SCIENTIFIC ARTICLE

Physician Empathy as a Driver of Hand Surgery

Patient Satisfaction
Mariano E. Menendez, MD,* Neal C. Chen, MD,* Chaitanya S. Mudgal, MD,*
Jesse B. Jupiter, MD,* David Ring, MD, PhD*

Purpose To examine the relationship between patient-rated physician empathy and patient
satisfaction after a single new hand surgery office visit.
Methods Directly after the office visit, 112 consecutive new patients rated their overall satis-
faction with the provider and completed the Consultation and Relational Empathy Measure, the
Newest Vital Sign health literacy test, a sociodemographic survey, and 3 Patient-Reported
Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper-
Extremity Function, and Depression. We also measured the waiting time in the office to see
the physician, the duration of the visit, and the time from booking until appointment. Multi-
variable logistic and linear regression models were used to identify factors independently
associated with patient satisfaction.
Results Patient-rated physician empathy correlated strongly with the degree of overall satis-
faction with the provider. After controlling for confounding effects, greater empathy was
independently associated with patient satisfaction, and it alone accounted for 65% of the
variation in satisfaction scores. Older patient age was also associated with satisfaction. There
were no differences between satisfied and dissatisfied patients with regard to waiting time in
the office, duration of the appointment, time from booking until appointment, and health
literacy.
Conclusions Physician empathy was the strongest driver of patient satisfaction in the hand surgery
office setting. As patient satisfaction plays a growing role in reimbursement, targeted educa-
tional programs to enhance empathic communication skills in hand surgeons merit consider-
ation. (J Hand Surg Am. 2015;40(9):1860e1865. Copyright Ó 2015 by the American Society
for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Prognostic II.
Key words Empathy, communication, patient satisfaction, health literacy, reimbursement.

A
S HEALTH CARE IN THE United States transitions
From the *Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard
Medical School, Boston, MA. from a fee-for-service to an outcomes-based
Received for publication April 23, 2015; accepted in revised form June 4, 2015.
environment, enhancing the patient experi-
ence has become a priority for both policymakers and
No benefits in any form have been received or will be received related directly or indirectly
to the subject of this article. clinical leaders.1 Patient satisfaction is a key dimension
Corresponding author: David Ring, MD, PhD, Department of Orthopaedic Surgery, of patient-centered care and is increasingly incentiv-
Massachusetts General Hospital, 55 Fruit St., Yawkey Center, Suite 2100, Boston, MA 02114; ized and publicly reported.2e5 Satisfied patients do not
e-mail: dring@partners.org. necessarily have better outcomes6,7 but are more likely
0363-5023/15/4009-0019$36.00/0 to comply with treatments, keep office appointments,
http://dx.doi.org/10.1016/j.jhsa.2015.06.105
and not file complaints or lawsuits.1,8e11

1860 r Ó 2015 ASSH r Published by Elsevier, Inc. All rights reserved.

