Author: Coelho, Ken Russell
Date published: March 1, 2012
Journal code: CRIM
What lacks in the current US Healthcare System? The very nature of western medicine propels us towards a systematic focus on the physical healing of the body set against a holistic approach, one which would encompass both, the objective and subjective measures of care. Studies report patient-rated communication as a priority in the top three out of seven aspects of patient care and rates of adherence to recommended treatments increased when a physician's knowledge of a patient as a whole person was strong (1). However, there is still emphasis placed on the physical approach of reductionist evidence based science. Universal reliance on the sole identification and treatment of the physical body dictates an inept means of imparting the best and most appropriate healthcare services since the social, emotional, mental, spiritual and environmental dimensions of health are not addressed and are extremely important to the continuum of healthcare (2). Holistic treatment encompassing physical diagnoses and care, a high degree of congenial clinicianpatient communication, and verbal and nonverbal cultural sensitivity are key to patient's maintaining excellent health. In this manner, the clinician-patient relationship would result in a supplementary personalized bond consequently enhancing communication which in-turn positively affects healthcare outcomes.
Traditionally, clinician-patient relationships have been assessed for numerous outcome variables such as - patient satisfaction, compliance, adherence to medical treatments (3,4,5), - patient care and adaptation to illness and treatments (3), - the quality of care as it relates to patient self-reported health care information (5), - sustenance of relationship and continuity of care from the same health care clinician (6) and - establishing patient rapport, and cultural sensitivity and understanding of socio cultural contexts (7,8). Effective clinician-patient relationships have correlated positively with of all these factors, leading to improved healthcare services and better overall patient health outcomes. However, a lack of an effective relationship causes these factors to dominate the relationship in a negative manner, which in the patients' mind provides a skewed representation of healthcare and their corresponding rights as a patient. The results - patients are unaware of their healthcare rights and are not empowered to take control of their health. The lack of a healthy clinician-patient relationship permits the clinician to dominate and place the patient in a position of subjugation and powerlessness, allowing for disparities in the quality of healthcare, dissatisfaction, and decreased health (9).
How can we move towards effectively enhancing the relationship between clinicians and patients so as to gain positive health outcomes? The key is to deliver our healthcare clinician community with an umbrella skill set that would afford an opportunity to better serve patient' healthcare needs, thereby enhancing favorable outcomes and encouraging healthy lifestyles. Clinician emotional intelligence (EI) is the foundation for attaining positive health outcomes; the development of EI as a core competence for healthcare clinicians enhances the clinicianpatient relationship and increases patient health outcomes. The ability to have an enhanced understanding of the patients' emotions seats the clinician in a position to influence and encourage healthy behaviors and lifestyles in their patients, improving the overall efficiency of the promotion of health and prevention of disease.
Goleman, in his much acclaimed article titled, "What makes you a leader?" published in the Harvard Review Best of 1998 (10), explains that interpersonal relationships can be enhanced by increasing one's self-awareness, self-regulation, motivation, empathy and social skills. Developing the five dimensional skills of EI have the potential to make clinicians improve accuracy in identifying and understanding their own emotions, giving them the opportunity to manage and regulate the emotional expressions of themselves and those of their patients. The ability to recognize, perceive, and regulate emotional expressions in-turn motivates positive and reassuring behaviors, attuning themselves to better serve patient needs in a fruitful and healthy relationship.
Developing these skills as a healthcare provider is evidently important in enhancing clinician-patient relationships. Research has shown that an enhanced relationship positively correlates with an increase in patient satisfaction, compliance and adherence, enhances the quality of patient care, and paves the way for a more culturally sensitive workforce that focuses on the holistic approach to healthcare treatment (5,4,11,3,12,6). Thus, creating an effective clinician-patient relationship will have farfetched influences on increasing health outcomes, thereby promoting healthy behaviors, lifestyles, and overall well-being.
Since the dimensionality of EI is broad and has been documented in other fields which require the effective art of communicating with skill (13,14,10), the development of EI as a core competence for the healthcare clinician workforce and its inclusion as part of routine health science curriculum and training is evident.
EI has previously been identified as a desirable leadership attribute in a number of fields and is also used as a means to assess leadership potential in employment by business corporations demonstrating the prospective importance of the applications of EI as a core skill for healthcare clinicians.
