2014
Health and Emotional Intelligence

Ankur Parey 13HS60021 3/5/2014

Table of Contents Introduction ........................................................................................................... 3 Overview of Emotional Intelligence ....................................................................... 3 Behaviors and outcomes ........................................................................................ 4 EQ in healthcare .................................................................................................... 4 Healthcare emotional intelligence ......................................................................... 4 Training implications .............................................................................................. 5 Training and Health Care ....................................................................................... 6 The physician and emotional intelligence .............................................................. 7 Conclusion ............................................................................................................. 8

Introduction
There is a renewed interest in healthcare, in the role of Emotional Intelligence — a set of behavioral competencies, distinct from traditional IQ, that impact performance. There is also a growing body of evidence that individual behaviors, including EQ, influence patient outcomes and organizational success. What is EQ? How does it apply to healthcare? How do we use it to improve performance? Everyone is striving to provide patient-centered care. Operational strategies like Lean or Six-Sigma help in designing new, patient-centered care models. Information systems make clinical and financial data more useful and enhance efficiency. These strategies and technologies are widely available, but not every organization is successful. Patient-centered care is not just about new care delivery models. It is, to a large degree, about relationships and interactions between providers and patients and among administrators, physicians, nurses and staff. With this realization, healthcare is exploring how we can apply the concept of Emotional Intelligence.

Overview of Emotional Intelligence
In the 1930s, psychological research identified “social intelligence” skills, distinct from traditional intelligence, that impact work performance. By the 1980s, research showed that overall performance was often the result of interpersonal, rather than technical skills. By the 1990s, the term “Emotional Intelligence” was widely discussed in business circles. A definition that includes about two dozen social and emotional abilities linked to successful performance in the workplace. These abilities can be grouped into five core areas: • Self awareness • Self regulation • Self motivation • Social awareness • Social skills Interest in the concept took off with Dan Goleman’s 1995 book “Emotional Intelligence.” Harvard Business Review printed an article on EQ in 1998. It was the most widely read article in its 40-year history. The concept continues to have widespread support in the business world but healthcare has been slow to apply EQ concepts.

Behaviors and outcomes
Efforts to improve quality of care will always begin with research and training on new diagnostic and treatment approaches. There is a growing body of evidence, however, that individual behaviors significantly influence outcomes and warrant more attention. For instance, relatively simple protocols can virtually eliminate certain hospital- acquired infections. Some hospitals, though, adopt these protocols but are unsuccessful. One possible reason could be, “For the process to work, each individual has to make a commitment to perform each step each time, and have the courage to correct their colleague when they see an error has been made.” Success requires staff members who see the value of new procedures, and a culture of communication, collaboration and adaptability. In fact, we are learning that behaviors like empathy and compassion actually impact patient outcomes. For instance, physician empathy improves patient satisfaction and adherence to treatment, and correlates with fewer medical errors. Empathetic physicians are better at managing chronic conditions like diabetes. Higher levels of communication and collaboration mean better outcomes in shock-trauma units. Inappropriate behavior by nurses and physicians is not only disruptive to the work environment but, more importantly, these behaviors can harm patients.

EQ in healthcare
What about the broader concept of EQ? Recent research reveals that EQ might be offered as an explanation for why some practitioners and organizations are better at delivering patient-centered care. EQ has been shown to positively contribute to the physician-patient relationship, increased empathy, teamwork, communication, stress management, organizational commitment, physician and nurse career satisfaction, and effective leadership. Several dozen nursing research studies demonstrate a correlation between EQ and performance of nurses, retention, stress adaptation, organizational citizenship and selected positive patient clinical outcomes. There is also evidence that EQ can be improved with training. If a provider has a better understanding of his or her behavioral propensities, he or she can adopt specific behaviors that will improve interactions with patients and colleagues.

