https://orcid.org/0000-0003-1020-0818
Abstract
Although personality characteristics of patients with SLE affect their disease activity and damage, it is unclear whether those of attending physicians affect the outcomes of patients with SLE. Grit is a personality trait for achieving long-term goals that may influence the decision-making for continuing treatment plans for patients. We aimed to evaluate the relationship between the grit of attending physicians and achievement of treatment goals in patients with SLE.
This cross-sectional study was conducted at five referral hospitals. The main exposure was ‘consistency of interest’ and ‘perseverance of effort’ of the attending physicians, measured by the Short Grit Scale. The primary outcome was achievement of a lupus low disease activity state (LLDAS). The association between physicians’ grit score and LLDAS was analysed by generalized estimating equation (GEE) logistic regression with cluster robust variance estimation, with adjustment for confounders.
The median (interquartile range) total, consistency and perseverance scores of 37 physicians were 3.1 (2.9–3.6), 3.3 (2.8–3.8) and 3.3 (3.0–3.5), respectively. Among the 386 patients, 154 (40%) had achieved LLDAS. Low consistency score (≤2.75) in physicians was related to LLDAS achievement independently using GEE logistic regression. The score of the question ‘I often set a goal but later choose to pursue a different one’ was significantly higher in patients achieving LLDAS.
Difficulty of attending physicians to change treatment goals might be related to lower LLDAS achievement in patients with SLE.
Low consistency of interest of attending physicians was associated with treatment goal achievement in SLE.
Physicians’ difficulty in changing the treatment goal may be related to lower LLDAS achievement.
Introduction
Owing to the development of therapeutic agents and better treatment strategies, long-term 10-year survival and 10-year renal survival rates in patients with SLE have reached ∼90% [1]. Thus, major concerns in the clinical course of patients with SLE have shifted from survival to minimizing chronic damage accumulation for maintaining quality of life (QOL) [2, 3]. In clinical practice, the concept of ‘treat to target’ for SLE has been introduced with an established goal of reducing the glucocorticoid dose as much as possible while controlling disease activity to prevent the accumulation of chronic damage. Recently, lupus low disease activity state (LLDAS) has been proposed as a therapeutic target for patients with SLE [4]. Achievement of LLDAS is associated with less damage accumulation over time and higher QOL [5, 6]. LLDAS consists of disease activity, organ involvement, physician’s assessment and treatment status. For achieving LLDAS, the alliance of patients and physicians to assess disease status and determine treatment strategies is essential [4].
Personality traits of patients affect various outcomes in patients with SLE. Resilience affects medication adherence [7, 8] and partially mediates the association between illness uncertainty and sleep quality [9]. There is no strong empirical evidence that the personalities of clinicians lead to enhanced quality of care based on a systematic review [10]. However, patient–doctor interaction mediates the relationship between illness coherence and trust in a physician [11]. Empowerment, including shared medical decision-making and knowledge acquisition, can also improve the quality of care in patients with SLE [12]. Additionally, the confidence of physicians in the accuracy of the diagnosis affects their decision and changes risk aversion in clinical practice [13]. Thus, the specific personality characteristics of physicians may affect patient outcomes directly or via quality of care.
Grit is a personality trait that is defined as trait-level perseverance and passion for long-term goals [14]. Grit is composed of ‘consistency of interest’ and ‘perseverance of effort’. Grit of patients affects the adherence to regular hospital visits among patients with type 2 diabetes [15]. In patients with Parkinson’s disease, grit is related to a positive attitude towards treatment and health-related QOL [16]. Although grit of physicians helps prevent burnout [17], it is unclear whether grit of physicians affects the outcomes of patients with SLE.
Therefore, this study aimed to evaluate the relationship between grit of their attending physicians and achievement of treatment goals in patients with SLE. Our hypothesis in the present study is that higher grit of the attending physicians is related to more frequent achieving LLDAS.
