Clarifying changes in student empathy throughout medical school: a scoping review

Is there an association among spirituality, resilience and empathy in medical students?

BACKGROUND

Spirituality has religious and nonreligious dimensions and is often linked to well-being, positive emotions, connection and meaning in life. Both empathy and resilience are important in medical training and future professional practice since they are considered core skills related to professionalism and patient care. Our study aimed to understand the relationships among spirituality, resilience, and empathy in medical students. We also aimed to determine whether there are differences by gender and between medical students in different years of a medical program.

METHODS

Medical students (n = 1370) of the first to fourth years of a six-year medical program, from six medical schools, completed questionnaires to assess empathy (Jefferson Empathy Scale and Davis Multidimensional Interpersonal Reactivity Scale) and resilience (Wagnild & Young Scale) and to rate their spirituality.

RESULTS

Medical students with high spirituality showed higher scores for both resilience and empathy (p < 0.001). In addition, we observed higher levels of both spirituality and empathy, but not resilience, in female medical students than in male medical students. In contrast, we did not detect significant differences in spirituality, empathy, or resilience between students in different years of medical school.

CONCLUSION

Medical students with high levels of spirituality have also higher scores for both empathy and resilience. Spirituality, empathy and resilience have similar values for students in different years of a medical program.

The integrated curriculum and student empathy: a longitudinal multi-cohort analysis

Research has demonstrated erosion of empathy in students during medical education. Particularly, U.S. studies have demonstrated empathy declines during clinical training in the third and fourth year of traditional medical programs. Yet, studies conducted outside the U.S. have not confirmed this trend. Timing and extent of patient interactions have been identified as empathy-protective factors. The need to examine empathy within different learning contexts has been noted, as has the need for longitudinal and time-series research designs to analyze trajectories. Between fall 2010 and spring 2019, we assessed empathy longitudinally among six student cohorts (N = 493) at a U.S. medical school, where patient interaction occurs early and throughout an integrated curriculum. Empathy levels of students in each cohort were assessed at five time points utilizing the Jefferson Scale of Physician Empathy-Student version. We hypothesized empathy levels will not degrade by program end, and trajectories will not show patterns of decline in Years Three and Four. Analysis of Variance (ANOVA) and Linear Mixed Model (LMM) analyses were used to analyze differences at baseline and changes in empathy trajectories. ANOVA analyses revealed statistically significant differences at baseline by class cohort (F(5, 487) = [23.28], p < 0.001). LMM analyses indicated empathy was either significantly higher or not different at the end of the program (F(19, 1676) = [13.97], p < 0.001). Empathy trajectories varied among cohorts; yet, none resulted in an overall empathy decline by the end of the program. Findings demonstrate empathy in U.S. medical students can be unchanged or higher by the end of medical education. Outcomes are consistent with reports of non-declining medical student empathy outside the U.S. and support the notion of context-specificity. Results further support recent research, suggesting decreases in empathy during training can stabilize or increase by program end. These findings have important implications for future empathy research context and design considerations, as well as program planning.

Why might medical student empathy change throughout medical school? a systematic review and thematic synthesis of qualitative studies

BACKGROUND

Several studies suggest that medical student empathy declines throughout medical school. However, no studies have synthesised the evidence regarding why empathy declines.

OBJECTIVE

To conduct a systematic review and thematic synthesis of qualitative studies investigating why student empathy may change throughout medical school.

METHODS

We included any qualitative study that investigated why empathy might change during medical school. We searched the Medline, Scopus, CINAHL, ERIC, and APA PsycInfo databases for relevant studies. All databases were searched from their inception to 18 July 2022. We also searched the reference lists of the included studies and contacted experts to identify additional studies. We used the Joanna Briggs Institute tool to evaluate the risk of bias in the included studies. Overall confidence in our results was assessed using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach. We used thematic methods to synthesise our findings.

RESULTS

Our searches yielded 2523 records, and 16 studies involving a total of 771 students were eligible for analysis. Most studies (n = 11) were from Europe or North America. The descriptive themes and sub-themes were identified for each study. Increased complexity in patients and their diseases, together with the 'hidden curriculum' (including a stressful workload, prioritisation of biomedical knowledge, and (sometimes) poor role models), led to student adaptations, such as cynicism and desensitisation. Students' prior lives and professional experiences appeared to exacerbate the decline in empathy. However, there were bias concerns for most of the included studies.

