4.1 Analysis of the main results
In this study, the average perceived empathy score of patients was 40.64 (SD = 5.16), which was slightly lower than American orthopedic patients of 46 (SD = 6.3) . This result indicates that the empathy of medical staff should be improved, or other medical factors have weakened the perceived empathy. As expected, our results demonstrated that patient’s age, hospital level, hospital type, and length of consultation affect the patient's perception of empathy, which is not completely consistent with previous research results. A study conducted in Argentina showed that patient’s age, education level and hospital type affected the patient’s empathy for doctors . In addition, studies have shown that gender and educational background have a significant impact on empathy perception [33–34]. But in this study, patients with different genders, educational level and income have no significant difference in perceived empathy.
This study found that: 1. The older the patient was, the higher the empathy evaluation of doctors. The reason for this result may be that patients of different ages have different expectations and needs for medical care. Old patients have more panic and negative attitudes towards the disease, and they need emotional care and support. At this time, if doctor show their understanding of elderly patients, respect and warmth would make them feel warm and trustworthy, so older patients are more sensitive to empathy than young people . 2. The difference in patient perception empathy scores between hospital levels and types indicated that higher-level hospitals may pay more attention to humanistic care, so medical staff have stronger empathy. Relevant research shows that compared with primary medical institutions, the management level, medical technology level and medical and health conditions of high-level hospitals are in a better state. Medical staff quickly and effectively receive and process patients’ information, which also greatly improves the quality of doctor-patient communication.. 3. The length of consultation affected the patient's perceived empathy. A foreign study have also found that more time consultation leads higher patient-perceived empathy. [37, 8]. However, our study found that the length of medical consultation and perceived empathy showed an inverted U-shaped curve. Shorter and longer consultation time made patients perceive higher empathy. The shorter time of the consultation, the higher the understanding of empathy may be because these patients themselves were milder and do not have too much negative, nervous, anxious, and worried emotions, so they did not have much needs of emotional care and understanding during the consultation. On the contrary, for patients with acute or serious illness, the length of consultation may be an effective predictor of the level of perceived empathy of patients. Unfortunately, medical resources are uneven, and the workload of medical personnel is too heavy. Because China’s doctors are faced with greater time pressure and workload, they usually spend less time communicating with patients and sometimes they may become impatient. This was a contradiction between the quantity and quality of consultations ,44.7% of patients think that doctors are busy with tasks and lack time and energy. In addition, some doctors pay more attention to disease diagnosis rather than listening to patients’ opinions, unwilling to communicate with patients, and lack proper training . All these will make patients feel that the medical staff lack empathy and care, which is not conducive to the construction of a good doctor-patient relationship.4. This showed that the patient's medical experience influenced the subsequent cognition and behavior, and the unpleasant medical experience before would cause hostile prejudice and negative stereotypes to the medical staff, so the score is low.
The results of regression analysis confirmed the mediating effect of communication on empathy in promoting the doctor-patient relationship, which is of great significance to medical education and clinical training, and it also supports the Effect model of empathic communication in the clinical encounter . It reveal the important position of empathy in clinical practice. Empathy is an important part of the doctor-patient relationship and the basis for promoting harmonious doctor-patient communication. As the regression results show: the more empathy a patient perceived in medical interaction, the more positive the evaluation of the doctor-patient communication process, and the more harmonious the doctor-patient relationship reported. Empathy improved the doctor-patient relationship by promoting harmonious and effective communication. Zwingmann(2017) et al. found that patient-centered empathic communication can reduce patients' anxiety and negative emotions in cancer diagnosis, and increase patients' trust in doctors . Relevant studies have also shown that the higher the doctor’s empathy, the more cordial and warm the patients feel. Empathy can strengthen the communication between the doctor and the patient, reduced the psychological distance, enhanced mutual trust, increased medical service satisfaction, and improved medical care outcome. . The application of empathy skills in clinical practice enhanced the affinity with patients and family members, avoided many potential conflicts between doctors and patients, and not only protected the interests of patients but also facilitated the smooth development of diagnosis and treatment.
4.2 Implications for clinical practice
First of all, the hospital should evaluate the empathy of doctors from different perspectives. It is suggested that self-assessment may be a good strategy if the purpose is to make doctors or medical students recognize the clinical value of empathy. However, if the goal is to improve the quality of clinical care, education and other interventions based on self-assessment may not be enough, because self-assessment cannot capture the patient's perceived reality . Hence, we need to give more consideration to patients' feelings in medical interaction. As our research results show, the more patients perceived empathy, the better they will evaluate the doctor’s communication process and relationship. Patient’s evaluation (direct feedback from beneficiaries)can promote medical staff to express their understanding and concern for patients. Last but not least, we cannot ignore the influence of other background factors on patients' perception of empathy.
Secondly, Considering the current medical situation in China, it is necessary to improve the empathy ability of medical staff and medical students. The root cause of many doctor-patient conflicts is that patients feel that the doctor is indifferent, impatient, and lack of communication. There is evidence that empathy can be cultivated and improved through intervention [41–42]. A study showed that when doctors received empathy training, patients' evaluation of doctors' empathy has been greatly improved . Some scholars found that nurses provide empathetic care for inpatients to help them recover from diseases faster. Additionally, empathy would gradually decline with the growth of grades, but empathy training and clinical practice can effectively prevent empathy from declining [44–45]. For medical students, we should attach importance to humanistic education and appropriately increase the training courses of psychological knowledge or empathic communication skills.. Moreover, research points out that simulated games, role-playing, Balint groups, standardized patients, narrative medicine, mindfulness training, feedback training, scenario simulation, group discussions, video viewing and analysis, material reading, lectures, etc. [1, 46–49] can effectively improve the empathy of medical providers.
Finally, the results of this study tell us that empathy is of great significance for establishing a positive doctor-patient relationship. Empathy promoted effective communication and improved poor doctor-patient relationship. Because the perceived empathy was affected by background factors (medical staff’s characteristics, patients’ characteristics, medical environment, etc.), hospitals not only provide convenient and comfortable medical environment for patients, but also provide humanized nursing services, respect and care. To be specific, the hospital administrator should take the needs of different patients into consideration and provide a good medical environment. For example, a reasonable hospital layout, convenient treatment process, warm consultation environment, reasonable consultation time and a comprehensive hospital management system  can keep patients in a positive mood, meet their psychological needs, and experience humanized services, enhance their perception of empathy . In addition, the study found the mediating effect of doctor-patient communication, which encouraged doctors to adopt empathic communication. An empathic communicating clinician can achieve improved patient outcomes. Listening and caring for patients is more important than providing professional medical advice when conveying empathy [5, 52–53]. Adopt a patient-centered communication, adhere to the principles of sincerity, respect and understanding, listen more, attach importance to nonverbal communication, respond to patient’s demands and give timely feedback. These measures can meet the psychological needs of patients, make patients feel caring, warm and valued in clinical encounter, and promote the construction of a good doctor-patient cooperation relationship.