Healthcare emotional intelligence
Working with a group of physician leaders at a progressive healthcare system, following was found out: “We appreciate the connection between EQ and patient care and physician career success, but when we took an EQ assessment, we found the results to be interesting but weren’t sure what to do with the

information.” Traditional EQ measurement tools do not provide practical recommendations for adopting patient-centric behaviors. Part of the problem is that the concept of EQ — how it is defined, measured and used — has not been looked at within the unique context of healthcare. Physicians, for instance, may score high on traditional measures of EQ, but other behavioral traits can prevent them from displaying the highly collaborative or patient-centered behaviors we’d expect. Whether a physician or nurse scores high or low in any of these areas is less important than their ability to understand their behavioral make-up and adapt accordingly. The construct includes four core areas:

1. Compassion - How compassion is measured, and how the results presented, are important. Studies have shown that there are some outstanding clinicians who don’t score on the high side of the compassion scale. For compassion to be useful, it must result in positive action. Even highly factual (vs. feeling) individuals can connect with patients and coworkers if they are aware and able to convey that they are trying to understand the other’s emotional state. 2. Awareness - The ability to understand a situation and either focus on the details or the big picture, as appropriate, is invaluable to creating a patient-centric culture and to successfully collaborating and working in teams. 3. Regulation - The ability to moderate emotions is critical to the ability to problem solve under stress and to maintain productive, professional relationships and behaviors. Those at either end of the spectrum can function well if they are aware of their natural reactions. Those who are highly excitable may be at a greater risk for impulsive negative remarks or actions (e.g., physician disruptive behavior). Those who are hyper-controlled, however, are often perceived as distant and uncaring. 4. Emotional Intelligence: The level of “social focus.” Are you so focused on the task at hand that you fail to read the needs of patients and colleagues, or are you easily able to read others’ emotions and use that information to achieve a positive outcome? For example, once you know that you are highly factual and less socially focused, you can get in the habit of making a special effort to evaluate how a patient or colleague is reacting to you and act accordingly.

Training implications
Obviously, we need to train and develop nurses, staff and physicians on how to provide patientcentered care. Traditionally, this has involved service excellence programs like those adapted to healthcare from Disney or the Ritz Carlton. These have moved some hospitals light years ahead of where they were ten years ago, but they only go so far. From a recent article in FierceHealthcare: “If you want to go from good to great, the key is not to focus primarily on . . . service excellence, argues Fred Lee, a patient relations and service consultant and author of “If Disney Ran Your Hospital.”… “A

service of courtesy is not enough in our business if we are not also meeting people’s emotional needs,” Lee said. Most complaints about doctors relate to poor communication, not clinical competence, and improving communication in health care is a current area of interest in policy and practice. Given the emphasis on insights into one's own and others' emotions that are described by models of EI, it might be offered as an explanation for why some practitioners appear to be better at delivering patient-centred care than others. Assessing and discriminating patient's emotions could have an impact on the quality and accuracy of history taking and diagnosis. In addition, if clinicians are able to understand patients' emotional reactions to prescribed treatments or lifestyle advice they may be better able to understand why some treatments are more or less acceptable to some patients. The ability to manage and read emotions would seem to be an important skill for any health professional and might potentially enhance patient-centered care, improve the quality of the professional-patient relationship, and increase patient levels of satisfaction with care and perhaps even concordance. Imagine a patient with bad reaction to anesthesia. It’s fairly routine but still uncomfortable and unnerving for the patient and the family. One nurse may be highly conscientious and clinically competent and taking all the right steps to address the situation. She’ll provide the right treatment and the patient’s symptoms will resolve, but she doesn’t attempt to calm the patient or instill a sense of confidence and even fails to pick up on the anxiety. Another nurse may not be quite as conscientious or experienced. She may even take a bit longer to figure out exactly what to do, but she is more comforting. She knows to put a hand on the patient’s shoulder and to assure the family that this is normal. The symptoms may resolve in the same amount of time, but the two patient and family experiences were very different. According to a CEO of a hospital, “We check all the boxes on our service excellence program and pat ourselves on the back, but our patient satisfaction scores have not improved.” The specific, individual behaviors and interactions of every physician, nurse and staff member are what drive patient-centered care. More importantly, they must understand something about their own behavioral make-up. The first nurse in the situation above may learn that she is highly factual and needs to make a special attempt to understand, and respond to, patient needs. The second may discover that she is so focused on meeting patient needs that she must be actively conscientiousness of the tasks that impact patient outcomes. The most successful patient-centered care training programs will combine service excellence principles with behavioral assessments that provide staff with useful insight into their own behavioral make-up — including healthcare- specific emotional intelligence.