Patients and methods
Study design and setting
This cross-sectional study used data from a multidisciplinary cohort study [Trust Measurement for Physicians and Patients with SLE (TRUMP2-SLE)] that included patients from five secondary or tertiary institutions and was conducted in 2020 to investigate the trust of patients with SLE in their physicians with regard to clinical manifestations and outcomes [18]. This study was conducted in accordance with the Declaration of Helsinki and the ethical guidelines for epidemiologic research in Japan. This study was approved by the ethics committee of Kochi Medical School (2021-160). All patients provided written informed consent to participate in the registry and gave permission for the publication of their data.
Study participants
Patients in TRUMP2-SLE were aged ≥20 years and were classified according to the revised 1997 ACR criteria for SLE classification [19]. TRUMP2-SLE also collected data on personality traits of physicians such as grit using self-administered questionnaires [20]. This study was performed using data obtained from electronic medical records and self-administered questionnaires completed by registered patients and their attending physicians between June 2020 and August 2021. The attending physicians were identified based on patient responses to the questionnaires. All study data were collected at the time of registration.
Outcome measures
The primary outcome measure was achievement of LLDAS [4], which requires the fulfilment of the following four criteria: (i) an SLEDAI-2000 (SLEDAI-2K [21], scale 0–105) score of ≤4, (ii) no active symptoms of major organ involvement (renal, CNS, cardiopulmonary system, vasculitis or fever) and no haemolytic anaemia or gastrointestinal activity, (iii) a physician global assessment (scale 0–3) score of ≤1, and (iv) a current prednisolone (or equivalent) dose of ≤7.5 mg daily and well-tolerated standard maintenance doses of immunosuppressive drugs. The secondary outcome measures were the SLEDAI-2K scores for disease activity, SLICC Damage Index (SLICC-DI) [22] score for chronic damage and treatment status. The attending physician did not know their grit score when assessing their patients’ disease activity.
Exposure
The main exposure included two components of grit of attending physicians: ‘consistency of interest’ and ‘perseverance of effort’. We used the Japanese version of the Short Grit Scale for measuring grit of attending physicians [20, 23]. The subdomains of ‘consistency of interest’ and ‘perseverance of effort’ were composed of the questions mentioned in Table 1. Each component was rated on a five-point Likert scale (‘very much like me’, ‘mostly like me’, ‘somewhat like me’, ‘not much like me’, ‘not like me at all’). The total grit score is calculated as an average of the 8 items. The maximum score on this scale is 5 (extremely gritty) and the lowest score is 1 (not at all gritty). Since a high score of each component in the ‘consistency of interest’ subdomain inversely indicated a low consistency, the score was reverse weighted for the calculation of the total and subdomain grit score. Finally, high subdomain ‘consistency of interest’ score indicates high perseverance.
Grit score of physicians
| Total scorea | 3.1 (2.9–3.6) |
|---|---|
| Consistency of interesta | 3.3 (2.8–3.8) |
| I have difficulty maintaining my focus on projects that take more than a few months to complete | 2.0 (2.0–4.0) |
| I have been obsessed with a certain idea or project for a short time but later lost interest | 3.0 (2.0–4.0) |
| I often set a goal but later choose to pursue a different one | 3.0 (2.0–4.0) |
| New ideas and projects sometimes distract me from previous ones | 3.0 (2.0–4.0) |
| Perseverance of effort | 3.3 (3.0–3.5) |
| I finish whatever I begin | 4.0 (2.0–4.0) |
| I am a hard worker | 3.0 (3.0–4.0) |
| Setbacks do not discourage me | 3.0 (3.0–4.0) |
| I am diligent | 3.0 (3.0–4.0) |
| Total scorea | 3.1 (2.9–3.6) |
|---|---|
| Consistency of interesta | 3.3 (2.8–3.8) |
| I have difficulty maintaining my focus on projects that take more than a few months to complete | 2.0 (2.0–4.0) |
| I have been obsessed with a certain idea or project for a short time but later lost interest | 3.0 (2.0–4.0) |
| I often set a goal but later choose to pursue a different one | 3.0 (2.0–4.0) |
| New ideas and projects sometimes distract me from previous ones | 3.0 (2.0–4.0) |
| Perseverance of effort | 3.3 (3.0–3.5) |
| I finish whatever I begin | 4.0 (2.0–4.0) |
| I am a hard worker | 3.0 (3.0–4.0) |
| Setbacks do not discourage me | 3.0 (3.0–4.0) |
| I am diligent | 3.0 (3.0–4.0) |
Each component is rated on a five-point Likert scale (‘very much like me’, ‘mostly like me’, ‘somewhat like me’, ‘not much like me’, ‘not like me at all’). Data are presented as median (interquartile range).