 EMPATHY AND PATIENT SATISFACTION
Despite growing interest, drivers of patient satis-
faction remain incompletely understood in the hand
surgery office setting.12e17 Patient satisfaction has
been inconsistently linked to emotional health,13,15,17
educational attainment,12 waiting time,16 involve-
ment in decision making,13 and expectations of care;14
yet, what is common to previous studies is the inability
to explain most of the variation in patient sat-
isfaction.12e17 Empathy—the ability to understand
and share the feelings, thoughts, or attitudes of
another—is an essential component of the patiente
physician relationship, but research on its influence on
patient satisfaction is scarce and confined to the pri-
mary care setting.18,19 In a highly specialized and
technical field such as hand surgery—in which the
usual model of clinical care is “find the problem and
fix it”—identifying whether patients value affective
concern is important for quality improvement purposes
and may have economic and clinical implications.
We undertook this study to examine the relationship
between physician empathy and patient satisfaction
after a single hand surgery new office visit. We tested
the primary null hypothesis that there was no associa-
tion between patient-rated physician empathy and the
degree of overall satisfaction with the provider. In
addition, we sought to identify other correlates of pa-
tient satisfaction (eg, health literacy, psychological
distress, waiting time, and duration of the appointment).
MATERIALS AND METHODS
Study design
After approval of our institutional review board, 115
patients visiting the office of 1 of 4 orthopedic hand
surgeons for the first time were asked to enroll in this
cross-sectional study. Patients were considered eli-
gible for the study if they were at least 18 years old
and spoke English fluently. Enrollment took place
between December 2013 and March 2014. The pa-
tients were consecutively enrolled one clinic day a
week. Three patients declined participation, leaving
112 patients in the cohort. Informed consent was ob-
tained from each participant before enrollment.
Immediately after the visit, a research fellow not
involved in patient care asked all consenting patients to
rate their overall satisfaction with the provider and to
complete a sociodemographic survey (eg, age, sex, race
and/or ethnicity, education, insurance status, work
status, and marital status), the Newest Vital Sign
(NVS) health literacy test,20 the Consultation and Re-
lational Empathy (CARE) Measure,21,22 and 3 Patient-
Reported Outcomes Measurement Information System
(PROMIS)-based computerized adaptive testing
questionnaires: Pain Interference,23 Upper-Extremity
J Hand Surg Am. r Vol. 40, September 2015
1861
Function,24 and Depression.25 We also measured the
waiting time in the office to see the physician (time
elapsed from front office registration until the attending
physician entered the room), the duration of the visit,
and the time from consultation request to actual
appointment. The management was classified as op-
erative, nonsurgical (eg, orthosis, corticosteroid injec-
tion, and hand therapy), diagnostic testing (eg, CT,
MRI, ultrasound, and electromyography), or coun-
seling and/or observation. Although the physicians
were aware of the existence of this study, they were
unaware of which patients were being enrolled into it,
and neither the patients nor providers knew they were
being timed. With the exception of the NVS test, all
questionnaires were completed using a laptop com-
puter, and the answers were collected in a spreadsheet.
The NVS was administered orally and the answers
were collected in the same spreadsheet.
Outcome measures
The primary outcome of interest was patient satisfac-
tion, measured directly after the office visit. Using an
item derived from the Clinician and Group-Consumer
Assessment of Healthcare Providers and Systems
Adult Visit Survey,26,27 we asked patients to rate their
overall satisfaction with the provider on a scale from
0 (worst doctor possible) to 10 (best doctor possible).
As described previously by Jha et al,28 patients were
considered satisfied if they rated this item with a 9 or
10. The Clinician and Group-Consumer Assessment of
Healthcare Providers and Systems survey is a stan-
dardized survey instrument developed by the Agency
for Healthcare Research and Quality to assess the pa-
tients’ experience and perception of care in ambulatory
office settings, including hand surgery.16,27,29
Our main explanatory variable was patient-rated
physician empathy, assessed using the CARE Mea-
sure.21,22 This validated questionnaire consists of 10
items that capture the patient’s perception of the
physician’s empathic understanding and behavior
during the appointment: “How was the doctor at. (1)
Making you feel at ease?; (2) Letting you tell your
‘story’?; (3) Really listening?; (4) Being interested in
you as a whole person?; (5) Fully understanding your