DISCUSSION

Many of the included studies included were small, and some did not include demographic participant data. Given the likely benefits of providing empathic care for patients and practitioners, medical education interventions should focus on developing an 'empathic hidden curriculum' that mitigates the decline in medical student empathy.

TRIAL REGISTRATION

A protocol for this systematic review was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) on 28 July 2022 (registration number CRD42022347856).

The effect of stress coping styles on empathy level in students of medicine: A cross-sectional study

We aimed to investigate the change in the ability of clinical empathy, which has a special importance in physician-patient relationship, during medical school years, and its relationship between stress coping styles. After the preliminary interview with 292 volunteer medical school students, the students were asked to answer the Hospital Anxiety Depression Scale, the Stress Coping Scale, and the student version of the Jefferson Doctor Empathy Scale. This study shows that the lowest median of the empathy level among medical school students was in the sixth year, and the decrease in empathy in the sixth year was mostly in the perspective taking component. When the relationship between empathy and coping styles with stress was examined, it was seen that self-confident approach was positively correlated with perspective taking (R = 0.182, P = .002) and standing in the patient's shoes (R = 0.172, P = .003). It was observed that the helpless approach, which is one of the negative coping styles, was inversely correlated with standing in the patient's shoes. As a result of the study, it was determined that the styles of coping with stress were related to the components of empathy, except for compassionate care. The self-confidence approach has an impact on the ability of standing in the patient's shoes and perspective-taking. During medical education, focusing on the approaches that increase the student's self-confidence against the stress will encounter throughout their professional life will undoubtedly increase the level of empathy.

When patients teach students empathy: a systematic review of interventions for promoting medical student empathy

BACKGROUND

Despite growing emphasis on empathic care, numerous studies demonstrate diminishing empathy in medical students. Involving patient educators in medical curricula may be a solution. Therefore, we conducted a systematic review to evaluate patient-involved interventions that promote empathy among medical students.

METHOD

A literature search of MEDLINE, Embase, PsycINFO, and ERIC databases was performed using the keywords "empathy," "medical student," and their synonyms. Results were independently screened in duplicate. Conflicts were resolved by group consensus. All English studies describing interventions that promote empathy in medical students engaging patient educators were included. Relevant data was extracted and summarized.

RESULTS

1467 studies were screened. 14 studies were included, of which 10 were pilot studies. Studies included patient involved interventions such as storytelling (5/14), shadowing patients (3/14), recorded videos (3/14), or combinations of methods (3/14). Qualitative measurements of empathy included written feedback and group discussions. Quantitative measurements included validated scales measuring empathy. All studies demonstrated increase in empathy among medical students. Participants reported satisfaction with training and patients reported being proud of giving back by training future physicians.

CONCLUSION

Interventions engaging patient educators were shown to have a positive impact on medical student empathy. Furthermore, patient-led education was shown to increase medical student understanding of subject and knowledge retention while empowering patients. Further implementation of patient-involved education is an important step forward in patient-partnered care and may identify additional advantages of patient engagement in medical education.

Empathy development and volunteering for undergraduate healthcare students: A scoping review

OBJECTIVES

Empathy in healthcare benefits patients and healthcare providers. However, empathy decline is a recent trend within healthcare education. There is a paucity of literature that investigates the impact of volunteering on the empathy levels of undergraduate healthcare students. This scoping review explores the literature regarding empathy and volunteering for healthcare students.

DESIGN

The Joanna Briggs Institute methodology for scoping reviews guided this study.

DATA SOURCES

The electronic databases MEDLINE, CINAHL, ProQuest, JBI, Cochrane, PubMed, PsychInfo, and PsychNurses were searched from January 2001 to August 2021. The original search was developed in MEDLINE and then adapted to the other databases.

REVIEW METHODS

This scoping review used the Joanna Briggs Institute scoping review methodology. The search retrieved a total of 310 articles. Following deduplication, 271 articles were reviewed by title and abstract. Thirty articles were reviewed in full text with twelve articles meeting the criteria for inclusion. Included studies were assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Five qualitative, four quantitative and three mixed method studies were included. A variety of volunteering interventions for undergraduate healthcare students were identified from countries including the United States of America, Singapore, Australia, and Brazil. Thematic analysis identified that volunteer undergraduate healthcare students practiced and developed empathy, and experienced professional and personal development.

