Empathy in medical students: A cross sectional comparative study

 

Murali Krishna V¹, Gautham Tailam^2*, Vishnu Gade³, Pramod KR Mallepalli⁴

 

¹Senior Resident, ²Assistant Professor, Department of Psychiatry, Kakatiya medical college, Warangal, Telangana, INDIA.

³Assistant Professor, Department of psychiatry, Prathima institute of Medical Sciences, Karimnagar, Telangana, INDIA.

 

Abstract               Background: Empathy is a capacity to predict and respond to feelings and behaviors’ of others by inferring their emotional states. The patient physician relationship is the center of medicine. One of the major tasks of medical educators is to help maintain and increase trainee empathy for patients. Aim: To measure empathy levels in medical students and to compare empathy levels by year,sex, locality and specialty choice. Methods: The evaluation was done in 584 medical students of Mamata Medical College by using self-structured demographic proforma and Jefferson’s physician empathy scale-student version. Data was analyzed and comparison was done using T-tests and one way- ANOVA. Results: In our study highest empathy scores were seen immediately after entering the medical college. Significantly low scores were seen in fourth year, internship students and post graduates when compared with first year students (p<0.01 ; p=<0.01 ;p=<0.01). Females out-rated males in empathy scores (p<0.01). Medical students prevailing from rural locality have higher scores when compared to semi urban and urban students. No considerable difference was seen based on choice of medical specialty. Conclusion: Development and maintenance of empathy in medical students can be done by more continuously emphasizing this in the medical education in internship.

Key words: empathy, medical students; Jefferson’s physician empathy scale

 

 

 

INTRODUCTION

Empathy is a capacity to predict and respond to feelings and behaviors’ of others by inferring their emotional states. The therapeutic relationship between doctor and patient is an integral part of healing and effective medical care.¹ Empathy is fundamental to the health care provider-patient relationship.² In terms of patient care, empathy is defined as a cognitive attribute that involves an ability to understand the patient’s experiences, pain, suffering and perspective combined with a capability to communicate this understanding and intention to help.³ Based on an extensive review of the literature on personality assessments and outcomes in medical education, empathy was identified as one of the most pertinent aspect of personality in health profession, education and patient care.⁴

 some researchers have described empathy as a cognitive attribute, which implies that it predominantly involves understanding another person’s concerns.⁵ Others have described -empathy as an affective or emotional characteristic, which implies that it primarily involves feeling another person’s pain and suffering.⁶ Yet, there is a third group that views empathy as both affective and cognitive.⁷

The cognitive domain of empathy involves the ability to understand another person’s inner experiences and feelings and a capability to view the outside world from the other person’s perspective.¹⁰ The affective domain involves the capacity to enter into or join the experiences and feelings of another person.⁸

 Empathy plays a key role in positive doctor-patient relationship and patient satisfaction, and contributes to optimal clinical outcomes.⁹ A higher level of empathy in physicians has been associated with increased engagement in care and compliance with therapy among patients and more accurate diagnoses by physicians. Medical research has shown that the use of a “warm, empathic style” by physicians during communications with patients is associated with improved treatment outcomes such as increased compliance with medical recommendations, decreased pain and reduced recovery time, as well as increased patient satisfaction and decreased medical litigation.¹⁰

 Empathy has been linked, theoretically or empirically, to a number of attributes, such as dutifulness, pro-social behavior, moral reasoning, good attitudes toward elderly patients, a reduction in malpractice litigation, competence in history taking and performance of physical examinations, patient satisfaction, physician satisfaction, better therapeutic relationship, and good clinical outcomes.

Sympathy, in contrast to cognitively defined empathy, is predominantly an affective or emotional attribute that involves intense feelings of a patient’s pain and suffering.¹¹ An empathic physician would be more concerned about understanding of the kind and quality of patients’ experiences, whereas a sympathetic physician would be more concerned about feeling the degree and intensity of patients’ pain and suffering. Cognitively defined empathy can lead to personal growth, career satisfaction, and optimal clinical outcomes, whereas affectively defined sympathy can lead to career burnout, compassion fatigue, exhaustion, and vicarious traumatization. An important implication for making a distinction between empathy and sympathy in medical education is the fact that affect and emotion are less amenable to change, whereas cognition and understanding can be substantially enhanced through education.