concerns?; (6) Showing care and compassion?; (7)
Being positive?; (8) Explaining things clearly?; (9)
Helping you take control?; (10) Making a plan of
action with you?” Each item is answered on a 5-point
Likert scale, with responses ranging from 1 (poor) to 5
(excellent). All responses are then added, giving a
maximum possible score of 50 and a minimum of 10.
The NVS is a validated 6-item instrument to deter-
mine health literacy and numeracy.20,30 It is based on a
1862 EMPATHY AND PATIENT SATISFACTION
nutrition label from an ice cream container, and the
overall test score ranges from 0 to 6.31
Fostered by the National Institutes of Health, the
PROMIS questionnaires use computerized adaptive
testing technology to tailor the most appropriate series of
questions for each patient based on their previous re-
sponses.32 The number of items administered ranges
from 4 to 12. The PROMIS Pain Interference ques-
tionnaire quantifies the extent to which pain impedes
physical, mental, and social activities;23,31 higher scores
indicate greater pain interference. The PROMIS Upper-
Extremity Function questionnaire determines the degree
of disability with physical activities that entail use of
the arm and hand, such as writing, tying shoelaces, and
lifting heavy objects24; lower scores represent higher
levels of upper-extremity disability. The PROMIS
Depression questionnaire evaluates depressive symp-
toms by measuring negative mood (guilt and sadness),
views of self (self-criticism and worthlessness), social
cognition, and decreased positive affect and engage-
ment (loss of interest, meaning, and purpose)25,33;
higher scores indicate greater symptoms of depression.
All 3 PROMIS questionnaires have been previously
validated.23e25
Statistical analysis
An a priori power analysis indicated that a minimum
sample size of 112 patients would provide 90% sta-
tistical power (a ¼ 0.05) to detect a 0.30 correlation
strength between the CARE Measure and overall
patient satisfaction with the provider.
To evaluate the association between each explana-
tory variable to patient satisfaction, we performed
bivariate analyses using the Pearson chi-square or the
Fisher exact (for cell sizes < 5) tests for categorical
variables and independent samples t tests for continuous
variables.
To minimize confounding, variables with P < .10
in bivariate analysis were inserted into multivariable
logistic regression analysis to determine factors inde-
pendently associated with patient satisfaction. All
covariates were entered into the model simultaneously
without further selection. Results were reported as
odds ratios with 95% confidence intervals. We used
the area under the receiver-operating characteristic
curve to evaluate model discrimination and the
HosmereLemeshow test to assess model calibration. To
better understand the amount of variation in satisfaction
scores explained by each of these factors (partial R2), we
also ran a multiple linear regression model. The partial
R2 measures the marginal contribution of 1 explanatory
variable when all others are already included in the
model. Statistical significance was set at P < .05.
J Hand Surg Am.
FIGURE 1: Correlation of Physician Empathy Measure with
patient satisfaction.
Patient characteristics
Our study sample consisted of 58 (52%) women and 54
men with a mean (SD) age of 51 (17) years. Most pa-
tients were white (92%), employed (66%), and either
single (35%) or married (49%). A total of 56% of pa-
tients had private insurance, 40% had government-
funded insurance (Medicare: 27%; Medicaid: 13%),
and 4.5% had workers’ compensation. The majority of
office visits were related to nontraumatic conditions
(69%). The average (SD) waiting time in the office to
see the provider was 32 (20) minutes, the mean (SD)
duration of the visit was 11 (7) minutes, and the
average (SD) time from booking until appointment
was 11 (10) days (Appendix A, available on the
Journal’s Web site at www.jhandsurg.org).
RESULTS
Patient-rated physician empathy correlated strongly
with the degree of overall satisfaction with the pro-
vider (r ¼ 0.85; P < .001; Fig. 1). After controlling for
confounding effects using multivariable modeling,
greater empathy was independently associated with
patient satisfaction, and it alone accounted for 65%
of the variation in satisfaction scores (Table 1).
Older patient age was also independently associated
with patient satisfaction. There were no differences
between satisfied and dissatisfied patients with regard
to waiting time in the office (32  20 vs 31  22 min;
P ¼ .82), duration of the appointment (11  7 vs 10  5
min; P ¼ .78), time from booking until appointment
(11  11 vs 9  6 d; P ¼ .29), second opinions (7.8% vs
0%; P ¼ .18), resident and/or fellow involvement
(58% vs 46%; P ¼ .30), management, and health lit-
eracy (NVS score 4.1  2.0 vs 4.4  2.0; P ¼ .60).
r Vol. 40, September 2015
 EMPATHY AND PATIENT SATISFACTION 1863