CONCLUSIONS

Volunteering interventions were primarily in a service-learning modality within community health and palliative healthcare settings. Inconsistencies exist in empathy definitions and empirical empathy measurement. There is a need for more research that explores empathy development through volunteer activities in acute care settings.

Does a sense of gratitude protect against empathy loss in medical students? An exploratory study

INTRODUCTION

The promotion of physicians' empathy (PE) skills in medical school plays a central role in physician-patient communication. However, a significant decline in empathy among medical students during their training has been repeatedly reported. Gratitude could be a possible protective factor for PE. However, as some students do not seem to be affected by this empathy loss, this study explores the relationship between gratitude and PE.

METHODS

Using validated questionnaires (JSPE-S, IRI and GQ-6), 88 medical students at LMU München evaluated their self-assessed PE and gratitude. In addition, they went through four OSCE stations focusing on general medicine, in which their empathy and communication skills were assessed by simulated patients (SP) and by an assessor using the Berlin Global Rating. Correlations were analysed using Pearson's correlation coefficient and gender differences were analysed using Mann-Whitney U-tests.

RESULTS

In the self-assessment, there was a significant, moderate correlation between students' attitude towards empathy (JSPE-S) and their gratitude (GQ-6) and a weak correlation between the IRI subscale "Empathy" and the GQ-6. In terms of the performance-based assessment, there were also weak correlations between PE or communication skills and gratitude. There were no gender-specific differences in the gratitude of the students.

CONCLUSION

We were able to demonstrate a correlational relationship between gratitude and empathy in medical students. Whether gratitude acts causally as a protective or supportive factor for empathy remains open. A causal relationship of gratitude to empathy should therefore be examined in a prospective study design.

Medical empathy in medical students in Madrid: A proposal for empathy level cut-off points for Spain

This study evaluates the degree of empathy among medical students and its influencing factors at three critical moments of their degree studies (beginning of first year and end of third and sixth years) as well as establishes low-, medium-, and high-empathy cut-off points to obtain valid and reliable results that can be extrapolated to the general population. This cross-sectional study of the eight (public and private) medical schools in the province of Madrid, used an electronic questionnaire with the Jefferson Scale of Empathy (JSE), Medical Student Well-Being Index, and other independent characteristics as measuring instruments. Of the 2,264 student participants, 1,679 (74.0%) were women, with a 50.7% participation rate. No significant differences were found in empathy levels by academic year. Regarding range, percentile and cut-off point tables were established to identify students with high, medium, and low empathy levels. Women (p<0.001), volunteer workers (p<0.001), and those preferring general specialties (internal medicine, psychiatry, pediatrics, or family medicine) scored higher on the JSE (p<0.02). Moreover, 41.6% presented high level of psychological distress. Women reported a lower well-being level and a higher risk of psychological distress (p = 0.004). In sum, the empathy of medical students in Madrid did not differ among the three critical moments of their university studies. The established cut-off points could be taken into account when accessing the medical degree and identifying students with low levels of empathy to implement curricular interventions to rectify this perceived deficiency. There was a high percentage of medical students with high levels of psychological distress.

Reliability of Greek version of the Toronto empathy questionnaire in medical students and associations with sociodemographic and lifestyle factors

BACKGROUND

Empathy is an important key driver of any therapeutic relationship. It is beneficial for both physicians and patients. Enhancing physician's empathy should be an important goal of medical education. As there was a literature gap regarding the topic of empathy among medical students in Greece, this study aimed to contribute to filling this gap.

METHODS

A cross-sectional study was conducted. A socio-demographic questionnaire and the 52-item Greek version of the Toronto composite empathy scale (TCES) for measuring the cognitive and emotional aspects of empathy in both personal and professional life was administered to all the medical students in the Aristotle University of Thessaloniki, in Greece. Descriptive statistics were displayed for demographics. The associations of the variables were quantified by Chi-2 independence tests and Pearson's Correlation Coefficient. The reliability and validity of the questionnaire was determined by Cronbach's α, Hotelling's T-Squared Test, and Pearson correlation. Paired and Independent Sample T-Tests and One-way ANOVAs indicated statistically significant mean differences among the variables or subgroups of the variables.

