practice, improve the patient–physician relationship, and reduce work-related stress (Looi, 2008), and this patient-centered relationship can further improve the clinical performance of residents in history-taking, making accurate diagnoses, and developing correct treatment plans (Li et al., 2021). Based on Maslow's Hierarchy of Needs theory (Hale et al., 2019), another possible explanation for the results could be that the perception of residents with work represents their need to be respected or need for self-actualization in clinical practice (Hui et al., 2019). Providers who consider healthcare work as a form of altruism are more likely to implement empathetic care, which can further lead to better clinical performance (Huber & MacDonald, 2011). In addition, residents with low empathy may have a negative attitude toward SRTP because of poor patient–physician relationship and work pressure, which could easily lead to job burnout, resulting in dissatisfaction with work and irresponsible attitude; the level of clinical performance will naturally decline accordingly (Huang et al., 2020).
Limitations and Future Research
This study has several limitations. First, the included residents were recruited only from Liaoning province in China, and therefore, may not be representative of a larger population. Furthermore, the two factors of work-related perception and clinical performance were all composed of self-reported simple items; however, these items are so subjective that the response bias and social desirability bias of using them to collect data cannot be avoided. Future studies could include behavioral or brain imaging investigations to enhance the confidence of the results. Finally, because this study was a multi-center cross-sectional study, the direction of causality for some factors could not be determined. In the future, a longitudinal study design should be employed to demonstrate causality.