TABLE 1. Multivariable Regression of Patient Satisfaction With Provider

Logistic Regression: Factors Associated with Patient Satisfaction with Provider*
95% CI
Predictor OR Lower Upper P

Age, per 10-y increase 2.4 1.2 4.8 .011

Female sex (reference: male) 0.28 0.044 1.8 .18
CARE measure, per 1-unit increase 1.6 1.3 1.9 < .001
PROMIS Depression, per 1-unit increase 0.93 0.83 1.0 .16

Linear Regression: Which Factors Account for the Variation in Patient Satisfaction?
Predictor Coefficient (b) Adjusted R2 Partial R2 P

Age, per 10-y intervals 0.13 0.029 < .001

Sex 0.12 0.0021 .33
0.75
CARE measure 0.16 0.65 < .001
PROMIS Depression 0.013 0.0085 .055

CI, confidence interval; OR, odds ratio. 2

*Area under the receiver-operating characteristic curve ¼ 0.98 (95% CI, 0.96e0.99); Nagelkerke R ¼ 0.77; P value for the HosmereLemeshow
test ¼ .99.

DISCUSSION sentences for questions, and inquiring about quizzical

With health care reimbursement transitioning from
volume-based to value-based, patient satisfaction is
becoming an increasingly emphasized quality metric.34
The determinants of patient satisfaction remain poorly
understood in the hand surgery office setting.12e17
Despite the popular saying: “patients do not care how
much you know until they know how much you care,”35
little is known about the influence of provider empathy
on patient satisfaction in a specialty surgical office. We
therefore sought to characterize the relationship be-
tween patient-rated physician empathy and patient
satisfaction after a single new hand surgery office visit.
Empathy was the strongest driver of patient satisfac-
tion with the hand surgeon, accounting for 65% of the
variation in satisfaction scores. Our findings underscore
the relevance of effective interpersonal communication
skills and suggest that it might be more important to
ensure that patients feel heard and cared for than it is to
provide expert medical advice.17,36 Empathy can be
taught and improved through interventions.37,38 A ran-
domized trial in 99 resident physicians from different
specialties demonstrated that the group of residents who
received empathy training showed greater improvement
on patient-rated empathy.38 To improve communication
with patients, hand surgeons might consider engaging
more in active listening by paraphrasing the patients’
statements, and scripting and practicing clear expla-
nations for common hand problems, pausing between
looks (eg, “Does that fit what you were thinking?). On the
basis of the available evidence in the primary care
setting,39e41 there might be a positive relationship be-
tween the hand surgeon’s empathy and clinical outcomes.
Given the strong link between patient satisfaction and
empathy documented herein, an issue that merits con-
sideration is whether physicians’ nontechnical skills
should be measured and incentivized. Future research
should evaluate whether incentivizing physician pro-
fessionalism leads to improvements in the patient
experience. Feedback from work team members (eg,
360-degree surveys) may also provide helpful infor-
mation into how satisfied patients are with their care.29
Older patient age was independently associated with
satisfaction with the provider, a finding that is consistent
with prior work in the emergency department and pri-
mary care settings42e44 but inconsistent with a recent
study in hand surgery patients.16 Whether age-related
discrepancies in satisfaction reflect differences in pa-
tient expectations of care, differences in perceptions of
care or true differences in care should be investigated
further.45 We found that neither the waiting time to see
the hand surgeon nor the duration of the visit was related
to patient satisfaction. It is possible that satisfaction re-
lates more to the patient-perceived duration of the visit
than to the actual encounter duration. Teunis et al16 also
showed that actual time spent with a hand surgeon was
not associated with patient satisfaction, yet they found