What is emotional intelligence?
EI was first introduced to scientific literature through the cutting edge work of Mayer and Salovey in 1990, and was initially defined as the ability to understand feelings within oneself and in others, using these feelings in guiding thought and action (15). All scholarly thought on EI before the 1990's was not in the domain of psychology but was introduced and applied to other disciplines such as anthropology, evolutionary sciences and cognitive study.
Although Mayer & Salovey's discussion of EI was the first, it provoked widespread excitement and discussion following numerous attempts to define EI. One such attempt by Daniel Goleman resulted in its definition as a multi-dimensional construct. This thoroughly hallmarked potential applications of EI in a number of fields. His book published in 1995 titled Emotional Intelligence: Why it can matter more than IQ?, led to the new and improved version of EI. Because of EI's surging applications to a variety of settings, it has become progressively important at the workplace; it has been touted to be an accurate measure for potential success rather than other traditional predictors of success such as IQ (10). Goleman contended that EI accounted for up to 80% of unexplained successes in life and that the remaining was mainly due to technical competence accounted by differences in IQ. EI is defined as the ability to motivate oneself, persists in the face of frustration, regulates one's moods, emotions, and behaviors, allows one to empathize with others, and gives people the ability to maintain an aboveaverage level of social skills (10). It is an overarching and inclusive definition which permits EI's existence as a multi-dimensional construct while maintaining its application to other fields that require effective communication skills, such as in healthcare. EI has also been discussed as a useful tool in health care intervention and prevention programs. A recently published review utilized Golemans' definition to establish and recognize the significance of EI as a desirable health promoting attribute and its conceptual use in a prevention based model for reducing high risk behaviors associated with alcohol and other drug (AOD) abuse in adolescents and adults (16). As a result, Goleman' definition continues to be a definitive reference on the subject (13).
How is emotional intelligence measured?
The most typical approach to measuring EI in individuals involve self-report measures of EI or EI related constructs (17, 18, 15, 19) which involves administering a set of questions in a questionnaire and scoring responses based on a methodology involving expert judgment, expert scores, or consensus among a large number of people. For example, one test requires participants to view a series of faces and report how much of each of the six basic emotions (viz., happy, sad, fear, surprise, anger and disgust) are present. Participants are also asked to answer questions about emotional scenarios and responses such as predicting the behavior of an employee reacting to a significantly increased workload, and solve emotional problems such as deciding what response is appropriate when a friend is upset over breaking up in a relationship. Similarly, other tests of EI use a self-report method, with self-report questionnaires to measure personality traits (viz., extroversion, agreeableness, conscientiousness).
Although self-report measures of EI have been around for decades and used widely, they do not come without limitations. A set of studies published by Davies et al. (20) reported problems. Firstly, many of these measures are riddled with poor reliabilities. Secondly, the ones that do appear to have better reliability in self-report, measure well established personality attributes such as those in the Big 5 personality inventory (i.e. neuroticism, extraversion, psychoticism, agreeableness and openness) Thirdly, statistical evidence by way of factor analysis no longer supports the discriminant validity of two EI constructs (i.e. emotional awareness and clarity) when unreliable measures are removed from the factor analysis.
Although there have been marked improvements in measures of EI over the years, there still exists a lot of room for improvements. Firstly, care must be taken to ensure that measures of EI are not muddled together with measures of personality traits and that there is distinct criterion and discriminant validity. Secondly, improvements in measurement should consider methodologies other than the sole focus on measures of self-report. Lastly, self-report measures of EI reporting variables in the form of a multidimensional construct such as is discussed in this article and in other examples (19, 21); lends itself to more reliability, with better discriminant and criterion validity, and should be reflected in future methodological innovations.
Why emotional intelligence for healthcare clinicians?
According to Goleman, EI's multidimensional construct is a contribution of five dimensions: self-awareness, self-regulation, motivation, empathy, and social skill. (10) A summary of their definitions and surging applications to the attributes of healthcare clinicians have been provided in Table 1.
