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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Assessment of psychological variables amongst Indian medical professionals: A cross-sectional study
Preeti Kodancha1, Aryan Dwivedi2, Ankith Appalla Rajesh Babu3, Suprakash Chaudhury4, Santosh Kumar5, Jyoti Prakash6
1 Department of Clinical Psychology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 MBBS Student, Dr. D Y Patil Medical College, Hospital and Research Centre, Maharashtra, India
3 MBBS Student, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
4 Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India
5 Department of Psychiatry, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar, India
6 Department of Psychiatry, Armed Forces Medical College (AFMC), Pune, India
| Date of Submission | 11-Mar-2022 |
| Date of Decision | 22-Aug-2022 |
| Date of Acceptance | 23-Aug-2022 |
| Date of Web Publication | 30-Dec-2022 |
Correspondence Address:
Santosh Kumar,
Associate Professor of Psychiatry, Indira Gandhi Institute of Medical Sciences (IGIMS), Sheikhpura, Patna – 800 014, Bihar
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjdrdypu.mjdrdypu_201_22
Background: The doctor–patient relationship is of critical importance to patient satisfaction and is impacted by various doctor-related factors. Aim: To assess the levels of emotional intelligence (EI), empathy, everyday/perceived discrimination and verbal aggression amongst medical professionals and medical students, and to understand the interrelations between these variables and their differences across groups. Materials and Methods: This cross-sectional study included convenience sampling of 191 medical students, and 94 medical professionals (residents and attending doctors). They were administered the Wong and Law emotional intelligence scale, Toronto empathy questionnaire, everyday discrimination scale and verbal aggression sub-scale from the Buss–Perry aggression scale. Data was analysed using Statistical Package for Social Sciences 20. Results: EI was significantly greater amongst professionals as compared to students, and positively correlated to years of experience in the medical profession. Everyday discrimination increased with years of experience in the medical fraternity and was also negatively correlated with the 'emotion regulation' component of EI. Female participants had higher levels of empathy and lower levels of everyday discrimination. Conclusion: In Indian medical professionals the levels of EI increase with years of experience and are higher for medical professionals than students. The levels of perceived discrimination increase with years of experience and were greater for medical professionals and male doctors. Perceived discrimination and verbal aggression showed a negative association with empathy and EI. Understanding the factors that impact the doctor–patient relationship, as well as the doctor's personal experience in the medical fraternity, are crucial to improve patient satisfaction, as well as to improve the well-being of the medical professionals.
Keywords: Doctor–patient relationship, empathy, emotional intelligence, everyday discrimination, medical professionals, medical students, verbal aggression
How to cite this URL:
Kodancha P, Dwivedi A, Rajesh Babu AA, Chaudhury S, Kumar S, Prakash J. Assessment of psychological variables amongst Indian medical professionals: A cross-sectional study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=366387 |
| Introduction | |  |
The term 'relationship' in doctor–patient relationship refers to an entity that encompasses the activities of two interacting persons, which allows the two people to feel at ease with variable degrees of intimacy allowing the patient to convey personal and intimate information in a safe environment.[1] This relationship dictates the patient's perception of the interventions, goals of treatment, and even the perception of the doctor.[2] In India, rapid commercialization and globalisation have led to a deterioration in the doctor–patient relationship.[3] Moreover, the doctor–patient ratio in India stands at 1:1404, well below the World Health Organisation prescribed norm. In tandem, the average time of a physician consultation in India is around 2.5 min—over 8 times lesser than the average consultation times in the top two countries for this statistic (USA and Sweden) where consultations last for over 20 min.[4] These factors, compounded by the increased workload during the COVID-19 pandemic, have resulted in an upward trend of aggression and violence against doctors, especially female specialists and resident doctors.[5]