J Hand Surg Am. r Vol. 40, September 2015

1864 EMPATHY AND PATIENT SATISFACTION
that longer waiting time correlated with decreased sa-
tisfaction. That study, however, had several limitations
including the fact that all patients were seen by a single
provider, and 44% were follow-up patients, who may
have been taking into consideration other aspects of care
unrelated to the visit (eg, treatment outcomes) when
completing the satisfaction survey. Teunis et al’s anal-
ysis consisted of automated stepwise regression models
that are known to yield biased estimates. Consistent with
a study in primary care patients,46 we found no associ-
ation between patient satisfaction and health literacy.
This is a concept that is gaining popularity in hand
surgery.31 It may be that patients value more feeling
heard and cared for than fully understanding the pro-
vider’s explanation. Given how little is known regarding
the relationship between health literacy and patient
satisfaction, more studies are encouraged to explore this
association.
Our findings should be interpreted cautiously in light
of some study limitations. First, we assessed physician
empathy from the patients’ perspective rather than re-
lying on more objective measures of empathy from
audio or video recorded visits or witnesses. Additional
research is needed to determine whether the use of these
methods yields similar results. Second, although we
included patients presenting to different hand surgeons,
this study was performed at a single urban academic
center serving predominantly white patients in the
Northeastern United States, and the results may not
generalize to other settings, populations, and regions.
Third, the results might have been different if we
enrolled patients presenting with a single condition or a
group of similar conditions, although inclusion of pa-
tients with the usual spectrum of illnesses in our office
could also be considered a strength. Fourth, we did not
collect patients’ expectation data preoperatively and on
the desired level of involvement in care, which may
influence satisfaction with the provider.14,47 Moreover,
we did not collect data on whether patients were
accompanied during the visit, which may influence
the patientephysician interaction.48 Fifth, this cross-
sectional study could not establish a causal relationship
between physician empathy and patient satisfaction.
Finally, these data represent empathy and patient satis-
faction with a single visit, which may be distinct from
what happens over several visits or after surgery.
Our study demonstrated that physician empathy was
the strongest determinant of patient satisfaction in the
hand surgery office setting. This information may help
raise awareness of the importance of interpersonal
communication skills in a technically oriented field such
as hand surgery. As patient satisfaction plays a growing
role in reimbursement, targeted educational programs to
J Hand Surg Am.
enhance empathic communication skills in hand sur-
geons merit consideration.
REFERENCES
1. Youm J, Chenok KE, Belkora J, Chiu V, Bozic KJ. The emerging
case for shared decision making in orthopaedics. Instr Course Lect.
2013;62:587e594.
2. Hudon C, Fortin M, Haggerty JL, Lambert M, Poitras ME.
Measuring patients’ perceptions of patient-centered care: a systematic
review of tools for family medicine. Ann Fam Med. 2011;9(2):
155e164.
3. Kupfer JM, Bond EU. Patient satisfaction and patient-centered care:
necessary but not equal. JAMA. 2012;308(2):139e140.
4. Szablowski KM. Hospital value-based purchasing (VBP) program:
measurement of quality and enforcement of quality improvement.
Conn Med. 2014;78(1):49e51.
5. Welty E, Yeager VA, Ouimet C, Menachemi N. Patient satisfaction
among Spanish-speaking patients in a public health setting. J Healthc
Qual. 2012;34(5):31e38.
