Exploring Empathy In A Dentist-Patient Relationship. Conclusions From Qualitative Exploratory Research Of Practicing Dentists

Objective: This study explored the factors influencing the development of empathy in a dentist-patient relationship. Design: An exploratory qualitative study. Place and duration of the study : Khyber Medical University KPK, Pakistan October 2019 to April 2020.was conducted during 2019-2020. Methodology: This exploratory qualitative study was conducted during 2019-2020. It was conducted on 12 dental surgeons, recruited from four major dental clinical specialties. A purposive sampling technique was used. In-depth interviews were conducted through a semi-structured format. The interviews were audio recorded, transcribed verbatim and analyzed, using the thematic analysis framework. Results: Three themes were extracted from the data. 1) Institutionalization of empathy 2) Barriers in the path of empathetic attitude and 3) Cultivating a Culture of empathy for better health care provision. The participants of the study observed tha t the development of empathy in a dentist-patient relationship includes a wide range of factors, ranging from curricular, personal, social, organizational, and cultural. These factors elaborate that empathy is a multidimensional phenomenon with roots deeply entrenched in professional and personal domains. Conclusion: Various factors are involved in developing an empathetic relationship between a dentist and a patient. The content about empathy in our present dental curriculum is very deficient. Contextual academic workload and time constraints affect the execution of empathy. However, empathy is a teachable attribute, hence the factors hampering empathy can be addressed, modified, and re-employed to enhance empathy.


Introduction
The word empathy emerged in 1909 by the union of two Greek roots, em and pathos (feeling into) but having Greek Linguistic ancestry, the word empathy is now, called a "recent intellectual heritage". 1,2 n the past, it has sometimes been used synonymously with sympathy. 3Literature defines clinical empathy as an ability to understand the patient's situation, feelings and perspective and communicate that understanding to the patient. 4,5 pathy is an essential constituent of helpful relationships and is considered as the sturdiest motivation for pro-social behaviour.It improves the provision of high-quality health care to the patients. 6linical empathy and related behaviour of dentists are related with numerous positive effects.Therefore, not only the medical education associations around the world but also other professional organizations in many countries acknowledge empathy as a necessary attribute that should developed and promoted in medical and dental education. 7,8 mpathy helps doctors build good rapport with their patients while the same time enhancing physician's satisfaction.Therefore, gentleness in tone and use of well-time words and phrases facilitate empathy during clinical encounters. 9There are two major components involved when it comes to professionalism.One element is a set of cognitive abilities, shown in academic achievements, performance during examinations, recalling factual knowledge and effectively performing procedural skills.The other element is that of behaviour or attitude, which includes personal qualities, values, and psychosocial features.The paradigm of a doctor's performance is a balanced blend of these two elements. 4,10,11 Eathy is one of the major components of professionalism and the most commonly declared quality of a humanistic doctor. 11,12 ultivating empathy among students and doctors is one of the major goals of medical education worldwide.Empathy plays an important role in a doctor-patient relationship. 13The role of empathy in dentist patients has not been studied extensively. 8However, evidence suggests that pediatric dentists who employ empathic listening and communication skills have better treatment outcomes.The dental fear of children and their disruptive behaviours during the treatment are reduced when the dentist exhibits empathic behaviour and directions. 14Demonstrating caring, and interpersonal skills can help patients overcome dental fears and enhance patient's satisfaction suffering from myofacial pain. 15American Dental Association has placed empathy as a second clinical competency for dental training.There are studies, which treat empathy as a "black box", using global construct measurements that do not shed enough light on the underlying factors that shape empathy in a dentist-patient relationship.16 Tough groups are active in Pakistan to determine empathy among doctors, but there is a dearth of qualitative research to explore empathy in a dentist-patient relationship.Therefore, the purpose of the study is to explore the factors influencing the development of empathy in a dentist-patient relationship.

Materials & Methods
This qualitative exploratory study was conducted during 2019 -2020.A total of 12 practising dental surgeons from 4 major clinical dental specialities such as Oral and Maxillofacial Surgery, Operative dentistry, Orthodontics and Prosthodontics were interviewed.A purposive sampling technique was used.Practising dentists holding an FCPS/ or relevant master's degree in clinical dentistry were included.The ethical approval was obtained from Khyber Medical University Ethical Board No.DIR/KMU-EB/EE/000715.Informed consent was taken from all the participants and confidentiality was ensured.Data were collected, using the semistructured interview approach.The interview questions were developed and validated by five experts.Face-toface interviews were conducted at the workplace of the participant.The duration of the interview varied from respondent to respondent but on average, each interview took 20-25 minutes.Interviews were recorded using a "Samsung Note 9 built-in voice recorder".The responses were kept confidential and anonymous.Interviews were transcribed from the voice recorder.After data collection, all the transcripts were reviewed and coded.The two researchers individually conducted in-vivo coding and the codes were reviewed through several discussions to build consensus on the final themes.