The aim of medical school education is to provide future physicians not only with knowledge about pathology and disease but also with experiences that will help them develop a good bedside manner, a term that refers to a physician’s understanding, professionalism, respect, and empathy. Empathy is critical to the development of professionalism in medical students as they progress through their training. Hozat et al had found in a study that medical graduates with higher empathy did better in clinical competence than on academic competence.¹² Empathy is believed to be teachable and has been incorporated formally in some medical curricula.

 The JSPE(Jefferson scale of physician empathy) is the most widely researched test and was specifically designed by researchers for the assessment of physician and student empathy. This scale was originally developed to measure the attitudes of medical students towards physician empathy in patient-care situations (JSPE-Student or S-version). The JSPE has been translated into 25 languages. The aim of the present study was to measure and compare empathy among medical students of various years.

 MATERIALS AND METHODS

The study was carried out at Mamata Medical College, Khammam. The study was approved by the institutional research ethics committee.

Participants

 Students who were studying in first year ,second year, third year and fourth year of M.B.B.S. degree course, pursuing internship, and postgraduate courses in Mamata Medical college, Khammam were included in this study by purposive sampling.

Tools

1. Socio-Demographic Proforma: This was a self-prepared semi structured Proforma designed for this study. It contained information about socio-demographic characteristics like age, gender, level of study and specialties opted or wish to opt in the future. The effect of specialization on empathy was assessed by grouping the choice of subjects into technology oriented (Pathology, Surgery and surgical subspecialties, Radiology, Radiation Oncology, Anesthesiology, Preventive and Social Medicine, Otorhinolaryngology) and people oriented (Internal medicine, Family medicine, Pediatrics, Neurology, Rehabilitation medicine, Psychiatry, Emergency medicine, Obstetrics and gynecology, Ophthalmology and Dermatology).

2. The Jefferson Scale of Physician Empathy (JSPE): This was designed to measure empathy specifically in medical students and physicians in the context of patient care. The scale was originally developed by the researchers at the Centre for research in medical education and health care at Jefferson Medical College, Philadelphia. We have used the revised JSPE (S) student version, for our assessment of empathy among our medical students. We have obtained prior permission from the authorities of Jefferson to use the scale to measure empathy on our medical students. The revised version contains self-reporting questionnaire having 20 Likert type items on a 7 point scale (1= strongly disagree, 7= strongly agree). The higher scores are interpreted as more empathetic behavior. Several studies have supported the validity and reliability of the JSPE among medical students and physicians.

 

 

Procedure

 After obtaining permission from the principal of Mamata Medical College for conducting the study, the students were explained about the study project and participants were assured of the confidentiality of their responses and the voluntary nature of their participation. Those who agreed for the study and gave informed consent were included and the data was collected in leisure periods. The students were instructed not to write their names to maintain confidentiality. The socio- demographic details were collected in self-prepared semi structured proforma. The JSPE-S version was distributed to the first, second, third, fourth year students during their regular classes. For the students who are doing Internship and post-graduation, the questionnaire was distributed during their clinical postings in respective departments.

Statistical Analyses

 The data collected was tabulated in an excel sheet, analyzed by SPSS 20 software under the guidance of a statistician. Empathy score differences by year of medical education were being examined by analysis of variance (ANOVA). Empathy scores for men and women, speciality opted are compared by using independent sample t- test.

 

RESULTS

 A total of 550 subjects participated in the present study. Among them 313 were female and 237 were male students. There were no invalid scales. The first year students had completed just a month in college, while the second year students had completed just about a month of their initial clinical rotations and the third year students had completed almost 18 months of clinical postings. The fourth year students are 8 months away from their final exams. Interns are a mixed batch who had completed 3-6 months of compulsory rotatory internship. Post-graduates are randomly selected from all the three years of post-graduation (Table 1).