Since a high score in each component of ‘consistency of interest’ inversely indicates the low consistency, the score of each component in ‘consistency of interest’ is reverse weighted for the calculation.
Grit score of physicians
| Total scorea | 3.1 (2.9–3.6) |
|---|---|
| Consistency of interesta | 3.3 (2.8–3.8) |
| I have difficulty maintaining my focus on projects that take more than a few months to complete | 2.0 (2.0–4.0) |
| I have been obsessed with a certain idea or project for a short time but later lost interest | 3.0 (2.0–4.0) |
| I often set a goal but later choose to pursue a different one | 3.0 (2.0–4.0) |
| New ideas and projects sometimes distract me from previous ones | 3.0 (2.0–4.0) |
| Perseverance of effort | 3.3 (3.0–3.5) |
| I finish whatever I begin | 4.0 (2.0–4.0) |
| I am a hard worker | 3.0 (3.0–4.0) |
| Setbacks do not discourage me | 3.0 (3.0–4.0) |
| I am diligent | 3.0 (3.0–4.0) |
| Total scorea | 3.1 (2.9–3.6) |
|---|---|
| Consistency of interesta | 3.3 (2.8–3.8) |
| I have difficulty maintaining my focus on projects that take more than a few months to complete | 2.0 (2.0–4.0) |
| I have been obsessed with a certain idea or project for a short time but later lost interest | 3.0 (2.0–4.0) |
| I often set a goal but later choose to pursue a different one | 3.0 (2.0–4.0) |
| New ideas and projects sometimes distract me from previous ones | 3.0 (2.0–4.0) |
| Perseverance of effort | 3.3 (3.0–3.5) |
| I finish whatever I begin | 4.0 (2.0–4.0) |
| I am a hard worker | 3.0 (3.0–4.0) |
| Setbacks do not discourage me | 3.0 (3.0–4.0) |
| I am diligent | 3.0 (3.0–4.0) |
Each component is rated on a five-point Likert scale (‘very much like me’, ‘mostly like me’, ‘somewhat like me’, ‘not much like me’, ‘not like me at all’). Data are presented as median (interquartile range).
Since a high score in each component of ‘consistency of interest’ inversely indicates the low consistency, the score of each component in ‘consistency of interest’ is reverse weighted for the calculation.
Statistical analysis
First, the descriptive statistics of the attending physicians and enrolled patients were expressed as the median and interquartile range (IQR) for continuous variables and as number (%) for categorical variables. Subsequently, achievement of LLDAS was described and compared among different ‘consistency’ and ‘perseverance’ scores divided by quartile points. As a secondary exposure, achievement of LLDAS was also compared among different total grit score groups divided by quartile points. Secondary outcome measures were also compared among total and subdomain scores of grit.
Considering the clustering of achievement of LLDAS by each attending physician, the association between the personality of the attending physician and achievement of LLDAS was analysed by generalized estimating equation (GEE) logistic regression with cluster robust variance estimation. The odds ratio (OR) was estimated with adjustment for confounders (age, sex, disease duration, use of HCQ and immunosuppressant, and SLICC-DI score). As a sensitivity analysis, we also estimated OR with adjustment for confounding factors including physicians’ age to mentioned above confounding factors. We used multiple imputation to handle the uncertainty caused by missing values of potential confounders under the assumption of missing values at random. Finally, we evaluated achievement of LLDAS among each item of ‘consistency’ and ‘perseverance’ for exploratory purposes.
Continuous variables were compared using the Mann–Whitney U test or Student’s t-test, depending on data distribution, and categorical variables were compared using the χ2 test or Fisher’s direct probability test, as appropriate. Spearman rank correlation was used to evaluate the relationship between physicians’ age and grit scores. Statistical significance was set at P < 0.05. All statistical analyses were performed using Statistical Package of Stata, version 17.0 (StataCorp, College Station, TX, USA).