6. Chang JT, Hays RD, Shekelle PG, et al. Patients’ global ratings of
their health care are not associated with the technical quality of their
care. Ann Intern Med. 2006;144(9):665e672.
7. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction:
a national study of patient satisfaction, health care utilization, ex-
penditures, and mortality. Arch Intern Med. 2012;172(5):405e411.
8. Guldvog B. Can patient satisfaction improve health among patients
with angina pectoris? Int J Qual Health Care. 1999;11(3):233e240.
9. Hickson GB, Clayton EW, Entman SS, et al. Obstetricians’ prior
malpractice experience and patients’ satisfaction with care. JAMA.
1994;272(20):1583e1587.
10. Kravitz R. Patient satisfaction with health care: critical outcome or
trivial pursuit? J Gen Intern Med. 1998;13(4):280e282.
11. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-
patient communication. The relationship with malpractice claims among
primary care physicians and surgeons. JAMA. 1997;277(7):553e559.
12. Barber LA, Hageman MG, King JD, Bekkers S, Bot AG, Ring D.
The influence of patients’ participation in research on their satisfac-
tion. J Hand Surg Am. 2014;39(8):1591e1594.e1593.
13. Bot AG, Bossen JK, Herndon JH, Ruchelsman DE, Ring D,
Vranceanu AM. Informed shared decision-making and patient satis-
faction. Psychosomatics. 2014;55(6):586e594.
14. Hageman MG, Briet JP, Bossen JK, Blok RD, Ring DC,
Vranceanu AM. Do previsit expectations correlate with satisfaction
of new patients presenting for evaluation with an orthopaedic surgical
practice? Clin Orthop Relat Res. 2015;473(2):716e721.
15. Lozano Calderon SA, Paiva A, Ring D. Patient satisfaction after open
carpal tunnel release correlates with depression. J Hand Surg Am.
2008;33(3):303e307.
16. Teunis T, Thornton ER, Jayakumar P, Ring D. Time seeing a hand
surgeon is not associated with patient satisfaction. Clin Orthop Relat
Res. 2015;473(7):2362e2368.
17. Vranceanu AM, Ring D. Factors associated with patient satisfaction.
J Hand Surg Am. 2011;36(9):1504e1508.
18. Kim SS, Kaplowitz S, Johnston MV. The effects of physician
empathy on patient satisfaction and compliance. Eval Health Prof.
2004;27(3):237e251.
19. Pollak KI, Alexander SC, Tulsky JA, et al. Physician empathy and
listening: associations with patient satisfaction and autonomy. J Am
Board Fam Med. 2011;24(6):665e672.
20. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in
primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514e522.
21. Mercer SW, Maxwell M, Heaney D, Watt GC. The consultation and
relational empathy (CARE) measure: development and preliminary
validation and reliability of an empathy-based consultation process
measure. Fam Pract. 2004;21(6):699e705.
22. Mercer SW, McConnachie A, Maxwell M, Heaney D, Watt GC.
Relevance and practical use of the Consultation and Relational
r Vol. 40, September 2015
 EMPATHY AND PATIENT SATISFACTION
Empathy (CARE) Measure in general practice. Fam Pract.
2005;22(3):328e334.
23. Amtmann D, Cook KF, Jensen MP, et al. Development of a PROMIS
item bank to measure pain interference. Pain. 2010;150(1):173e182.
24. Hays RD, Spritzer KL, Amtmann D, et al. Upper-extremity and
mobility subdomains from the Patient-Reported Outcomes Mea-
surement Information System (PROMIS) adult physical functioning
item bank. Arch Phys Med Rehabil. 2013;94(11):2291e2296.
25. Pilkonis PA, Choi SW, Reise SP, et al. Item banks for measuring
emotional distress from the Patient-Reported Outcomes Measurement
Information System (PROMIS(R)): depression, anxiety, and anger.
Assessment. 2011;18(3):263e283.
26. Crofton C, Lubalin JS, Darby C. Consumer Assessment of Health Plans
Study (CAHPS): Foreword. Med Care. 1999;37(3 Suppl):MS1eMS9.
27. Dyer N, Sorra JS, Smith SA, Cleary PD, Hays RD. Psychometric
properties of the Consumer Assessment of Healthcare Providers and