Table 1: Demographic characteristics of the total sample

Table 1 depicts the distribution of study subjects according to the year of study ,gender, locality ailing from , specialization opted/ wish to opt in future among the 139 study subjects from first year 44 (31.5%) were male and 95 (68.5%) were female, among the 118 study subjects from second year 46 (22%) were male and 72 (78%) were female, among the 89 study subjects from third year 45 (25%) were male and 54 (75%) were female, among the 87 study subjects from fourth year 42 (17.1%) were male and 45 (82.9%) were female and among the 72 interns 34 (23.2%) were male and 38 (76.8%) were female, among 45 post-graduates 26 were male and 19 were female In all the years of study the proportion of female students is found to higher than male students (Table 2).

 

Table 2: Comparison of mean empathy scores across year

Table 2 depicts the mean empathy level of the study subjects across the year of study, mean empathy level for the total sample is (94.74±11.51) the mean empathy score was highest in first year students 99.3±12.02(mean ± SD) and least for post graduates 87.00 ± 11.51 (mean ± SD) followed by interns89.26±8.33. One way ANOVA test showed that the difference in mean empathy level across the year of study was statistically significant (P < 0.05).

Table 3: Comparison of mean empathy scores as per year of study

Table 3 depicts the comparison of mean empathy score among the years of study in the total sample. Mean difference in empathy score was found to be significant between first year vs. third year, fourth year, internship, post-graduation ; second year vs. third year, fourth year, internship, post-graduation; third year vs internship, post-graduation and between fourth year vs internship, post-graduation students (P < 0.05).

Table 4: Comparison of mean empathy scores across gender

Table 4 depicts the mean empathy level across gender based on the year of study. Mean empathy score of female students (97.36±11.79) in the total sample was significantly (P<0.001) higher than that of male students (91.27±10.16). Mean empathy scores of female students in first year, second year, fourth year (102.92±10.27, 100.90±10.24, 96.80±13.53) were significantly (P value <0.001, 0.009, 0.005) higher than that of male students (91.47±11.88, 95.76±10.30, 89.33±10.66). There is no difference in the mean empathy level across gender among the students from the other years of study.

Table 5: Comparison of mean empathy scores across locality

Year	Empathy scores
	mean	SD
RURAL	99.79	11.74
SEMIURBAN	93.29	12.29
URBAN	94.06	11.15
F=8.45 P value<0.001

Table 5 depicts the mean empathy level of the study subjects across the locality. Mean empathy level was highest in students ailing from rural background (99.79±11.74) followed by students ailing from urban (94.06±11.15) and semi-urban (93.29±12.29) backgrounds. One way ANOVA test showed that the difference in mean empathy level across the year of study was statistically significant (P < 0.001).

Table 6: ANOVA multiple comparison for locality

Table 6 depicts the comparison of mean empathy scores based on locality ailing from. Mean difference in empathy score was found to be statistically significant between the students ailing from rural and semi-urban backgrounds(P=0.001), rural and urban backgrounds(P<0.001).

 

DISCUSSION

The present cross-sectional descriptive study was conducted with the aim to assess the empathy level among Indian medical students. The size of the total sample was 550 which was higher than that of several studies, and lower than that of Chen et al.¹³ in contrast to these studies post graduates were also included in the study.

Mean empathy scores

The mean empathy score of students in this study was 94.74±11.51which is lower than that reported by many studies. Lt Col R. Shashi kumar et al in an Indian study reported an empathy score of 102.91.¹⁴ Average score of 109-114 was reported by Mangione et al.¹⁵ Roh et al had reported a mean empathy score of 103, 104.30 in Korean and Japanese medical students.¹⁶ The empathy scores at the entry point of medical school is much less than those found in US by Chen et al (115.5)¹³

Difference in empathy level could be a result of their different cultural values, religious beliefs or traditions. Cultural differences, ethnicity, religious beliefs, and sex stereotyping may lead to empathy score disparity and can also influence empathic engagement during clinical encounters. Morling and Lamoreaux have reported that Asians have more collectivistic and less individualistic social cultures than Westerners.¹⁷

Year of study

The mean empathy score of first year students was 99.30±12.02 where as that of post-graduates was 87.00±8.16.first and second year students have significantly higher scores when compared to third year, fourth year, interns and post-graduates. There was a decrease of mean empathy score when compared from first year to post graduation which reached a significant level at 3rd year. There was a slight increase in scores from third year to fourth year but which was not significant.

