International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 704 www.internationaljournalofcaringsciences.org R E V I E W P A P E R . The Relationship between Physician Emotional Intelligence and Quality of Care Jamie B. Morales, MSc in Health Administration, University of La Verne Radiology Coordinator, Southern California Managed Care Organization, Anaheim, CA , USA Corespondence: Jamie B. Morales, Radiology Coordinator, Southern California Managed Care Organization 1221 N. Boden Dr. Anaheim, CA 92805 USA. E-mail: jamie.morales@laverne.edu Abstract The purpose of this literature review is to evaluate the relationship between physician emotional intelligence and quality of care. Although there is movement towards placing more emphasis on emotional intelligence, its true impact on healthcare and the quality of care that is provided is seemingly unknown in terms of a comprehensive understanding. In an attempt to determine the overall impact of physician emotional intelligence on quality of care, this literature review determines three domains which seem to be impacted the most according to the literature. These three domains are impact on physician-patient interaction, impact on staff, and direct impact on physician. Each of these domains are broad categories where there is a strong proven relationship with physician emotional intelligence; in addition, under each of these domains is a large amount of sub categories that impact quality of care as well. All three domains are strongly connected to each other and throughout the literature review common themes began to develop across the domains such as trust, communication, and job satisfaction. Understanding the impact of physician emotional intelligence on all of these domains is fundamental to better understanding the importance of developing and continuously improving emotional intelligence in areas such as healthcare. Keywords: emotional intelligence, quality of care, physician, patient, organizational climate Background The healthcare industry is currently in a state of complete change and organizations are trying to find ways to offer affordable services without sacrificing quality. This has shifted some focus toward the way health care professionals deliver care. A patient's perception of quality of care is impacted not only by the type of medical care received, but also by the manner in which it is delivered. Healthcare organizations continue to closely analyze and improve any areas that impact quality of care. However, one area that seems to receive less attention is the emotional intelligence of the physicians and the impact it has on quality of care. Emotional intelligence is defined as a specific set of skills that can be developed by an individual which enables them to understand both their own and other's emotions which improves their relationships and overall lives (Boylan & Loughrey, 2007). There are a number of ways physician emotional intelligence can impact quality of care, first is through patient-physician interaction (Weng et al., 2008). Secondly, a physician's emotional intelligence can impact the performance of their staff. A physician who lacks emotional intelligence lacks the ability to effectively communicate with their staff; these inefficiencies in communication can create a poor organizational climate at work and contribute to an overall increase in medical errors (Agarwal et al., 2010). Lastly, emotional intelligence can have a negative impact on the physician themselves. This direct impact on the physician shapes their interaction with staff and patient thus coming full circle. With limited research on emotional intelligence its true impact is yet to be determined, furthermore without a International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 705 www.internationaljournalofcaringsciences.org justifiable impact there continues to be an inconsistent focus on emotional intelligence in the healthcare setting. Literature Review Impact on Physician-Patient Interaction As a medical student embarks on the path of becoming a physician, one of the requirements is becoming accredited through the Accreditation Council for Graduate Medical Education (ACGME) (Arora et al., 2010). The ACGME has a set of core competencies in the United States; these core competencies are patient care, professionalism, system-based practice, interpersonal and communication skills, medical knowledge, and practice-based learning and improvement. Arora et al. (2010) suggested that emotional intelligence contributed towards many of the skills that helped a medical professional achieve these core competencies. Trust. As Arora et al. (2010) found emotional intelligence had an impact on the ACGME core competency patient care, which more specifically refers to compassionate and empathetic patientcentered care. According to Weng et al. (2008) one way to improve this type of patient care is through gaining the trust of the patient. Findings suggested a positive correlation between emotional intelligence and patient trust; furthermore patient trust was positively correlated with patient satisfaction with the physician and the hospital. Weng et al. (2010) conducted a