Systems (CAHPS(R)) Clinician and Group Adult Visit Survey. Med
Care. 2012;50(Suppl):S28eS34.
28. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of
hospital care in the United States. N Engl J Med. 2008;359(18):
1921e1931.
29. Hageman MG, Ring DC, Gregory PJ, Rubash HE, Harmon L. Do
360-degree feedback survey results relate to patient satisfaction
measures? Clin Orthop Relat Res. 2015;473(5):1590e1597.
30. Morrison AK, Chanmugathas R, Schapira MM, Gorelick MH,
Hoffmann RG, Brousseau DC. Caregiver low health literacy and
nonurgent use of the pediatric emergency department for febrile
illness. Acad Pediatr. 2014;14(5):505e509.
31. Menendez ME, Mudgal CS, Jupiter JB, Ring D. Health literacy in
hand surgery patients: a cross-sectional survey. J Hand Surg Am.
2015;40(4):798e804.e2.
32. Chakravarty EF, Bjorner JB, Fries JF. Improving patient reported
outcomes using item response theory and computerized adaptive
testing. J Rheumatol. 2007;34(6):1426e1431.
33. Menendez ME, Bot AG, Hageman MG, Neuhaus V, Mudgal CS,
Ring D. Computerized adaptive testing of psychological factors:
relation to upper-extremity disability. J Bone Joint Surg Am.
2013;95(20):e149.
34. Banka G, Edgington S, Kyulo N, et al. Improving patient satisfaction
through physician education, feedback, and incentives [published
online ahead of print May 27, 2015]. J Hosp Med. http://dx.doi.org/
10.1002/jhm.2373.
35. Brown SW, Nelson A-M, Bronkesh SJ, Wood SD. Patient Satis-
faction Pays. 1st ed. Gaithersburg, MD: Aspen Publishers; 1993.
J Hand Surg Am. r Vol. 40, September 2015
1865
36. Vranceanu AM, Cooper C, Ring D. Integrating patient values into
evidence-based practice: effective communication for shared decision-
making. Hand Clin. 2009;25(1):83e96, vii.
37. Riess H, Kelley JM, Bailey R, Konowitz PM, Gray ST. Improving
empathy and relational skills in otolaryngology residents: a pilot
study. Otolaryngol Head Neck Surg. 2011;144(1):120e122.
38. Riess H, Kelley JM, Bailey RW, Dunn EJ, Phillips M. Empathy
training for resident physicians: a randomized controlled trial of a
neuroscience-informed curriculum. J Gen Intern Med. 2012;27(10):
1280e1286.
39. Del Canale S, 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):1243e1249.
40. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C,
Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic
patients. Acad Med. 2011;86(3):359e364.
41. Rakel DP, Hoeft TJ, Barrett BP, Chewning BA, Craig BM, Niu M.
Practitioner empathy and the duration of the common cold. Fam Med.
2009;41(7):494e501.
42. Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Pa-
tient satisfaction with time spent with their physician. J Fam Pract.
1998;47(2):133e137.
43. Sun BC, Adams J, Orav EJ, Rucker DW, Brennan TA, Burstin HR.
Determinants of patient satisfaction and willingness to return with
emergency care. Ann Emerg Med. 2000;35(5):426e434.
44. Schwartz TM, Tai M, Babu KM, Merchant RC. Lack of association
between Press Ganey emergency department patient satisfaction
scores and emergency department administration of analgesic medi-
cations. Ann Emerg Med. 2014;64(5):469e481.
45. Jaipaul CK, Rosenthal GE. Are older patients more satisfied with
hospital care than younger patients? J Gen Intern Med. 2003;18(1):
23e30.
46. Shea JA, Guerra CE, Ravenell KL, McDonald VJ, Henry CA,
Asch DA. Health literacy weakly but consistently predicts primary
care patient dissatisfaction. Int J Qual Health Care. 2007;19(1):
45e49.
47. Nam KP, Gong HS, Bae KJ, Rhee SH, Lee HJ, Baek GH. The effect
of patient involvement in surgical decision making for carpal tunnel
release on patient-reported outcome. J Hand Surg Am. 2014;39(3):
493e498.
48. Brown JB, Brett P, Stewart M, Marshall JN. Roles and influence of
people who accompany patients on visits to the doctor. Can Fam
Physician. 1998;44:1644e1650.
1865.e1 EMPATHY AND PATIENT SATISFACTION