Emotional intelligence (EI) the 'ability to monitor one's own and other's feelings and emotions, to discriminate amongst them and to use this information to guide one's thinking and actions' is linked to lesser levels of burnout and greater job satisfaction amongst medical professionals,[6] which in turn are correlated to higher degrees of patient satisfaction.[7],[8] EI is one of the strongest predictors of resident well-being.[9] The closely related personality trait of 'empathy'—which enables one to identify with another's situation, thoughts or condition by placing oneself in their situation—has consistently been linked with improved patient outcomes, ratings on clinical competence, grades and also fewer clinical errors.[10] Physician empathy influences patient satisfaction as well as compliance through a plethora of mediating factors including information exchange, perceived expertise, interpersonal trust and partnership.[11] Verbal aggression is considered to be both a trait and a relational pattern.[12] Aggression amongst medical professionals is a primary source of stress and an indicator of poor professional quality of life.[13],[14] However, some studies suggest that medical professionals have lower levels of verbal aggression than the general population.[15] Thus this phenomenon needs further exploration amongst medical professionals. 'Everyday/perceived discrimination' or 'the belief that one has experienced unfair treatment based on personal characteristics' has not been evaluated in the medical profession.[8] Perceived discrimination is a chronic stressor that invokes poor mental and physical health outcomes.[16],[17] Most literature on discrimination amongst medical professionals sheds light on the experiences of doctors belonging to ethical minorities.[18] Perceived discrimination is associated with lower satisfaction with care, reduced adherence to care, lower quality patient/provider communication, underutilization of preventive health services and poor overall self-reported health.[19]
Despite the overwhelming evidence for the direct role of EI and empathy in determining patient outcomes, Indian studies in this field are limited.[9],[20] There is also a dearth of literature regarding perceived discrimination and verbal aggression. Hence, our study aims to understand the levels of EI, empathy, verbal aggression and everyday/perceived discrimination amongst Indian medical professionals and medical students, and the interrelations between these factors, to develop a rounded understanding of the constellation of doctor-dependent factors that mould the doctor–patient relationship. It also attempts to gauge how the above-stated variables vary by age and gender amongst Indian medical professionals.
| Materials and Methods | | |
Design
The current study follows a cross-sectional survey design, with data gathered from three institutions and two separate sample groups—medical professionals and students.
Sample
The non-probability sampling technique of convenience sampling was used to recruit the sample.
Inclusion criteria
The individual must be medical professionals who have completed their undergraduate degree in medicine, as well as residents (qualified medical graduates pursuing postgraduate specialisation) or medical students who are pursuing an undergraduate degree in medicine. The individuals must be above the age of 18 years.
Exclusion criteria
The individuals must not have retired from their work in the medical profession or dropped out from their medical education and they must not be suffering from a psychiatric disorder.
Sample Size calculation
- The sample size was calculated using the following formula:
n = required sample size
T = confidence level at 95%
P = estimated prevalence of verbal aggression 30.8%
M = margin of error at 5%
n = 327.5
The sample size calculated comes to around 328. However, due to the physical restrictions during the pandemic, a total of 285 doctors and medical students could be included in the study.
Tools
Sociodemographic survey form
This self-made questionnaire enquired about the socio-demographic details of the subjects.
Wong and Law emotional intelligence scale
This 16-item scale has high reliability (Cronbach's α = 0.83, split-half reliability coefficient = 0.89), and significant concurrent validity for an Indian population.[21],[22]
Toronto empathy questionnaire
This 16-item questionnaire has a high test–retest reliability (r = 0.81), as well as good discriminant and convergent validities.[23]
Everyday discrimination scale (EDS)
This 9-item scale was used to measure everyday discrimination. The EDS is a widely used scale with excellent psychometric properties (Cronbach's α = 0.87).[24]
Verbal aggression sub-scale from the Buss–Perry aggression scale
The 5-item verbal aggression sub-scale has good reliability (Cronbach's α =0.68).[25],[26]
Method
Data was collected via Google form filled anonymously over a period of 3 weeks in September 2020, while the country was still grappling with the first wave of the COVID-19 pandemic. After data collection was completed, responses were collated and audited.
Statistical analysis
Data analysis was conducted using the Statistical Package for Social Sciences 20 (IBM, Atlanta, USA). Descriptive statistics were used to understand the nature of the data. Spearman's rank-order correlation was used to measure the relationship between the various variables. Mann–Whitney U test was used to understand the levels of variables across groups. Multiple linear regression was used to understand the predictive relations between the variables.