Training and Health Care
The idea that individuals can be trained to be more emotionally intelligent is one which is discussed with enthusiasm in nursing management literature. It could be hypothesized that increasing EI in individuals employed in health care may lead to more effective management and better functioning teams of

professionals, in addition to direct benefits for patient care. However, assessing the value of training in EI poses a number of challenges. It is unclear how responsive to training EI is. Some of the models suggest competencies which can be developed with training, while other conceptualizations describe personality characteristics which are difficult to change—with the implication that EI cannot be significantly influenced by training. In addition, it is unclear whether current measures are sensitive enough to detect changes over time in response to training. There is little formal evaluation or description of training programs which may improve EI in health care professionals. Wagner et al. described the administration of the EQi (a self-report trait measure of EI) to medical students which they hope to follow up at two and three years into training after an intervention to where EI scores are fed back to students with reflection and discussion. If EI is conceptualized as an ability that can be learned and changed, it could be a useful way of thinking about and addressing aspects of the doctor-patient interface which work less well. However, before widespread recommendation of and training in EI is suggested, we need to be able to measure it reliably in order to determine whether it explains differences in the quality of care.

The physician and emotional intelligence
Given the enthusiasm that emotional intelligence has generated in other fields, the paucity of research involving emotional intelligence and physicians is surprising. The studies have been preliminary and largely negative in their findings. There has been only one study addressing the relationship between patient satisfaction and physician emotional intelligence. The study, by Wagner et al, was small, and most physicians in this academic family medicine department scored highly in emotional intelligence, so the study lacked power to find the difference it was seeking. Despite this, it was found that there was a positive correlation between physician happiness and patient satisfaction – a finding that is at some level unsurprising, but also suggestive that the patient’s emotional intelligence in reading the physician’s level of happiness is also in play during a clinical encounter. Large employers of physicians should perhaps take note regarding this linkage of physician and patient satisfaction if they wish to improve patient approval. A second study by Azimi et al examined the relationship between the emotional intelligence of dental students and patient satisfaction. Here there was a significant positive correlation: patient satisfaction was higher when the dental student scored higher on his or her emotional intelligence exam. It is worth noting differences between these two studies to ask why the results are different. The two studies both used the same exam to determine the clinician’s emotional intelligence, so this does not confound comparing the two. The study on dental students was larger, and therefore had more power, and the range of emotional intelligences among dental students was also larger, again making the task of discerning a difference easier. But we may also conjecture that the time spent in a typical dental exam significantly exceeds the time spent in a typical medical visit, making the emotional intelligence of the practitioner more obvious to the patient, who has more time to observe the clinician. Given the currently hectic schedules of primary care physicians, it may be difficult to prove any benefit of emotionally intelligent physicians because too little meaningful interaction actually occurs in a typical office visit. Rather than trying to prove the obvious (that physicians need emotional intelligence to best serve their patients), perhaps we

need to focus instead on creating environments and practices that allow emotional intelligence to exert an actual force in the doctor–patient relationship. The other reason that it has been hard to establish the benefit of emotionally intelligent care providers may be related to the construct of emotional intelligence itself. Some components, such as a physician’s ability to express accurately her own emotions, may be less clinically relevant than other aspects, such as reading the patient’s emotional state and expressing empathy. In fact, the literature on expressions of empathy and care shows a much more positive correlation with patient outcomes than does the literature on emotional intelligence taken as a whole.

Conclusion
The clinical encounter, as a care-giving relationship, involves both intellect, understood narrowly, and emotional intellect for both sides of the therapeutic dyad. For physicians, both emotional intelligence and empathy are crucial. Patient emotional intelligence deserves further study, although it is already clear that low emotional intelligence is associated with greater illness and health care utilization, and that efforts to augment emotional intelligence may be of benefit, particularly in chronic disease. Screening for emotional intelligence could someday become a part of health care evaluation, and even cost containment, because it appears to play a role in both the development and treatment of illness. Physician emotional intelligence may contribute to better outcomes and patient satisfaction, although further research may establish this relationship more completely. It may be of greater research interest to arrive at a consistent definition of empathy, and continue to investigate its role in outcomes and patient satisfaction, because it appears that empathy may be the most important component of emotional intelligence in the health care setting. Emotional intelligence and empathy can be understood as being both innate and learned. That is, education, age, and gender all impact their development, but some people more easily acquire these abilities than others. Given the importance, even centrality, of empathy to the doctor–patient relationship, testing for empathy in medical student applications seems entirely reasonable. Furthermore, every effort needs to be made to eliminate the aspects of medical education that are dehumanizing and contribute to a loss of empathy among physicians. Work hour restrictions, courses in medical humanities and narrative medicine, and training in psychosocial medicine all have the potential to improve empathy among new physicians. Continuing Medical Education (CME) credits in these same areas may benefit existing physicians.