larger scaled observational study to further examine the correlation between physician emotional intelligence and patient trust. The findings suggested that even when researching on a larger scale the correlation remained significant, patient trust was positively correlated with a physician's self-rated and externally rated emotional intelligence. In addition to improved perception of a physician and the organization, patient trust can also have a positive impact on the patient's health (Kearley et al., 2001). There was a significant response of patients valuing a personal doctor-relationship and preferring to see these physicians when experiencing a significant health problem. Findings stated that when patients have a personal relationship with their doctors it improves patient enablement and compliance with directions. This increased compliance results and better patient prognosis. As health conditions worsen patient's become more dependent on their physician and therefore that relationship is tested more rigorously. Shenolikar et al. (2004) conducted a study to examine the impact of a patient's trust in their physician and the patient-physician encounter in critical medical situations. It was found that patients demonstrated higher degrees of trust in physicians when the patient had been hospitalized or evaluated for a serious medical condition. Given that patient's trust increases in their physicians during these critical times, it is that much more important that physicians conduct themselves in ways that maintain that level of trust. As Arora et al. (2010) found it is emotional intelligence that enables a physician to conduct themselves in a manner that preserves this level of patient trust. Communication. Another core competency that can be impacted by the emotional intelligence of a physician is interpersonal communication skills (Arora et al., 2010). In order for communication with patients to be effective both the physician and patient must be in a certain frame of mind. Goleman (2006) performed a literature review to analyze the importance of emotions in terms of learning and focus. The literature suggested in times of stress the ability to think and focus is diminished because the energy to emotional centers is lessened. A physician has the task of making sure their patient is at ease so that they are able to focus on the information being given to them. In order to ensure this level of focus a physician must display emotional intelligence competencies such as empathy, mindfulness, and empathetic communication style (Cherry et al., 2012). An example of a physician-patient encounter where communication plays a large role is referred to as breaking bad news, which is the delivery on information in the healthcare domain that creates a negative view of a person's health (Villagran et al., 2010). Currently there are processes that have been established and utilized in medical schools; however the researchers suggested that there were missing components. To enhance some of the current protocols a set of core competencies were International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 706 www.internationaljournalofcaringsciences.org identified; referred to as COMFORT. COMFORT is an acronym for communication, orientation, mindfulness, family, ongoing, reiterative messages, and team. COMFORT was designed to ensure physicians did not forget about the emotional aspect of delivering bad news. Many of the core competencies in COMFORT are those that are possessed by an emotionally intelligent individual. As recommended by Villagran et al. (2010) emotional training early on in a medical school better prepares these individuals for their career as a physician. Cherry et al. (2012) performed a systematic review of the literature to evaluate the importance of structured educational sessions to increase emotional intelligence for medical students. By enhancing emotional intelligence of a medical student it was suggested that they will have a better developed ability to relate and empathize thus improving communication and decision making. The patient's voice. As a healthcare organization one way to continue monitoring the physicianpatient relationship is to simply listen to the voice of the patient (Last, 2012). Rather than focusing entirely on data provided by systems, it is suggested to invite the opinions of patients to identify key areas for improvement such as the emotional intelligence of the physician. Traditionally patient satisfaction and quality of care is focused on quality and outcome frameworks which do not take into consideration attitudes and behaviors of the clinicians. It is the presence of emotional intelligence in a healthcare clinician that develops these individuals into effective leaders with enhanced decision making skills and a great sense of trust from their patients. Impact on Staff A physician's emotional intelligence can impact the individual relationships within the work setting and carry over to the entire organizational climate (Momeni, 2009). In fact, it is suggested that physician behavior can impact employee satisfaction, employee turnover, and the cost of conflict and malpractice liability (Around-Thomas, 2004). The emotional intelligence of a physician can impact these individual and interconnected relationships by hindering communication which in turn can impact quality of care (Herkenhoff, 2009). Communication. Goleman (1995) discussed the importance of emotional intelligence in any setting where the collaboration of individuals is key to the success of the team. If the leader of the team is unapproachable or lacks interpersonal skills the communication of the team is hindered. In addition Herkenhoff (2010) found that physicians with lower emotional intelligence were more likely to demonstrate one or more defensive tactics. These defensive tactics were determined by the physicians who participated in the study; the four most common were labeling, power play, sarcasm, and deception. It was recommended that development of emotional intelligence competencies might improve communication effectiveness and in addition the sharing of limited resources. Koczwara et al. (2011) conducted a study to evaluate the introduction of a medical appraiser development center that combines development center methods and the concept of emotional intelligence. General practitioner appraisal is the process in which physicians are able to reflect on their work and identify their strengths and possible weaknesses. It also allows fellow physicians to offer feedback to their colleagues. The findings suggested that the introduction of the concept of emotional intelligence when conducting these appraisals enhanced appraiser confidence and increased awareness of self and others. Appraisers were more aware of how the appraisal could impact the appraisee and therefore were more prepared for the appraisal. Effective communication becomes more difficult as the tension of the situation increases; emotional intelligence is a competency that facilitates communication during these stressful times (Around-Thomas, 2004). A physician's failure to consistently demonstrate respect for others can be damaging to communication and can even create these types of problematic behaviors between physicians and staff. Around-Thomas (2004) suggests that as a healthcare team there needs to be an effort to create norms that are emotionally intelligent and support behaviors for improving trust, group identity, and group efficacy. Agarwal et al. (2010) assessed the economic impact of communication inefficiencies in United States hospitals. The hospital communication International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 707 www.internationaljournalofcaringsciences.org quality was based on four sub groups; efficiency of resource utilization, effectiveness of core operations, quality of work life, and service quality. The most impacted in regards to economic impact was efficiency of resource utilization. Poor communication resulted in a significant excess of cost attributed to unproductive use of staff's time such as correcting errors or confirming direction repeatedly. Organizational climate. Momeni (2009) found in previous literature that overall organizational climate was highly impacted by a manager's emotional intelligence. The data proposed the higher a manager's emotional intelligence the better the manager's organizational culture was. In addition the data indicated that 55% of organizational culture is caused by a manager's emotional intelligence. Self-awareness and social awareness demonstrated by the manager were the competencies of emotional intelligence that proved to be most impactful on organizational culture. Furthermore self-awareness was considered a fundamental building block of other skills such as good communications skills, interpersonal expertise, and mentoring abilities. If emotional intelligence can impact organizational climate it is important that emotional intelligence is achieved at an organizational level (Gantt and Agazarian, 2004). Organizational emotional intelligence implies that on all levels the organization is able to adapt to change because of the ability to change perspectives. The concept of changing perspectives and recognizing impact to others is referred to as contextualizing. Rather than viewing things from a self-centered perspective or even a team-centered perspective, the goal is to view things from a system-centered perspective; this enables organizations on all different levels to be more efficient at decision making. In order to accomplish this an organization needs emotionally intelligence employees. Clarke (2006) conducted a case study to examine the development of emotional intelligence within the healthcare setting. Three common themes were found; emotional content of the work involved, learned processes, and emotional skills, knowledge or abilities. Findings suggested that the ability to manage emotions was a significant job requirement of working in an emotionally charged environment. The ability to manage one's emotions was important as well as the ability to assist others with their emotions. It was found that emotional abilities took on meaning and significance through social interaction with individuals within the healthcare environment. Clarke (2006) proposes that by engaging in social