Patient and public involvement
Neither the general public nor patients with SLE were involved in the planning, recruitment and conducting of this study.
Results
Attending physicians’ grit
The median (IQR) age of 37 attending physicians was 40 (35–43) years, and seven (19%) participants were women. All attending physicians were rheumatologists. The median (IQR) total, subdomain, and each item of the grit score are shown in Table 1. There was no statistical difference in the total, subdomain and each item score based on sex. Age had poor correlation to the total (rs = 0.19, P = 0.19), consistency (rs = 0.17, P = 0.23) and perseverance (rs = 0.12, P = 0.40) scores. When divided by the first or third quartile points, the proportion of high total grit (≥4.25), low consistency (≤2.75) and high perseverance (≥4.5) were 139 (36%), 130 (34%) and 148 (38%), respectively.
Patient characteristics
In total, 386 patients were enrolled. The median (IQR) age was 45 (36–56) years, and 339 (88%) patients were women. The median (IQR) disease duration was 13 (7–20) years. The median (IQR) SLEDAI-2K and SLICC-DI scores at the time of registration were 4 (2–8) and 1 (1–2), respectively. The median (IQR) dose of daily prednisolone was 6 (4–10) mg. Immunosuppressants and HCQ were administered to 245 (64%) and 188 (50%) patients, respectively.
Attending physicians’ grit and patients’ LLDAS achievement
There were no missing data in the information required to evaluate the LLDAS. LLDAS was achieved in 154 (40%) patients. The characteristics of patients achieving and not achieving LLDAS are shown in Table 2. Patients achieving LLDAS were older, and had longer disease duration than those not achieving LLDAS.
Characteristics of patients achieving and not achieving LLDAS
| Achievement of LLDAS (N = 154) | Number of missing data | No achievement of LLDAS (N = 232) | Number of missing data | P-value | |
|---|---|---|---|---|---|
| Age, median (IQR), years | 48 (39–60) | 0 | 41 (34–53) | 2 | 0.001 |
| Female patients, n (%) | 130 (84.4) | 0 | 209 (90.9) | 2 | 0.054 |
| Disease duration, median (IQR), months | 170 (97–261) | 5 | 145 (64–215) | 9 | 0.005 |
| SLEDAI-2K, median (IQR) | 2 (0–4) | 0 | 6 (4–10) | 0 | <0.001 |
| SLICC-DI, median (IQR) | 1 (0–2) | 0 | 1 (1–2) | 0 | 0.014 |
| PSL dose, median (IQR), mg/day | 5 (2–5) | 0 | 9 (6–13) | 0 | <0.001 |
| Current immunosuppressant use, n (%) | 86 (55.8) | 0 | 159 (68.5) | 0 | 0.011 |
| Current HCQ use, n (%) | 67 (44.7) | 4 | 121 (53.5) | 6 | 0.092 |
| Achievement of LLDAS (N = 154) | Number of missing data | No achievement of LLDAS (N = 232) | Number of missing data | P-value | |
|---|---|---|---|---|---|
| Age, median (IQR), years | 48 (39–60) | 0 | 41 (34–53) | 2 | 0.001 |
| Female patients, n (%) | 130 (84.4) | 0 | 209 (90.9) | 2 | 0.054 |
| Disease duration, median (IQR), months | 170 (97–261) | 5 | 145 (64–215) | 9 | 0.005 |
| SLEDAI-2K, median (IQR) | 2 (0–4) | 0 | 6 (4–10) | 0 | <0.001 |
| SLICC-DI, median (IQR) | 1 (0–2) | 0 | 1 (1–2) | 0 | 0.014 |
| PSL dose, median (IQR), mg/day | 5 (2–5) | 0 | 9 (6–13) | 0 | <0.001 |
| Current immunosuppressant use, n (%) | 86 (55.8) | 0 | 159 (68.5) | 0 | 0.011 |
| Current HCQ use, n (%) | 67 (44.7) | 4 | 121 (53.5) | 6 | 0.092 |
LLDAS: lupus low disease activity state; IQR: interquartile range; PSL: prednisolone; SLEDAI-2 K: SLEDAI 2000; SLICC-DI: SLICC Damage Index.