APPENDIX A. Characteristics of the Study Population

Satisfaction With Provider
Parameter All Patients Satisfied (9e10) Dissatisfied ( 8) P

Total* 112 (100) 90 (80) 22 (20)

Age† (y) 51  17 (20e84) 53  16 (20e84) 44  15 (21e69) .022
Sex*
Female 58 (52) 43 (48) 15 (68)
.086
Male 54 (48) 47 (52) 7 (32)
Race and/or ethnicity*
White 103 (92) 82 (91) 21 (96)
.50
Non-white 9 (8.0) 8 (8.9) 1 (4.5)
Education† (y) 15  3.0 (0e22) 15  3.1 (0e22) 15  2.3 (12e20) .98
Insurance status*
Medicare 30 (27) 28 (31) 2 (9.1)
Medicaid 14 (13) 10 (11) 4 (18)
.14
Private 63 (56) 49 (54) 14 (64)
Workers’ compensation 5 (4.5) 3 (3.3) 2 (9.1)
Working status*
Working 74 (66) 58 (64) 16 (73)
Unemployed 5 (4.5) 3 (3.3) 2 (9.1)
.17
Disabled 11 (9.8) 8 (8.9) 3 (14)
Retired 22 (20) 21 (23) 1 (4.5)
Marital status*
Single 39 (35) 29 (32) 10 (46)
Married 55 (49) 45 (50) 10 (46)
.60
Separated or divorced 11 (9.8) 10 (11) 1 (4.5)
Widowed 7 (6.3) 6 (6.7) 1 (4.5)
Diagnosis*
Traumatic 35 (31) 28 (31) 7 (32)
.95
Nontraumatic 77 (69) 62 (69) 15 (68)
Appointment type*
First opinion 105 (94) 83 (92) 22 (100)
.18
Second opinion 7 (6.3) 7 (7.8) 0 (0)
Management*
Operative 20 (18) 17 (19) 3 (14)
Nonsurgical 43 (38) 35 (39) 8 (36)
.74
Diagnostic test 23 (21) 19 (21) 4 (18)
Counseling and/or observation 26 (23) 19 (21) 7 (32)
Resident and/or fellow involvement*
No 50 (45) 38 (42) 12 (55)
.30
Yes 62 (55) 52 (58) 10 (46)
Time from booking until appointment† (d) 11  10 (0e60) 11  11 (0e60) 9  6 (0e21) .29
†
Waiting time to see the provider (min) 32  20 (3e81) 32  20 (3e81) 31  22 (6e80) .82
Duration of visit† (min) 11  7 (3e42) 11  7 (3e42) 10  5 (3e22) .78
†
CARE Measure 46  6.8 (20e50) 48  3.2 (39e50) 36  8.2 (20e48) < .001
NVS Health Literacy† 4.2  2.0 (0e6) 4.1  2.0 (0e6) 4.4  2.0 (0e6) .60

(Continued)

J Hand Surg Am. r Vol. 40, September 2015

 EMPATHY AND PATIENT SATISFACTION 1865.e2

APPENDIX A. Characteristics of the Study Population (Continued)

Satisfaction With Provider
Parameter All Patients Satisfied (9e10) Dissatisfied ( 8) P

PROMIS instruments†
Pain interference 56  7.7 (32e73) 56  7.8 (32e72) 56  7.5 (39e73) .87
Upper extremity function 39  9.9 (19e62) 39  9.4 (22e62) 41  12 (19e56) .42
Depression 48  8.9 (34e73) 47  9.3 (34e73) 50  7.1 (34e58) .087

*The values are given as the number of patients, with the percentage in parentheses.
†The values are given as the mean and the standard deviation, with the range in parentheses.

J Hand Surg Am. r Vol. 40, September 2015