Ethical considerations
The current work complies with the ethical standards of the Helsinki Declaration of 1975, as revised in 2008. The study was approved by the Institutional Ethical Subcommittee (Letter No. I. E. S. C./61/2020). The participants were informed of the voluntary nature of the participation, their right to withdraw from the study, and clauses on confidentiality and anonymity of data. Written informed consent was obtained.
| Results | | |
The sample consisted of 285 participants, with ages ranging from 18 to 63 years [Mean age = 24.99; standard deviation (SD) = 9.37]. There were 156 females and 129 males. The study sample included 191 medical students and 94 medical professionals, which further consisted of 45 attending doctors and 49 residents. The participants were engaged with private, public and government-aided institutions. The descriptive statistics of the data is given in [Table 1]. | Table 1: Descriptive statistics for empathy, EI, everyday discrimination and verbal aggression
Click here to view |
Empathy had a significant negative association with the total level of 'EI', as well as the levels of the sub-domains of 'Emotional Regulation' and 'Use of Emotions'. Perceived discrimination showed weak negative associations with empathy and all subscales of EI—and showed a significant negative correlation with 'Emotional Regulation' [Table 2]. | Table 2: Results of Spearman's rank-order correlation for empathy, EI, everyday discrimination and verbal aggression
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Both the participants' age and years of experience in the medical fraternity were significantly positively correlated to all the subscales of EI and the total score, except 'Emotional Regulation' with which they were negatively correlated. The participants' age and years of experience in the medical fraternity had a significant positive association with the levels of perceived discrimination [Table 3]. | Table 3: Results of Spearman's rank-order correlation of empathy, EI, everyday discrimination and verbal aggression with age and experience
Click here to view |
Levels of EI and all its domains except 'Emotional Regulation' were found to be significantly higher for the medical professionals than for the students. Medical professionals also had greater levels of perceived discrimination. Levels of verbal aggression did not differ significantly between doctors and students [Table 4]. | Table 4: Comparison of levels of empathy, EI, everyday discrimination and verbal aggression amongst medical professionals and medical students
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The levels of empathy, emotional regulation and use of emotions were significantly higher for females than for males. The degree of everyday discrimination is significantly greater for males than for females [Table 5]. | Table 5: Comparison of levels of empathy, EI, everyday discrimination and verbal aggression amongst male and female subjects
Click here to view |
Results from the multiple regression to predict empathy from gender, age, total EI and its subscales, category of doctors, discrimination and aggression showed that these variables statistically significantly predicted empathy, F (2, 282) = 6.443, P<0.002, R2=0.044. Only gender and total EI added statistically significantly to the prediction, P<0.05 [Table 6]. | Table 6: Multiple regression analysis for predictors of empathy: coefficients
Click here to view |
Another multiple regression was run to predict discrimination from gender, age, total EI and its subscales, category of doctors, empathy and aggression. These variables statistically significantly predicted empathy, F (3, 281) = 8.744, P<0.001, R2=0.085. Only the age, gender and category added statistically significantly to the prediction, P<0.05 [Table 7]. | Table 7: Multiple regression analysis for predictors of everyday discrimination coefficients
Click here to view |
| Discussion | | |
The current study was an attempt to explore various factors intrinsic to the doctor such as EI, empathy, verbal aggression and everyday/perceived discrimination amongst Indian medical professionals and students, and the interrelations between these factors, while gauging the influence of experience and gender on these variables, to develop a comprehensive understanding of the collection of doctor-dependent factors that mould the doctor–patient relationship. The study was situated in the times of the COVID-19 pandemic when there are rampant reports of mistreatment of and discrimination against medical professionals, and very minimal consultation times between the doctor and the patient.
The age of the participants and their years of experience in the medical fraternity showed parallel trends with regard to EI—both the variables were significantly positively correlated to 'Self Emotions Appraisal', 'Use of Emotions', 'Others-Emotion Appraisal' and the total EI scores. This is in concurrence with research literature—experience is an important contributory factor in the development of EI. As individuals mature, they become more sensitive to the feeling of others.[27] Studies of changes in EI across adult life suggest that despite the additional emotional challenges that older people face, they experience more subjective well-being. In addition, studies of affective processing across the lifespan suggest that older adults may be more adept at regulating their emotions than younger adults. Put together, this would suggest that particular aspects of EI may increase with age.[28] There is clearly a developmental component of EI, indicating that EI can be learned.[29] Hence, the inclusion of empathy in medical curricula can possibly lead to an increase in EI amongst medical students.[30] In contrast, the 'Emotional Regulation' component of EI showed a negative correlation with age and years of experience. There is some literature that suggests that younger adults report a greater ability to prevent strong emotions from interfering with their work as compared to either middle age or older adults.[31]
Empathy had a significant negative association with emotional regulation, use of emotions and the total level of EI in the current study. This is in contrast to existing literature.[22],[32] This may be attributed to the fact that the data is drawn from a relatively small population from a limited age range.[23] Other contributory factors that elicited such findings could include social desirability biases or online modes of data collection.[31],[33]
Perceived discrimination showed weak negative associations with empathy and all subscales of EI and showed a significant negative correlation with 'Emotional Regulation'. Current literature exploring perceived discrimination and its association with empathy and EI is very limited. However, it is known that EI and empathy are predictors of resident well-being, and their deficit leads to burnout and stress.[9] EI is also a factor that contributes towards understanding doctors' work-related issues with recorded positive correlations between nurse-rated EI of a doctor and patient satisfaction.[6] In view of the above, low EI and empathy could imply increased levels of stress, a lack of understanding of a doctor's own work-related issues and low patient satisfaction. Further, there is ample indirect evidence to suggest that these variables are linked to better patient outcomes and clinical competence.[34] Lower levels of EI and empathy could thus serve as a facilitator for increased perceived discrimination from patients and faculty members (in the case of medical students) by virtue of decreased clinical competence and poorer patient outcomes.
