This study is one of the rare studies that focuses on patient and contextual variables, rather than solely on physicians, in order to explain PPPE in family medicine dealing with chronic diseases. The first striking result is that when physician variables were placed in competition with patient and contextual variables in the same model, PPPE was not explained by physician variables (except for physician age, one of the 11 physician variables tested, but with a small effect size). Even reflective activities by the physician, such as Balint-group attendance and being a clinical supervisor, were not significant. This finding may help take some of the spotlight off the GPs, who may be unfairly considered as the sole individuals responsible for PPPE. Consequently, empathy training for physicians would gain from being embedded more fully in specific contexts, not only bad-news contexts, which have been extensively studied, but also such as short consultations, which have received almost no attention despite their high frequency. Indeed, the average length of GP consultations is 15 minutes in continental Europe [34] and 10.9 minutes in England [35]. Congruent with previous meta-analytic data [36], we found that longer consultations led to increased PPPE, especially for a time < 20 minutes. It is difficult for physicians to be perceived as empathic within the space of 10 minutes, which underlines the dynamic and interpersonal process at stake in empathy [19, 37]. As Main (2022) and Murphy et al. (2022) have convincingly argued, empathy is an iterative process of genuine curiosity towards patients that involves paying attention to them, drawing inferences, seeking feedback from the patient to check the inferences drawn, trying to consider what might help and so on. The back-and-forth communication requires more than just a few minutes, especially in a setting where medical issues are front and centre, leaving limited cognitive resources available for this empathic process.
Nevertheless, in 10-minute consultations, patients with high ES were able to compensate for the lack of time and still perceive high physician empathy. High ES helps patients to communicate their needs efficiently, as well as to understand and tolerate frustration. Therefore, we assume that, despite limited time, patients with high ES were able to get the help they needed. For this reason, physicians were still perceived as empathetic, as, with the help of cooperative and “efficient” patients, they were able to respond to their needs despite time constraints. This explanation aligns with the finding that cooperative/thankful patients are more susceptible to perceiving health-care professionals as empathetic (Pavlova et al., 2022). By contrast, in five- to ten-minute consultations, patients with low ES did not find their physician empathetic. They probably need more support, which requires more time. Moreover, the greatest effect size in our results was found for the number of consultations in the last 12 months. The mutual understanding that builds up over the course of consultations enables greater PPPE. Our findings confirm similar results that have been found in GP, revealing the benefits of higher frequencies of visits for both therapeutic alliance [38] and patients’ ability to cope with their health problems [39].
Taken together, our results point to three recommendations.
First, the first consultation(s) with a new patient whose ES is unknown, as well as consultations with infrequently seen patients, should ideally last at least 20 minutes, to allow the empathic process to unfold, leading to PPPE and the numerous positive outcomes of empathy. Twenty minutes may be considered costly from an economic perspective, but cost-effectiveness analyses show that reduced health-care costs are made possible by patient-centered care [40, 41], of which empathy is a core element. Furthermore, given an eight-hour working day, twenty-minute consultations allow 24 consultations a day, which is the threshold of general practice deemed sustainable [34].
Second, another recommendation is that more time be devoted to patients with low ES. These patients can be identified by physicians using several different criteria. They have more somatic symptom disorders and related conditions [42], more health consumption, such as reimbursed and non-reimbursed drug consumption or consultations with GP and psychiatrists [43], increased rates of alcohol disorders, anxiety, depression, perceived stress, social phobia, emotional, mental and physical work fatigue, and suicidal ideation [44]. These symptoms/signs or medical antecedents could help GPs not only to prioritise longer consultations with such patients, but also to refer them to mental health specialists, as these fragile patients need tailored help. In fact, results from cancer care suggest that even the most empathetic GPs would probably not be able to alleviate these patients’ suffering [29].
Third, chronic illnesses that can have an impact on patients' intimacy may require more attention. Time was an important component for understanding PPPE, but the content and unfolding of doctor-patient interactions should also be considered. When doctors talk much more than patients in consultations, hindering the unfolding for the empathic process, patients show a poor prognosis understanding in cancer care [45]. In clinical domains dealing with intimate areas, such as prostate cancer, consultation duration does not always coincide with a prolonged conversation on psychosocial relevant issues [46]. This may be the reason why we found that patients with genitourinary issues report lower physician empathy scores. Intimate concerns related to incontinence, prostate and reproductive organs may be difficult for patients to disclose and may be overlooked by physicians, leading to less perceived empathy. In fact, if the patients themselves do not spontaneously raise the topic of sexual health, most physicians fail to address it with chronic patients in GP [47]. Furthermore, patients with genitourinary issues may also have to get undressed for clinical examination, which makes them vulnerable, thus requiring greater physician empathy and consideration, which may also explain why PPPE was lower in those patients.
Limitations
The mean PPPE score of 45 in our sample is slightly higher than those for GPs in other countries which are around 42–43 [36]. Many hypotheses are possible. Although the GPs were clearly invited to enroll eligible patients consecutively over three days, most of them took more time to recruit patients. They may have proposed the study to their most “willing” patients or when they had enough time. It is also possible that patients who were dissatisfied with their GP did not dare to participate and were thus underrepresented. Furthermore, our patient sample was mostly poorly educated (only 13% have a university degree), and low education is known to be associated with higher PPPE [48], probably due to reduced expectations from GPs. Finally, it is possible that physicians, knowing that they would be assessed on their empathy, made extra efforts to appear empathetic, even without being aware of it. Two specificities of our physician sample should also be kept in mind. Women were underrepresented, with only 22% of the doctors being female, whereas it is now estimated that 49% of GPs in France are women [49]. The GPs were also mostly experienced ones. Finally, the five items used to assess ES yielded a poor Cronbach’s alpha so that the results should be replicated using a short validated version of ES such as the 12-item scale of ES published after our patient recruitment in 2020 [50].