Characteristics of patients achieving and not achieving LLDAS
| Achievement of LLDAS (N = 154) | Number of missing data | No achievement of LLDAS (N = 232) | Number of missing data | P-value | |
|---|---|---|---|---|---|
| Age, median (IQR), years | 48 (39–60) | 0 | 41 (34–53) | 2 | 0.001 |
| Female patients, n (%) | 130 (84.4) | 0 | 209 (90.9) | 2 | 0.054 |
| Disease duration, median (IQR), months | 170 (97–261) | 5 | 145 (64–215) | 9 | 0.005 |
| SLEDAI-2K, median (IQR) | 2 (0–4) | 0 | 6 (4–10) | 0 | <0.001 |
| SLICC-DI, median (IQR) | 1 (0–2) | 0 | 1 (1–2) | 0 | 0.014 |
| PSL dose, median (IQR), mg/day | 5 (2–5) | 0 | 9 (6–13) | 0 | <0.001 |
| Current immunosuppressant use, n (%) | 86 (55.8) | 0 | 159 (68.5) | 0 | 0.011 |
| Current HCQ use, n (%) | 67 (44.7) | 4 | 121 (53.5) | 6 | 0.092 |
| Achievement of LLDAS (N = 154) | Number of missing data | No achievement of LLDAS (N = 232) | Number of missing data | P-value | |
|---|---|---|---|---|---|
| Age, median (IQR), years | 48 (39–60) | 0 | 41 (34–53) | 2 | 0.001 |
| Female patients, n (%) | 130 (84.4) | 0 | 209 (90.9) | 2 | 0.054 |
| Disease duration, median (IQR), months | 170 (97–261) | 5 | 145 (64–215) | 9 | 0.005 |
| SLEDAI-2K, median (IQR) | 2 (0–4) | 0 | 6 (4–10) | 0 | <0.001 |
| SLICC-DI, median (IQR) | 1 (0–2) | 0 | 1 (1–2) | 0 | 0.014 |
| PSL dose, median (IQR), mg/day | 5 (2–5) | 0 | 9 (6–13) | 0 | <0.001 |
| Current immunosuppressant use, n (%) | 86 (55.8) | 0 | 159 (68.5) | 0 | 0.011 |
| Current HCQ use, n (%) | 67 (44.7) | 4 | 121 (53.5) | 6 | 0.092 |
LLDAS: lupus low disease activity state; IQR: interquartile range; PSL: prednisolone; SLEDAI-2 K: SLEDAI 2000; SLICC-DI: SLICC Damage Index.
Low consistency of interest of attending physicians was more frequent in the patients achieving LLDAS than in those not achieving LLDAS (Fig. 1). Glucocorticoid-free status, HCQ use and immunosuppressant use were not different between patients whose attending physicians had low consistency and those whose physicians had non-low consistency (10% vs 9%, P = 0.71; 49% vs 50%, P = 0.912; and 62% vs 64%, P = 0.58, respectively). The total grit score and perseverance of effort were not statistically different among the two groups. Even after adjusting confounders using GEE logistic regression with cluster robust variance estimation, low consistency of interest showed statistical association with LLDAS achievement (adjusted OR 1.63, 95% CI 1.17, 2.27). Sensitivity analysis including physicians’ age as a confounding factor did not change the magnitude of the association between low consistency of interest and LLDAS achievement (adjusted OR 1.65, 95% CI 1.21, 2.24). There were no statistical differences in the SLEDAI-2K and SLICC-DI scores between patients whose attending physicians had a high grit score and those whose physicians had a low grit score [SLEDAI-2K: 4 (2–8) vs 4 (2–7), P = 0.60 and SLICC-DI: 1 (1–2) vs 1 (1–2), P = 0.86, respectively].
Total grit and subdomain between patients achieving and not achieving LLDAS. Each score is categorized by quartile points. χ2 test is used test for assessing difference between two groups. LLDAS: lupus low disease activity state
The result of the explanatory analysis of each item related to LLDAS is shown in Fig. 2. The score of the question ‘I often set a goal but later choose to pursue a different one’ was statistically higher in patients achieving LLDAS than in those not achieving LLDAS [3.0 (3.0–4.0) vs 3.0 (2.0–3.0), P = 0.006]. The score of other questions showed no statistical difference between the two groups.