The age and years of experience in the medical fraternity had a significant positive association with the levels of perceived discrimination. There is mixed evidence in this regard—while some studies show a positive correlation between age and perceived discrimination, others show negative correlations.[35],[36] With regard to the medical fraternity specifically, there are no studies on perceived discrimination faced by medical professionals. However, one potential cause for the greater degree of perceived discrimination amongst the older generation might be workplace ageism which is the 'systemic stereotyping of and discrimination against people on the basis of their age'.[37] However, various other factors may have contributory roles to mediate this relationship, and further exploration is warranted to understand their nature.
Verbal aggression showed weak negative associations with empathy, as well as the subscales of EI in the present study. While few studies look at verbal aggression specifically, existing literature indicates a marked negative relationship between empathy and EI with aggression as a whole.[38] However, these variables have not been explored in a medical setting. Hence, the lack of significant correlation observed by the current study may be either due to the lack of such an association specifically in the medical fraternity, or social desirability factors amongst individuals in the medical fraternity due to the prevailing attitude regarding the nobility of the profession. The general trend in literature is only to study the aggression against doctors and not the aggression that the medical professionals may engender.[39],[40]
Another important result was that there was no significant difference in the levels of empathy between medical professionals and students. This finding is in contrast with the results of an earlier study which suggested that cynicism increases as an individual progress in medical education, leading to a decrease in empathy.[41] The result may owe to the fact that empathy is a relatively stable constitutional trait, meaning it is not relatively heavily influenced by one's experiences, as compared to other psychological variables.[42] The results pertaining to empathy hold implications for a satisfactory doctor–patient relationship, which has an impact on clinical competence and is hence an important variable amongst the medical fraternity.[41] The levels of 'Self Emotions Appraisal', 'Use of Emotions', 'Others-Emotion Appraisal' and the total EI scores were significantly greater amongst medical professionals compared to medical students. Interpersonal ability, stress management and adaptability are all factors affecting EI.[43] This could explain the findings in this study, as all these three factors become increasingly relevant as medical education progresses, thereby explaining why doctors possibly score much higher in EI given their increased experience. Higher EI is significantly associated with lower rates of burnout and higher job satisfaction and in addition, less burnout was not only associated with higher levels of patient satisfaction but also with higher levels of job satisfaction.[6]
Females were shown to have higher levels of empathy compared to their male counterparts, in concurrence with vast amounts of literature.[44] Findings also indicated that females had significantly greater levels of certain components of EI (emotional regulation and use of emotions), as compared to males—as depicted by existing literature.[45] This consistent disparity in the empathy and EI levels of males and females may be due to extrinsic factors (role expected by society) or intrinsic factors (biological characteristics) as has been shown in neurologically based studies of empathy.[46] The parental investment theory also affords a reasonable explanation for higher empathy scores amongst women—mothers are expected to develop a stronger sense of caring and to be more skilled in understanding their offspring's emotions and needs to ensure their survival.[47] Women have a greater emotional receptivity and are more likely to develop and value interpersonal relationships and to offer more emotional support than men, tending to have more humanistic attitudes, greater social sensitivity and greater care. On the other hand, men would tend to adopt attitudes of 'justice, independence and control'.[46] This could imply that females render a different type of medical care altogether based on a better understanding of the patient's experiences and feelings. Given the increasing number of women in medicine and the high proportion of female patients, this could have significant implications for medical care altogether.[41]
The regression analysis yielded the following findings indicated that gender and total EI score predict empathy. The role of gender in predicting empathy is backed by numerous studies, most of which indicate that females have higher levels of empathy.[47] However, EI has been positively associated with empathy in some studies.[32] Our study does associate the two concepts, but negatively as opposed to positively. This could owe to limitations such as social desirability biases of the respondents and relatively small sample sizes. There is also literature suggesting that women use more strategies for emotional regulation than men.[48] This would interestingly link EI with gender, both of which are associated with empathy as per our regression analysis findings and existing literature.