RESULTS

The 52-item TCES, 26 for the personal (Per) setting and another 26 for professional (Pro) life, equally divided into cognitive (Cog) and emotional (Emo) empathy in each case. The overall reliability of the TCES questionnaire was found to be high (Cronbach's α = 0.895, significant positive correlations between the subscales). The mean total score of empathy showed that students had a moderately high empathy. Further, there was a statistically significant difference in means between the Per-Cog and Per-Emo settings (p < 0.001), the Pro-Cog and Pro-Emo (p < 0.001), the Per-Cog and Pro-Cog (p = 0.004), and the Per-Emo and Pro-Emo (p < 0.001). Females had significantly higher empathy scores (mean score 208.04) than males (192.5) on the Per-Cog, Per-Emo and Pro-Emo subscales. Furthermore, a positive correlation was found between empathy and factors such as love for animals, interest in medical ethics, belief in God, having an ill person in the family, class year or carrier intention.

CONCLUSIONS

The TCES is applicable to medical students. For the most part our findings were consistent with previous literature. However, we identified some nuances that might draw researchers' attention. The results of this study may contribute to plan interventions in the curriculum to enhance empathy in the medical students.

Beyond empathy decline: Do the barriers to compassion change across medical training?

BACKGROUND

Despite being a mandated, foundational value in healthcare, research on compassion remains limited. Studying the individual, patient, clinical, and contextual factors that interfere with compassion-the "barriers"-may clarify our understanding of the origins of compassion and identify potential targets for improving patient-centred care. Studies of the related construct of empathy have suggested that medical students report declines with increasing clinical experience. In contrast, when comparing physicians with medical students, increased clinical experience predicts lower barriers to compassion. Whether-and how-a similar experience-related decline in the factors that interfere with compassion occurs across medical training remains unknown.

AIMS

To describe how the barriers to compassion vary across clinical training in medical students.

METHOD

New Zealand medical students (N = 351) in their clinical years (Years 4-6) completed measures of the Barriers to Physician Compassion (BPCQ) and potential covariates such as demographics, work burden factors, and dispositional factors. The BPCQ indexes the extent to which barriers in four domains (individual, patient, clinical, and contextual) interfere with a physician/student's compassion towards patients. Analyses of variance and regression analyses were used to explore the effect of year level on the four types of barriers.

RESULTS

Year 4 students reported slightly lower student-related, environmental and patient/family-related (but not clinical) barriers than Year 6 students (effect size: ɷ² < 0.05); all barriers increased comparably across training. Controlling for relevant confounds, regression analyses confirmed that lower year level predicted lower barriers to compassion. Higher self-compassion, but not gender, predicted lower barriers.

CONCLUSIONS

In extending studies of empathy decline, this report suggests that students experience higher barriers to compassion as clinical training progresses. This is in contrast to existing studies contrasting physicians with medical students, where greater experience was associated with lower perceived barriers to compassion. Self-compassion may offset increases in barriers to care.

The development of empathy in the healthcare setting: a qualitative approach

BACKGROUND

Healthcare professionals' empathetic behaviors have been known to lead to higher satisfaction levels and produce better health outcomes for patients. However, empathy could decrease over time especially during training and clinical practice. This study explored factors that contributed to the development of empathy in the healthcare setting. Findings could be used to improve the effectiveness and sustainability of empathy training.

METHOD

A qualitative approach, informed by aspects of grounded theory, was utilized to identify factors that enabled the development of empathy from the perspectives of doctors, nurses, allied healthcare workers and students. Twelve sessions of focus group discussions were conducted with 60 participants from two hospitals, a medical school, and a nursing school. Data was analyzed independently by three investigators who later corroborated to refine the codes, subthemes, and themes. Factors which influence the development of empathy were identified and categorized. This formed the basis of the creation of a tentative theory of empathy development for the healthcare setting.

RESULTS

The authors identified various personal (e.g. inherent characteristics, physiological and mental states, professional identity) and external (e.g. work environment, life experience, situational stressors) factors that affected the development of empathy. These could be further categorized into three groups based on the stability of their impact on the individuals' empathy state, contributed by high, medium, or low stability factors. Findings suggest empathy is more trait-like and stable in nature but is also susceptible to fluctuation depending on the circumstances faced by healthcare professionals. Interventions targeting medium and low stability factors could potentially promote the development of empathy in the clinical setting.