Newton et al and a study at Boston university described a progressive decline in empathy levels beginning in the first year of medical school which is similar to that reported in this study.¹⁸ This study finding is similar to those studies in US. Some western studies among medical students found significant fall in empathy levels when they progressed from non-clinical to clinical training.¹⁹ some studies reported a decline in empathy levels among medical students as they progress though their medical school education, especially between the ends of the second and the third years of medical school, and into resident training.²⁰ A study conducted at Jefferson Medical College reported that empathy scores did not alter significantly during the first two years (preclinical years), they decreased during the 3rd year (first clinical year) and remained low until graduation. In some studies empathy scores increased during the year after school entrance, decreased slightly in the second year and decreased significantly in the third year (first clinical year).²¹ One study from Trinidad and Tobago reported that empathy declined significantly in the first year.²² A recent study on empathy performed with medical school students in Japan showed that the empathy increased between their first year and the end of training year. A study on empathy of medical school students conducted at a Korean medical school also revealed that later years of training were associated with significantly better empathy.²³ Further some studies reported the adverse impact of medical training on empathy²⁴

Medical education and medical students in this college varies from that of other countries in many ways. Students here have no exposure to humanities subjects such as economy, literature, philosophy and other sciences as in Japan and USA. Students in this college are exposed to clinical rotation right from the beginning of second year in contrast to beginning of third year in USA, Iran and fifth year in Japan.

The significant lowering of scores in 3rd year may be due to a reason that this year students have examination for non-people oriented subjects and therefore probably are more inclined towards these subjects. Very low scores of empathy in post graduates may be due to the stress they face during their pg entrance exams due to extremely high competition. According to a study by Katoaka et al the different entrance methods in medical schools and different cultures across various countries may account for variation in empathy.²⁵ According to Neumann et al the decline in empathy may be due to fact that students themselves were overwhelmed by the mortality and morbidity that they encounter in clinical rotations and most often they do not have anybody to help them to deal with such issues.²³ The emphasis on technological and data-driven medical decision making may diminish the connection between patient and physician which may be one of reasons for the decrease in empathy.²⁴ some potential factors for fall in empathy are long work hours, dependence on technology, negative experiences, burnout, and limited bedside interaction.²⁶ The mixed messages that students receive during their clinical experiences, such as being encouraged by supervising physicians to assess patients as soon as possible and to consider diagnostic treatment codes may contribute to declines in empathy.²⁷

Gender

Mean empathy score of female students (97.36±11.79) in the total sample was significantly (P<0.001) higher than that of male students (91.27±10.16). Mean empathy scores of female students in first year, second year, fourth year (102.92±10.27, 100.90±10.24, 96.80±13.53) were significantly (P value <0.001, 0.009, 0.005) higher than that of male students (91.47±11.88, 95.76±10.30, 89.33±10.66)

This is consistent with the findings of other studies. Hojat et al also had found that female students scored significantly higher on empathy than male students among medical students (p < 0.01). Newton et al had in study found female students to have same empathy as male students but had significant decline across medical years of education only in those who chose noncore (non-people oriented subjects) for specialization (2.25-fold decrease) one study in Italy has not indicated a significant difference in empathy scores between genders.¹⁸ A study from Iran also did not find any significant difference at all though female students did score more than male students. However, Further research is needed to determine whether this may be due to cultural peculiarities, translation of the scale or sampling.¹⁸