structures and relationships within the organizational setting, emotional abilities and knowledge are able to develop. Job satisfaction. Jofri et al. (2012) found that emotional intelligence of managers and employees had a relationship with communication effectiveness and job satisfaction of the employee. In addition it was suggested that emotional intelligence is not necessarily a predictor of effective communication or job satisfaction as much as it is a catalyst for improved working relationships. Emotional intelligence enhances one's intellectual abilities therefore improving the relationships between staff. Cheang (2011) describes that as a clinician many become detached in order to accomplish tasks; not that as individuals they are unable to empathize, but that as clinicians it becomes necessary to detach in order to be productive. This detachment results in tasks taking priority over people. A leader who is emotionally intelligent is able to effectively make decisions while being self-aware and aware of others. A whole systems approach can be made; meaning when decisions are made there is a clear sense of individual's value to the organization and how to align their activities and direction with the direction of the organization. Maintaining this self-awareness and awareness of others keeps employees engaged and motivated which increases job satisfaction (Jofri et al., 2012). Direct Impact on Physician Law et al. (2004) conducted a study to test existing emotional intelligence scales and establish a predictive validity of emotional intelligence in organizational atmospheres. Prior to conducting the research they set out to determine a proper definition for emotional intelligence. The definition determined was one that used four dimensions to identify a person who was emotionally intelligent; appraisal and expression of emotion in oneself, appraisal and recognition of emotion in others, regulation of emotion in oneself, International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 708 www.internationaljournalofcaringsciences.org and use of emotion to facilitate performance. In addition emotional intelligence was found to be different from personality dimensions, instead it was viewed as a construct of a person that can be developed through education and continued training. Job satisfaction. Law et al. (2004) found that emotional intelligence was positively associated with life satisfaction, negatively associated with feeling powerlessness, and positively associated with job performance. The higher an individual was self-rated and rated by others on the emotional intelligence scale the more likely the individual was to be satisfied with life. In addition these individuals with high ratings of emotional intelligence were more likely to feel empowered and perform well in their job, which led to increased job satisfaction. Weng et al. (2011) researched the relationship between a physician's emotional intelligence and doctor burnout, job satisfaction, and patient satisfaction. Emotional intelligence was divided into sub dimensions in order to measure it more efficiently; these sub dimensions included selfemotion appraisal, other's emotional appraisal, use of emotion, and regulation of emotions. Job burnout was measured by three sub dimensions including emotional exhaustion, depersonalization, and reduced personal accomplishment. Higher emotional intelligence was correlated with less burnout and higher job satisfaction. Furthermore, it was found that the sub dimension of depersonalization had a significant negative impact on patient satisfaction. Psilopanagioti et al. (2012) conducted a study to measure the correlation between emotional intelligence, emotional labor, and job satisfaction among physicians. Emotional labor is the suppressing or faking of emotions to meet expectations and organizational rules. Emotional labor can include surface acting which is altering the outward appearance of an emotion, or deep acting which is adjusting internal feelings by attempting to understand and sympathize with others. Findings demonstrated a negative correlation between surface acting and job satisfaction; those who faked their emotional intelligence were less satisfied with their jobs. Emotional labor can impact job satisfaction by increasing emotional demands which can lead to more stress, psychological distress, and symptoms of depression. Leadership skills. In addition to personal job satisfaction, emotional intelligence can better prepare a physician for the leadership role they are to assume when becoming a physician. Henochowicz and Hetherington (2006) performed a literature review to examine the state of leadership coaching for physicians and nonmedical healthcare leaders. The authors suggest that healthcare organizations must find a way to continue to be patient centered while they are expanding. It is suggested that leadership training could be a solution because it allows the development of interpersonal and emotional intelligence competencies. There are several skills and attributes that are desired in a physician who is in a leadership role. One of those qualities is the ability to conduct ethical decision