Results
A total of 12 dental surgeons (n=12) were interviewed.The respondents' demographic information is given in Table 1.Female Orthodontics The data was analyzed manually with each transcript handled separately to get perception codes.The first cycle of coding which was the initial analysis was done by open coding.After that, the second cycle of coding was performed to find out relationships by axial coding.This was then followed by Thematic Analysis to create meaningful patterns.A total of 41 open codes were extracted.The sub-themes and themes were generated as given in Table 2.In my opinion, it is the increased patient load that stops you from behaving in an empathetic manner.For instance, if we were to cater for an OPD of 20-30 patients in the operative department how can we be empathetic, as compared to 3-4 scheduled appointments where one has the energy and temperament to give enough time to the patient?(#10) One of the main reasons is the educational level of the patient.We receive patients coming from far-flung remote areas of Rawalpindi, with almost no interaction with female dentists.If we try to be empathetic, they might think we are being frank.Being a prosthodontist we deal with elder patients, who are already, irritated due to their general health issues.Therefore, they take out their frustration on their dentists.They sometimes attack you at the start of the conversation, showing their aggression therefore we become less empathetic and take a step back.(

Benevolence
We do not belong to a culture of empathy.It is a very harsh reality as our religion Islam teaches us to be empathetic, but it is hardly seen in society.Therefore, the clinical environment is not an exception.While dealing in an empathetic way we think we are doing some extra favor to our patients however this should be part of our daily practice.(#9)