The findings on gender differences in empathy are in agreement with the reports that female physicians spend more time with their patients, have fewer patients, and render more preventive and patient-oriented care.²⁸ Several explanations can be offered for gender differences in empathy Studies have suggested that females are more receptive to emotions than males, have evolved with more caring attitude towards offspring as compared to male which contributes to better understanding and being more empathetic. Women offer more emotional support and patient-orientated care, possibly because they tend to value interpersonal relationships highly and have more competent understanding of emotions and caring attitude. On the basis of the evolutionary theory of parental investment, women are believed to develop more caregiving attitudes toward their offspring than men.²⁹ More empirical evidence is needed to test the hypothesis that relates gender differences on empathy to intrinsic (e.g., evolutionary gender characteristics) or to extrinsic (e.g., gender role expectations) factors .³⁰

Speciality

From the total of 550 students, 307 opted for people oriented specialities and 243 opted for technology oriented specialities. Mean empathy score of people oriented specialities (94.63) did not differ significantly (t=0.236, P value=0.236) from that of technology oriented specialities. Change in awareness and perceptions of specialties may change the choice of specialties so it could be a bias in assessing the effect of changing empathy levels on choice of specialties.

In a 2001 study by Hojat et al intended specialties, which may also predict empathy levels, were identified as either people-oriented specialties or technology-oriented specialties. This finding is in consonance with one Indian study which reported no differences in empathy among medical students with different specialty preferences. This finding is contrary to findings of studies which had shown that medical students who plan to pursue people oriented specializations such as internal medicine, family medicine, psychiatry and pediatrics showed higher empathetic scores and across all years of study in medical school than those who choose to pursue technology oriented specialties such as radiology, surgery and anesthesiology In a recent study, medical students who planned to pursue specialties such as family medicine and pediatrics scored higher on empathy measures than their counterparts who planned to pursue radiology or pathology.³¹

 Further subgroup analysis of the data revealed a fact that empathy scores have been highest among students choosing people oriented subjects in first, third and fifth semesters. Hojat et al found decline in empathy scores among those choosing technology oriented specialization in third year.²⁶ Little empirical evidence is available to link empathy and physician specialty.

Locality

The empathy scores of students ailing from rural background are significantly higher than that of students ailing from semi-urban and urban backgrounds. This may be due to the differences among social, cultural, financial and medical aspects in these localities. To conclude, There is a decline in empathy levels with progressing years in medical college. Female students are found to be more empathetic than male students. There are no differences in empathy levels based on choice of speciality/ speciality opted. Empathy levels are higher in students from rural background as compared to those from semi-urban and urban backgrounds.

 

LIMITATIONS

Findings from a study done at a single medical college that is unique in many aspects may not be representative of empathy levels among medical undergraduates across the country. This being just a cross sectional study the difference seen at different years of training may not be representative of actual decline from high baseline scores.

 