making (Desphande, 2009). In this study the researcher examines the correlation between ethical decision making and several different influences. Findings suggest that the emotional intelligence of hospital employees had an impact on their ethical behavior. Employees, including physicians, who exemplify skills such as honesty and empathy, were more likely to make ethical decisions. Another characteristic valued in an individual in a leadership role would be the ability to effectively problem solve. According to Mayer et al. (2003) testing for emotional intelligence means testing for effective problem solving as well. In the context of physicians it allows a measurement of their ability to problem solve in the work environment when dealing with their own emotions, staff emotions, and most importantly the emotions of their patients. Vezhavan and Sivasubramanian (2013) determined that emotional intelligence also impacted the individual by improving performance at work, physician health, mental health, and relationships. In order to develop emotional intelligence there were five key skills identified; ability to quickly reduce stress, ability to recognize and manage emotions, ability to connect with others using nonverbal communication, ability to use humor to deal with challenges, and the ability to resolve International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 709 www.internationaljournalofcaringsciences.org conflicts positively and with confidence. Vezhavan and Sivasubramanian (2013) suggested that in order to encourage these skills within the organization emotional intelligence should be a requirement of new hires. Developing emotional intelligence. As the literature has suggested emotional intelligence is a type of intelligence that is not always innately present, instead it is a competency that is taught and enhanced through continuous training (Boylan & Loughrey, 2007). In an attempt to better develop emotional intelligence medical educators have been incorporating exercises that improve emotional intelligence in themselves and their students. The role of the facilitator is crucial to developing emotional intelligence in general practitioners and registrars. According to Sadri (2013) emotional intelligence is quickly becoming just as important as intellectual intelligence. Emotional intelligence is considered especially important in positions that heavily involve interpersonal skills. Sadri (2013) found that emotional intelligence allows people to perceive, evaluate, anticipate, and manage emotions more effectively which in turn allows them to better collaborate and motivate their staff. In addition the research found that those who worked for a manager or leader that had been trained in emotional intelligence were more successful. Hen and Goroshit (2011) conducted a study of undergraduate students to determine whether or not there was a measurable change in emotional intelligence after taking a course that covered the topic. The results showed for the advanced-year students there was a significant increase in the overall emotional intelligence mean suggesting that early intervention of emotional intelligence education was beneficial. Education prior to the work setting allows future physicians to begin preparing for emotionally charged situations early on. As emotional intelligence becomes a topic of discussion organizations are beginning to pay closer attention to the behaviors and attitudes of those they hire (Hernandez, 2012). A physician acts as a leader on multiple levels within the healthcare organization and therefore their intellectual, emotional, and social abilities should be screened thoroughly during the hiring process. An individual who lacks emotional intelligence might possess maladaptive traits that could pose serious problems after employment. In addition an employee with poor behavior or attitude can potentially destroy up to five times the energy in the workplace in comparison to a positive enthusiastic employee who can enlighten and create energy (Hernandez, 2012). Discussion The goal of this literature review was to gather information on the impact or potential impact emotional intelligence of a physician has on quality of care. As healthcare continues to transform organizations have shifted focus to the quality of care and how to utilize it to create success. It is this importance placed on quality of care that brings new light to the importance of emotional intelligence. With emotional intelligence of physicians directly and indirectly impacting so many elements of quality of care, it seems likely that focusing on this area would be a worthy place to begin making improvements. Although the literature regarding emotional intelligence is vast, that which is specific to the emotional intelligence of a physician is not quite as great. With additional research on the topic emotional intelligence can begin being implemented as part of the curriculum within medical schools, and in addition can become a core competency expected of all physicians. With this addition to medical school physicians will be better prepared, and through continuous training they can enhance their emotional