CONCLUSIONS

Understanding factors that impact the development of empathy allows us to develop measures that could be implemented during training or at the workplace leading to improve the quality of care and higher clinical work satisfaction.

Relationship between self-reported cognitive and behavioural empathy among medical students

OBJECTIVE

The aim of this study was to explore the relationship between cognitive and behavioural empathy in medical students.

METHODS

Fourteen 4th year medical students recruited on the basis of their scores on the self-reported Jefferson Scale of Empathy (JSE-S) were divided into two groups: low JSE-S scorers (n = 8) (M = 96.75, SD = 10.3) and high JSE-S scorers (n = 6) (M = 121.3, SD = 2.94). They were discreetly videotaped while taking history with an incognito standardized patient. Students' behavioural empathy was measured using the Verona Coding System (VR-CoDES-P) and rating of non-verbal behaviour.

RESULTS

Patients expressed the same number of concerns per encounter in both groups but gave more cues to high-scorers (p = 0.029). However, students of both groups demonstrated the same amount of verbal empathy (high: 16% vs low: 15% p = 1.00). High JSE-S scorers' non-verbal communication tended to be rated slightly higher than low JSE-S-scorers with a higher use of facial expression (p = 0.008).

CONCLUSION

This study did not reveal any differences of students' verbal empathy to patients' cues and concerns between low and high JSE_S scorers.

PRACTICE IMPLICATIONS

The VR-CoDES_P is a useful tool to assess medical students and physicians empathic behaviour, allowing to disentangle the different components of empathy.

Understanding moral empathy: A verbatim-theatre supported phenomenological exploration of the empathy imperative

OBJECTIVES

Several studies have measured a decline in empathy during medical training, speculating that factors within the formal, informal and hidden curricula are responsible for this phenomenon. Although the medical education literature describes the moral domain of empathy as most fundamental to the empathic response, most research into the decline has examined the cognitive, affective and behavioural domains. This study distinguishes itself by focusing on how moral empathy is affected through training.

METHODS

Ten medical residents from core education specialties at McMaster University participated in lightly structured interviews concerning their training experiences. Interview transcripts were analysed by way of a descriptive phenomenological approach. Analyses afforded descriptions of the way medical training influences moral empathy. These descriptions were then used to generate a verbatim theatre play that was performed for an audience of residents, educators, learners, researchers and scholars. Following the play, audience participants completed a survey to member-check the descriptions and to glean other reflective experiences in resident training that impact moral empathy. The survey results informed revisions to the codebook that was subsequently used to re-analyse the interview transcripts. This resulted in a final, refined version of the influence of training on learner moral empathy.

RESULTS

The findings suggest that a resident's sense of moral empathy relies upon the notion of an innate capacity for empathy, and is influenced by their clinical and classroom education, and specific experiences with patients during training. Importantly, these factors are rarely experienced as having a direct deleterious impact on residents' moral empathy but rather are experienced as challenges to their ability to act on their moral empathy.

CONCLUSIONS

The study promotes reflection of what it means to experience empathy in the moral domain. The description offers a new perspective from which to view empathic declines that have been previously reported, while also highlighting a moral-behavioural tension that has implications for competency-based assessment and the way empathy is conceptualised in medical education.

Validation of the Romanian Version of the Toronto Empathy Questionnaire (TEQ) among Undergraduate Medical Students

Medical professionals require adequate abilities to identify others’ emotions and express personal emotions. We aimed to determine the validity and reliability of an empathy measuring tool in medical students for this study. We employed Spreng’s Toronto Empathy Questionnaire (TEQ) as a starting point for this validation. The process was performed in several steps, including an English-Romanian-English translation and a focus group meeting to establish each question’s degree of understandability and usability, with minor improvements of wording in each step. We checked internal and external consistency in a pilot group (n = 67). For construct and convergent validity, we used a sample of 649 students. The overall internal and external reliability performed well, with Cronbach’s alpha = 0.727 and respective ICC = 0.776. The principal component analysis resulted in 3 components: prosocial helping behavior, inappropriate sensitivity, dismissive attitude. Component 1 includes positively worded questions, and components 2 and 3 include negatively worded questions. Women had significantly higher scores than men in convergent validity, but we did not highlight any differences for other demographic factors. The Romanian version of the TEQ is a reliable and valid tool to measure empathy among undergraduate medical students that may be further used in subsequent research.