Each component score in subdomain between patients achieving and not achieving LLDAS. Median and interquartile range are indicated by either a black dot or white circle and a vertical line, respectively. Each component is rated on a five-point Likert scale (‘very much like me’, ‘mostly like me’, ‘somewhat like me’, ‘not much like me’, ‘not like me at all’). The Mann–Whitney U test is used for comparison of two groups. LLDAS: lupus low disease activity state
Discussion
In the present study, we mainly focused on the association between grit of attending physicians and achievement of LLDAS in patients with SLE. LLDAS was achieved in 154 (40%) patients. Contrary to our hypothesis, low consistency of interest of attending physicians was related to a higher proportion of patients achieving LLDAS. The fact that the more the item ‘set a goal but later chose a different goal’ applies, the greater likelihood of achieving LLDAS may suggest that the attending physician is flexible in changing the treatment goal rather than sticking to it.
A better patient–doctor interaction might improve the quality of care in patients with SLE [11, 12]. Since some personalities of clinicians are related to an enhanced quality of care [10], specific personality characteristics of physicians may affect the outcome of patients with SLE via patient–doctor interactions. Complete remission (absence of clinical activity without the use of glucocorticoid and immunosuppressive drugs) is the ideal goal of treatment for patients with SLE, but complete remission is infrequent and achievement of LLDAS is recommended as an alternative goal [24]. Physicians with a high consistency of interest may rigidly pursue the ideal goal of freeing the patient from the use of glucocorticoids, but may instead contribute to relapse. Since the present study is a cross-sectional study, we could not evaluate the change of the treatments. A longitudinal study could elucidate the mechanism of the present results.
The grit of physicians might improve based on clinical practice experience. A previous study showed no difference in grit among medical specialists [25, 26]. The duration of clinical practice experience is related to increased grit [26, 27]. In a previous study, surgeons with >21 years of clinical experience had higher grit than those with 10–20 years of clinical experience, but the effect size for this relationship was weak [28]. However, time postgraduation was associated with grit among US general surgery residents [29]. Since physicians in the present study were limited to rheumatologists with 10–20 years of clinical experience, no physician characteristics related to grit scores were found in the present study. Postgraduate education including appropriate clinical experience may contribute to further improvement of patient outcomes via changes in grit.
This study has some limitations. First, this was a cross-sectional study; thus, reverse causality might exist. Patients with more difficulty in achieving LLDAS may require the care of physicians with a high consistency of interests. However, this possibility is likely to be small because patients commonly cannot choose their attending physicians in the clinical setting. Second, grit score has been developed as a measurement of personality for personal goal achievement and does not support the goal achievement of others. While ‘consistency of interests’ in the Short Grit Scale is a positive component for goal attainment, it may not be appropriate for assessing flexibility with respect to treatment goals. Third, we did not collect data on SLEDAI-2K at the disease onset. However, while SLEDAI-2K at the disease onset may affect the current LLDAS, we believe it is unlikely to confound the association between the physicians’ grit and LLDAS because SLEDAI-2K at the disease onset does not affect attending physicians’ grit.
In conclusion, low consistency of interest of attending physicians was associated with achievement of treatment goal in patients with SLE. Difficulty of attending physicians to change the treatment goal may be related to lower LLDAS achievement. Future studies should clarify whether improving the grit of physicians contributes to LLDAS achievement in patients with SLE.
Data availability statement
The datasets used and analysed in the present study are available on reasonable request to the corresponding author.
Funding
This study was supported by the JSPS KAKENHI (grant number: JP 19KT0021). The funder had no role in the study design, analyses, interpretation of the data, writing of the manuscript or the decision to submit it for publication.
Disclosure statement: K.S. received a speaker’s fee from Glaxo Smith Kline K.K. and a research grant from Pfizer Inc.
Acknowledgements
We are grateful to all collaborators working on TRUMP2-SLE project. We also gratefully acknowledge Hisashi Noma (Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan) for his advice on statistical analysis.
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