The regression analysis also showed that everyday discrimination is linked with category, age and gender. Everyday discrimination is a construct that has previously been largely studied from the context of race. It has been reported that younger individuals from a given ethnic race were more discriminated against compared to older individuals from the same race.[49] Contrarily, our study's results indicate higher perceived discrimination amongst the older individuals of the Indian medical fraternity compared to the younger ones. However, it is again important to emphasise that this comparison draws at the common denominator of age, with race and profession being used, respectively, to flesh out differences.
The current findings, including differences in the levels of various variables between the sample groups, open up broader avenues for further research in the field. Perceived discrimination and verbal aggression were variables that had not been explored in relation to each other, and to the medical fraternity. However, these variables are of particular interest, more recently owing to the COVID-19 pandemic, and more generally, in the Indian context. The positive correlation between perceived discrimination and age as shown by the study brings to light an area for further exploration to provide causal explanations for the same.
As for implications for medical practice, EI and empathy play a key role in determining the experience that a patient has in a doctor's cabin. The doctors' empathy, active listening skills, understanding of patients/their own views and ability to handle stress are linked to the construct of EI.[21] Individuals with higher EI cope better with the emotional demands of stressful encounters because they can accurately perceive and appraise their emotions and can effectively regulate their mood states.[50] One of the popular explanations for the efficacy of EI in determining physician success is that individuals with low EI may engage in damaging behaviours and poor management skills.[51] Evidently, one way to develop EI would be to allow lifespan development to take its course, allowing the medical professional to falter in interpersonal relations along the way and learn from their mistakes. A more active approach would be to inculcate EI training into the medical curriculum such that even the young medical professional is competent in managing interpersonal interactions with the patients. Obviously, the comprehensive 'know-how' for handling the doctor–patient relationship cannot be fully learned in school.[52] In addition to clinical training that emphasises empathic care, medical students can be provided practical training in EI-building, given how EI can be developed through appropriate interventions.[6]
The findings regarding perceived discrimination—that male doctors and experienced doctors experience higher levels—are also a cause for concern. Since perceived discrimination impacts various factors including well-being, there is an urgent need to rectify the same.
Limitations
The size of the sample is limited and from only three centres. These factors, taken together, limit the generalizability of the findings. The category of medical students is largely homogenous. But, the category of 'medical professional' includes both residents as well as attending doctors. There is also wide variability in the years of experience of the attending doctors. Considering this heterogeneous group with widely varying experiences may have hindered a comprehensive understanding of the phenomena. Further, the study was carried out during the COVID-19 pandemic, which may have impacted the findings.
| Conclusion | | |
In Indian medical professionals, the levels of EI increase with the year of experience and are greater for medical professionals than students. The levels of everyday discrimination were found to increase with the years of experience and were greater for medical professionals and male doctors. Understanding the various factors that impact the doctor–patient relationship, as well as the doctor's personal experience in the medical fraternity, are crucial—both to improve patient care and satisfaction, as well as to improve the well-being of the medical professionals and students.
Acknowledgements
The authors would like to extend their sincere gratitude to Dr. Amitav Banerjee, Professor and HOD and Dr. Hetal Rathod, Professor, Department of Preventive and Social Medicine, Dr. D. Y. Patil Medical College, Pune for their guidance. The authors are grateful to Dr. Sarita Mulkalwar, Department of Pharmacology, Dr. Siva, Resident, Department of Surgery and Dr. Biswajeet Chakrabarty, Resident, Department of Preventive and Social Medicine, Dr. D. Y, Patil Medical College, Pune for facilitating the process of data collection.
Declaration of patient consent
The authors certify that they have obtained all appropriate subject/participant consent forms. In the form, the subject/participant has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The subject/participant understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]
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