In someone else's shoes, are all wearers the same? Empathy in multi-ethnic Asian medical students

Objectives

Considerable research interest has been observed in ascertaining the actual pattern of empathy skill acquisition, but this aspect remains largely unexplored in Asian medical students. This study explored the empathy trait in Asian medical students from different levels of seniority and investigated the association between students’ empathy traits and their socio-demographic and socio-economic backgrounds.

Methods

To explore the empathy trait, the Year 1 to Year 5 medical students completed the students’ socio-demographic/economic and validated Interpersonal Reactivity Index (IRI) questionnaires.

Results

The participants scored highest in the empathetic concerns (EC) and lowest in the personal distress (PD) subscale. Female participants scored significantly higher on the EC, PD, and fantasy subscales. Participants who went to government high schools scored higher on the PD and EC subscales. Participants who stated a preference for specialisation that required more communication with patients scored higher on the EC and Perspective Taking subscales.

Conclusions

The empathy traits of Asian medical students may have cultural influences that are determined by their geographical background. Consistent observations regarding the inclination toward cognitive empathy traits in females were observed. This study also found that empathy traits are predictive of choices for postgraduate speciality training and that there is a difference in medical students’ empathy traits during the different phases of study in medical school.

A Systematic Review of Educational Interventions and Their Impact on Empathy and Compassion of Undergraduate Medical Students

Introduction: A compassionate and patient-centered care leads to improved clinical outcomes. Promoting empathy and compassion of medical students is a forerunner of their well-being, emotional stability, and a patient-centered care. However, there is slender evidence about best educational interventions that can inculcate empathy and compassion skills. Our objective was to conduct a systematic review of research evaluating the associations between spectrum, effectiveness, frequency of teaching modalities and their outcomes on compassion and empathy to highlight best practices.

Methods: We searched the Web of Science, PubMed, Scopus, and EBSCO Host on 22nd July 2020. We adapted our search strategy from a previously published systematic review on education for compassion and empathy. Selected studies were required to have used unique educational interventions for promoting empathy and compassion of medical students. The research questions were based on Participants (medical students), Intervention (empathy and/or compassion related teaching), Comparison, and Outcome.

Results: We analyzed 24 articles from the initial yield of 2,861. Twenty-two were quantitative studies with a mean of 12.8 on MERSQI. Twelve were randomized controlled trials while 5 measured outcomes with single group pre- and post-tests. There was no association found between duration, frequency and complexity of an educational intervention and its effectiveness. Twenty used multimodality curricula, and of those 18 reported statistically significant positive improvement in empathy, while 3 of 4 single modality were effective. Only three studies looked for long-term effects of educational interventions. Fourteen studies evaluated Kirkpatrick's level one (self-reported knowledge), 2 level three (behavior), and 6 level four (patient outcomes). We identified six major educational constructs of teaching empathy and compassion; communication, mindfulness, early clinical exposure, technology-enhanced learning, comics and arts and culture.

Discussion: Our review couldn't identify a standard teaching construct in place and highlighted that different teaching tools carry similar impact in promoting compassion and empathy and a sustainable program rather than a single training activity is essential.

Comparison of empathy with patients between first-year and last-year medical students of Tehran University of Medical Sciences

PURPOSE

This study was conducted to assess the developmental factors of empathy among medical students of Tehran University of Medical Sciences (TUMS).

METHODS

To assess the empathy levels, 42 first-year and an equal number of last-year medical students were randomly selected. They answered a questionnaire including the medical student version of the Jefferson Scale, demographic, and some related variables. Statistical analyses were performed using the Chi-square test, T-test, univariate, and multivariate regressions.

RESULT

The study population consisted of 51 (60.7 %) men and 33 (39.3 %) women with a mean (SD) age of 22.24 (4.10) years. The Jefferson score was 110.19 ± 13.61 and 103.52 ± 20.00 in first- and last-year medical students, respectively. Moreover, medical students who completely passed at least one of the considered empathy courses of the TUMS curriculum had higher empathy scores compared to their counterparts (109.83 ± 15.54 vs. 103.68 ± 19.02). There was no significant association between empathy and gender, self-experience of illness, marital status, family history of chronic disease, and parents' education (all P-values > 0.05). After adjusting for the effects of confounders, the empathy scores were significantly associated with the academic year level (p = 0.04), level of interest in medicine (p = 0.001), and passing the empathy courses (p = 0.04).