Role of emotional intelligence in public health
If EI is to be developed as a core competence for healthcare clinicians, it has the potential to create a highly competent workforce of "emotionally intelligent" clinicians, which would ultimately enhance clinician-patient relationships. An enhanced clinician-patient relationship would result in an affinity to each other in the relationship (5), with little or no communication gap (22, 8), with patients feeling empowered, knowledgeable, and in control of their health (3, 11), and feeling treated holistically resulting in superior quality of healthcare (6, 4). All of these factors influence the level of patient-care received from clinicians and is directly related to health promotion behaviors that encourage healthy lifestyle modifications and the prevention of diseases.
When patients have an affinity to their clinician, they are more likely to continue to see the same clinician, comply with follow-up appointments and as a result, will have a sustained long term relationship with their clinician, establishing an effective rapport (5). Improving and narrowing the communication barriers between the clinician and the patient are clear indicators of an enhanced clinicianpatient relationship with heightened health outcomes (3). An enhanced clinician-patient relationship also leads to an increase in patients' medical knowledge and competence, empowering themselves to make the right decisions regarding their health status (3, 11). This ultimately leads to an increase in patients' adherence and compliance to clinician diagnoses, treatment plans, and recommended procedures and resources after assessing and scrutinizing their clinicians' motivations for them.
The role of EI is clearly apparent in the future of the United States' healthcare system where increasing minority demographics call for a high degree of cultural and emotional sensitivity in our clinician workforce. Recent demographic trends demonstrate that ethnic minorities constitute twenty-five percent of the current population and in fact will be the majority of the US population in 2050 (23). As people from different cultural backgrounds and ethnic minority groups immigrate to the United States to establish permanent residency and citizenship, encounters between clinicians and patients from different cultural backgrounds are becoming common-place. Literature has also shown that a large majority of American clinicians lack the information to understand how culture influences the clinical encounter and the skills to effectively bridge potential differences in communication (8). EI provides the clinician with the skills necessary to address these cultural differences by permitting the clinician to use their selfawareness, self-regulation, motivation, empathy and social skills to partake in behaviors which facilitate sensitive dialogue between the clinician and the patient. Increased clinician sensitivity to patients' diverse cultural backgrounds will help narrow the clinician-patient communication divide, and will enhance the relationship, thereby resulting in an increase in desirable health outcomes.
Even though EI has increasingly become recognized as a useful tool in healthcare, more in-depth research should focus on studying the role of emotional intelligence in workplace settings, with a specific focus on healthcare due to current lack of knowledge in the area and its rising importance of useful applications in the field. Research should target the creation of reliable and valid tests of measuring EI to reflect the multidimensional nature of the construct. In addition, since EI enhances the satisfaction and outcomes in the clinician patient relationship, future research studies should also seek to decipher the effect of EI on patients' intent to initiate legal action against healthcare providers, i.e. research testing the hypothesis whether more satisfied patients would be less likely to initiate legal action, perhaps leading to a reduction in longitudinal costs related to healthcare services. Finally, educational curriculum for staff training and development programs in healthcare organization's should essentially reflect new and emerging research on emotional intelligence and communication strategies which seek to enhance the clinicianpatient relationship and ultimately influence broad based improvement in patient and clinical health outcomes.
Author would like to thank Bernard Griego, Associate Director of the Center for Public Health Practice at the School of Public Health - University of California, Berkeley for his outstanding mentorship in his course, Public Health 14: Healthy People, during which the initial draft of this paper was written. Final version was drafted when corresponding author was affiliated with Performance Improvement and Patient Safety Division of San Francisco Department of Public Health, San Francisco General Hospital & Trauma Center. No funding was sought in the creation of this work.
Conflict of Interest: The author has no conflicts of interest to report.
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Correspondence concerning this article should be addressed to Ken Russell Coelho; Performance Improvement and Patient Safety Division, San Francisco Department of Public Health/ San Francisco General Hospital & Trauma Center, Bldg. 20, 3rd Floor, Suite 2300, San Francisco, CA 94110 USA | Email: firstname.lastname@example.org
Paper Received: 23 November 2011 | Paper Revised: 19 February 2012 | Paper publication: 08 March 2012
Ken Russell Coelho (1, 2) *
1) Performance Improvement and Patient Safety Division, San Francisco Department of Public Health/ San Francisco General Hospital & Trauma Center, Bldg. 20, 3rd Floor, Suite 2300, San Francisco, CA 94110 USA
2) Psychology Department, University of California at Berkeley, USA
* Corresponding Author