REFERENCES

1. Larson EB, Yao X. Clinical empathy as emotional labor in patient-physician relationship. JAMA 2005;293(9):1100-1106.
2. Spiro H. Commentary: The practice of empathy. Acad Med 2009;84:1177-9.
3. Jefferson scale of Empathy (JSPE). Center for research in medical education and health care (CRMEHC4. Grace EG, Sarlani E, Balciunas BA. Referring patients for stress-related disorders. Gen Dent 2002;50(6):538-9.
4. Basch MF. Empathic understanding: a review of the concept and some theoretical considerations. J Am Psychoanal Assoc. 1983;31:101-26.
5. Eisenberg N. Empathy and related emotional response. San Francisco, CA: Jossey-Bass; 1989.
6. Hoffman ML. The development of empathy. In: Rushton J. and Sorrentino R, editors. Altruism and helping behavior: social personality developmental perspectives. Hillsdale, NJ: Erlbaum; 1981. p.41-63.
7. Hodges SD, Wegner DM. Automatic and controlled empathy. In: Ickes W, editor. Empathic accuracy, New York: Guilford; 1997. p.311-339
8. Aring CD: Sympathy and empathy. JAMA 1958; 167:448–452
9. Neumann M, Wirtz M, Bollschweiler E, Mercer SW, Warm M, Wolf J, Pfaff H: Determinants and patient reporting long-term outcomes of physician empathy in oncology: A structural equation modeling approach. Patient Educ Couns 2007, 69(1–3):63–75.Halpern J. From Detached Concern to Empathy: Humanizing Medical Practice. New York, NY: Oxford University Press; 2001.
10. Hojat M, Spandorfer J, Louis DZ, Gonnella JS. Empathic and sympathet-ic orientations toward patient care: conceptualization, measurement, and psychometrics. Acad Med. 2011;86:989-995.
11. Linley PA, Joseph S. Therapy work and therapists’ positive and negative well-being. J Soc Clin Psychol. 2007;26:385-403.
12. Hojat M, Gonnella JS, Mangione S, et al. Empathy inmedical students as related to academic performance,clinical competence and gender. Med Educ. 2002;36:522e527.
13. Chen D, Lew R, Hershman W, et al. A cross-sectional measurement of medical student empathy. J Gen Intern Med 2007;22(10):1434-1438.
14. Lt Col R. Shashikumar a,*, Med Cdt Richa Chaudhary b, Surg Cmde V.S.S.R. Ryali c, Col P.S. Bhat d, Kalpana Srivastava e, Lt Col J. Prakash a, D. Basannar f Cross sectional assessment of empathy among undergraduates from a medical college medical journal armed forces india 70 (2014) 179-185
15. Mangione S, Kane GC, Caruso JW, et al. Assessment of empathy in different years of internal medicine training. Med Teach 2002;24(4):370-373.
16. Roh MS, Hahm BJ, Lee DH, Suh DH. Evaluation of empathy among Korean medical students: a cross-sectional study using the Korean version of the Jefferson Scale of Physician Empathy. Teach Learn Med 2010;22(3):167-171.
17. Morling B, Lamoreaux M. Measuring culture outside the head: a meta-analysis of individualism-collectivism in cultural products. Personality and Social Psychology Review 2008;12:199-221.
18. Newton B, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Acad Med. 2008;83(3):244-249.
19. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, Magee M: An empirical study of decline in empathy in medical school. Med Educ 2004, 38(9):934–941.
20. Di Lillo M, Cicchetti A, Lo Scalzo A, Taroni F, Hojat M. The Jefferson Scale of Physician Empathy: preliminary psychometrics and group comparisons in Italian physicians. Acad Med. 2009;84(9):1198-1202.
21. Mangione S, Kane GC, Caruso JW, Gonnella JS, Nasca TJ, Hojat M. Assessment of empathy in different years of internal medicine training. Med Teach. 2002;24(4):370-373.
22. Nunes P, Williams S, Sa1 B, Stevenson K. A study of empathy decline in students from five health disciplines during their first year of training International Journal of Medical Education. 2011; 2:12-17.
23. Neumann M, Edelha¨user F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86:996e1009.
24. Chen P. The rise of desktop medicine. New York Times. March 31, 2011.
25. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. Measurement of empathy among Japanese medical students: psychometrics and score differences by gender and level of medical education. Acad Med 2009;84(9):1192-1197
26. Berg K, Majdan JF, Berg D, Veloski J, Hojat M. Medical students’ self-reported empathy and simulated patients’ assessments of student empathy: an analysis by gender and ethnicity. Acad Med. 2011;86(8):984-988.
27. Rosenthal S, Howard B, Schlussel YR, et al. Humanism at heart: preserving empathy in third-year. Acad Med. 2011;86(3):350-358.
28. Bertakis KD, Helms LJ, Callahan EJ, Azari R, Robbins JA: The influence of gender on physician practice style. Med Care 1995; 33:407–416
29. Trivers RL: Parental investment and sexual selection, in Sexual Selection and the Descent of Man. Edited by Campbell B. Chicago, Aldine, 1972, pp 136–179
30. Eisenberg N, Lennon R: Sex differences in empathy and related capacities. Psychol Bull 1983; 94:100–131
31. Newton BW, Savidge MA, Barber L, Cleveland E, Clardy J, Beeman G, Hart T: Differences in medical students’ empathy. Acad Med 2000; 75:1215