Discussion
This study explored the factors affecting empathy in a dentist-patient relationship, the factors that promoted or inhibited the development of empathy and the influential factors during their undergraduate and postgraduate education in dental institutions.The respondents of the study mentioned numerous factors some of them related to dental curriculum, interaction with a large number of patients, their own reflections and enthusiastic self-development and workplace structure and organization.Three themes emerged because of the study.
All participants unanimously identified that the formal curriculum hardly mentions terms such as empathy, optimal patient-doctor relationship, empathetic orientation, inter-personal skills, collaborative attitude etc. 17 A few dental institutions that have adopted integrated formal curriculum are offering communication skills, interpersonal skills and behavioral sciences related education but they are not assessed systematically.The study showed that the formal dental curriculum's prime focus is the technical aspects of all treatment regimens while neglecting the behavioural component.This causes a techniquecentric approach resulting in a technology-oriented dentist who ignores patient patient-centred approach.This was similar to the study conducted by Ahrweiler and his colleagues. 6e respondents of the study mentioned the aspects of the informal curriculum with stress given on role modelling and the role of supervisors.It is an imperative factor in workplace-based teaching and learning but negative role modelling can produce undesirable effects. 18In-depth discussions revealed two reasons, overburdened faculty and fewer faculty hired per department.The present dental and medical education environment and commercialization have caused institutional cuts in the number of faculty hired per department.Not only that there is a shortage of dental faculty in different areas of Pakistan.Hence, a smaller number of dental surgeons are hired, where assistant and associate professors mostly juggle their clinical, supervisory, academic, and administrative duties.
Senior dental surgeons do not have time for empathetic interactions with their patients because of time constraints, job stress and workload.This is somehow, translated as unintentional role modelling which culminates into apathetic dealing with the patients, leading to less patient satisfaction and care. 19n the present study, lack of communication skills appeared as an important factor.The mimics the supervisor and does not bother to display an empathetic attitude with the patient leading to unsatisfactory encounters with patients.The results were similar to a study conducted in Germany where respondents also highlighted the same issues as ours.6 Interpersonal skills are closely associated with communication skills when it comes to empathetic patient interaction.Doctors/dentists lacking interpersonal skills find it hard to establish empathetic relationships with patients. 20verburdened faculty cannot be optimum role models for displaying good interpersonal skills. 21e altruistic role of the physician is replaced with a businessperson-like approach. 22This phenomenon has become very apparent in Pakistan, with the mushroom growth of private medical and dental colleges.The policy of strict student selection in medical and dental schools is losing its rigour and the admission policy is dependent on the affording capacity of the student.This has led to a decreasing level of empathy where a shift from altruism to a business-like attitude is evident.This attitude has a synergistic interaction with the commercially oriented institutes.
Another significant factor affecting the empathy in a dentist-patient relationship is the stress related to dental school and residency. 23In this study respondents pointed out stressors hampering empathy, for instance, working conditions, perceived as negative were the increased patient load, lack of time and time pressure.Other prominent causes pointed out were pressure to perform, professional rivalry, over-fatigue, and exhaustion.Stress does not just diminish the empathy towards patients it also has a detrimental effect on the health of dentists.These results were similar to other studies, which showed how stress at the workplace is related to organizational, psychological and social factors. 24fascinating concept of the culture of the institute emerged, which in simple words is the clinical environment comprising of the collective attitude of health care professionals, administrative staff, and students.The senior staff plays the role of leaders if there is an attitude of prioritizing patient's needs and concerns the junior staff will certainly become patient oriented.However, if the seniors exhibit a callous nonchalant attitude, other working staff will practice the same hence desensitization of the students as well as trainees will be the outcome. 10,25  respondents also considered the difference between the "class" and "educational level" of dentists and patients a hindrance in developing empathy towards patients.This is linked to time constraints where the dentist finds it hard to discuss the treatment plan with the majority of the patients having little to no exposure to dental clinics.Nonetheless, these aspects are quite contextual.Similar findings were seen in other studies as well. 26,27  conventional concept regarding the concept of empathy has gender differences.Females are pictured as more caring, empathetic, and nurturing, whereas males are portrayed as more rational and less emotional.Research suggests this gender difference could be largely because of cultural expectations about the roles of genders.However, empathy is dependent on evolutionary and developmental precursors. 28,29 this study, respondents felt that females have this inborn attribute of empathy, but due to the societal values and our working environment, they are more careful when expressing their concern for their patients especially males since there have been reported incidences of female doctor's harassment issues at the workplace. 30This along with multiple other issues such as family/personal issues, professional burnout, and no time for relaxation are a hurdle in their empathetic attitude.
A small portion of dentists were recruited in this study.This was the main limitation of the study.Similar studies should be carried out, including the majority of the dentists from all regions of Pakistan to enhance the generalizability of the study.There is a need for an indepth investigation to explore the issues of class, gender, race, and cultural competences that affect empathy in a dentist-patient relationship.

Conclusion
Various factors are involved in developing an empathetic relationship between a dentist and a patient.The content about empathy in our present dental curriculum is very much deficient.Contextual academic workload and time constraints affect the execution of empathy.The significant findings that affect the development of dental surgeon empathy possibly

Theme 1 :
Institutionalization of empathy All the participants of the study pointed out the importance of institutionalization of empathy as no element of empathy was exclusively taught in undergraduate and postgraduate programs in dentistry.The sub-themes identified were a) Deficiency in curriculum, b) Lack of clarity in understanding empathy, c) Lack of role modelling, d) Role of supervisor to be redefined and e) Overburdened faculty.Theme 2: Barriers in the path of empathetic attitude Numerous factors affected the development of empathy in a dentist-patient relationship.The sub-themes identified were, a) Increased patient load, b) Dearth of professional enthusiasm and interpersonal skills, c) Lack of effective communication skills, d) Professional rivalry, e) Education level of the patient, f) Time constraints, g) Materialism, h) Lack of, i) awareness in faculty and students regarding the importance of empathy.Theme 3: Cultivating a culture of empathy for better healthcare provision.All the participants acknowledged the fact that we need to work together in developing a culture of empathy in society, which will automatically be translated into dental institutions assuring better healthcare facilities to the masses.The following sub-themes were identified as a) Lack of culture of empathy, b) Personal factors of dental surgeons, c) Desensitization, d) Lack of empathy in patients, e) Societal values, f) Gender-related issues, g) Patient trust, confidence and blessings, h) Good rapport of dental surgeon, i) Alleviating pain and suffering of the patient, j) Patient's increased compliance and satisfaction, k) Benevolence.
, confidence and blessings Good rapport with the dental surgeon Alleviating the pain and suffering of the patient Patient's increased compliance and satisfaction

Table 1
Demographics of study participants

Table 2
Themes, sub-themes and quotations