intelligence throughout their careers. As Law et al. (2004) stated, emotional intelligence is not necessarily a characteristic of an innate trait of an individual; instead it is a type of intelligence that can be nurtured with the proper education and training. References Agarwal, R., Sands, D. Z., Schneider, J., & Smaltz, D. H. (2010) Quantifying the economic impact of communication inefficiencies in U.S. hospitals. Journal of Healthcare Management, 55: 265-282. Arond-Thomas, M. (2004) Understanding emotional intelligence can help alter problem behavior. Physician Executive, 30: 36-39. International Journal of Caring Sciences September-December 2014 Volume 7 Issue 3 710 www.internationaljournalofcaringsciences.org Arora, S., Ashrafian, H., Davis, R., Athanasiou, T., Darzi, A., & Sevdalis, N. (2010) Emotional intelligence in medicine: a systematic review through the context of the ACGME competencies. Medical Education, 44: 749-764. Boylan, O., & Loughrey, C. (2007) Developing emotional intelligence in GP trainers and registrars. Education for Primary Care, 18: 745-748. Cheang, P. P. (2011) Learning about leadership-a personal account. Medical Teacher, 33: 491-493. Cherry, M., Fletcher, I., O'Sullivan, H., & Shaw, N. (2012) What impact do structured educational sessions to increase emotional intelligence have on medical students? BEME Guide No. 17. Medical Teacher, 34: 11-19. Clarke, N. (2006) Developing emotional intelligence through workplace learning: Findings from a case study in healthcare. Human Resource Development International, 9: 447-465. Deshpande, S. (2009) A study of ethical decision making by physicians and nurses in hospitals. Journal of Business Ethics, 90: 387-397. Goleman, D. (2006) The Socially intelligent leader. Educational Leadership, 64: 76-81. Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ. Bantam Books, New York, NY. Gantt, S. P., & Agazarian, Y. M. (2004) Systemscentered emotional intelligence: Beyond Iindividual systems to organizational systems. Organizational Analysis, 12: 147-169. Hen, M., & Goroshit, M. (2011) Emotional competencies in the education of mental health professionals. Social Work Education, 30: 811-829. Henochowicz, S., & Hetherington, D. (2006) Leadership coaching in health care. Leadership and Organization Development Journal, 27: 83-189. Herkenhoff, L. (2010) Case study: Emotional intelligence as a differentiator in values-based healthcare communication. Journal of Communication in Healthcare, 3: 62-77. Hernandez, J. S. (2012) Tips for recruiting and retaining the best physicians. Physician Executive, 38: 6467. Jorfi, H., Fauzy Bin Yacco, H., & Shah, I. (2012) Role of gender in emotional intelligence: Relationship among emotional intelligence, communication effectiveness and job satisfaction. International Journal of Management, 29: 590-597. Kearley, K., Freeman, G. K., & Heath, A. (2001) An exploration of the value of the personal doctorrelationship in general practice. British Journal of General Practice, 51: 712-718. Koczwara, A., Tavabie, A., & Patterson, F. (2011) Evaluation of GP appraiser development centers using emotional intelligence: Can positive learning outcomes be transferred to practice? Education for Primary Care, 22: 399-408. Last, R. (2012) Using patient stories to shape better services. Practice Nurse, 42: 33-37. Law, K. S., Chi-Sum, W., & Song, L. J. (2004) The construct and criterion validity of emotional intelligence and its potential utility for management studies. Journal of Applied Psychology, 89: 483-496. Mayer, J. D., Salovey, P., Caruso, D. R., & Sitarenios, G. (2003) Measuring emotional intelligence with the MSCEIT V2.0. Emotion, 3: 97-105. Momeni, N. (2009) The relation between managers' emotional intelligence and the organizational climate they create. Public Personnel Management, 38: 35-48. Psilopanagioti, A., Anagnostopoulos, F., Mourtou, E., & Niakas, D. (2012). Emotional intelligence, emotional labor, and job satisfaction among physicians in Greece. BMC Health Services Research, 12: 463-474. Sadri, G. (2013) Improving emotional intelligence. Industrial Management, 55: 18- 22. Shenolikar, R., Balkrishnan, R., & Hall, M. A. (2004) How patient-physician encounters in critical medical situations affect trust: Results of a national survey. BMC Health Services Research, 424-426. Vezhavan, T. T., & Sivasubramanian, M. M. (2013) Emotional intelligence: A strategy for effective administration. Language in India, 13: 637-646. Villagran, M., Goldsmith, J., Wittenberg-Lyles, E., & Baldwin, P. (2010). Creating COMFORT: A communication-based model for breaking bad news. Communication Education, 59: 220-234. Weng, H., Chen, H., Chen, H., Lu, K. & Hung, S. (2008) Doctors' emotional intelligence and the patient–doctor relationship. Medical Education, 42: 703-711. Weng, H., Chen, Y., Lin, C., Tu, Y., Lin, H., & Yu, S. (2011) Specialty differences in the association between healthcare climate and patient trust. Medical Education, 45: 905-912. Weng, H., Hung, C., Liu, Y., Cheng, Y., Yen, C., Chang, C., & Huang, C. (2011) Associations between emotional intelligence and doctor burnout, job satisfaction and patient's satisfaction. Medical Education, 45: 835-842.