CONCLUSIONS

The data provided from a top Iranian medical school indicated that the academic year level, level of interest in medicine, and passing the empathy courses were significantly associated with the empathy level. Further studies are recommended.

Development and Cross-National Validation of a French Version of the Jefferson Scale of Empathy for Students

Empathy is a multifaceted personal ability combining emotional and cognitive features modulated by cultural specificities. It is widely recognized as a key clinical competence that should be valued during professional training. The Jefferson Scale of Empathy for medical students (JSE-S) has been developed for this purpose and validated in several languages, but not in French. The aims of this study were to gather validity evidence for a newly developed version of the JSE-S and compare it between two French-speaking contexts. In total, 1,433 undergraduate medical students from the universities of Lyon (UL), France and Geneva (UG), Switzerland participated in the study completing the JSE-S in French. Total and partial scores of the three subscales (“perspective taking,” “compassionate care” and “walking in patient’s shoes”) were calculated for each site. Construct validity of the JSE-S was analyzed considering three sources of evidence: content, internal structure and relations to other variables. A first-order Confirmatory Factor Analysis using structural equation modeling examined the three latent variables of the JSE-S subscales. Cronbach’s α coefficients were 0.75 (UG) and 0.81 (UL). The items’ discrimination power ranged between 0.29 and 1.60 (median effect size of 1.24). The overall correlations between items and total or partial scores derived from the latent JSE-S subscales were consistently similar in both study sites. Findings of this study confirm the latent structure of the JSE-S in French and its cross-national reproducibility. The comparable underlying structure of the questionnaire tested in two distinct French-speaking contexts endorses the generalizability of its measure.

Scoping reviews in medical education: A scoping review

OBJECTIVES

Over the last two decades, the number of scoping reviews in core medical education journals has increased by 4200%. Despite this growth, research on scoping reviews provides limited information about their nature, including how they are conducted or why medical educators undertake this knowledge synthesis type. This gap makes it difficult to know where the field stands and may hamper attempts to improve the conduct, reporting and utility of scoping reviews. Thus, this review characterises the nature of medical education scoping reviews to identify areas for improvement and highlight future research opportunities.

METHOD

The authors searched PubMed for scoping reviews published between 1/1999 and 4/2020 in 14 medical education journals. The authors extracted and summarised key bibliometric data, the rationales given for conducting a scoping review, the research questions and key reporting elements as described in the PRISMA-ScR. Rationales and research questions were mapped to Arksey and O'Malley's reasons for conducting a scoping review.

RESULTS

One hundred and one scoping reviews were included. On average, 10.1 scoping reviews (SD = 13.1, median = 4) were published annually with the most reviews published in 2019 (n = 42). Authors described multiple reasons for undertaking scoping reviews; the most prevalent being to summarise and disseminate research findings (n = 77). In 11 reviews, the rationales for the scoping review and the research questions aligned. No review addressed all elements of the PRISMA-ScR, with few authors publishing a protocol (n = 2) or including stakeholders (n = 20). Authors identified shortcomings of scoping reviews, including lack of critical appraisal.

CONCLUSIONS

Scoping reviews are increasingly conducted in medical education and published by most core journals. Scoping reviews aim to map the depth and breadth of emerging topics; as such, they have the potential to play a critical role in the practice, policy and research of medical education. However, these results suggest improvements are needed for this role to be fully realised.

Measures of Burnout and Empathy in United States Doctor of Pharmacy Students: Time for a Change?

PURPOSE

To review interim data regarding longitudinal burnout and empathy levels in a single Doctor of Pharmacy class cohort.

METHODS

Students were emailed an electronic survey during their first semester and annually at the end of each academic year for a total of 3 years (2017-2020). Validated survey tools included the Jefferson Scale of Empathy (JSE) and the Maslach Burnout Inventory (MBI) student version. The JSE survey consists of 20 questions, with higher scores denoting more empathy. The MBI student version contains 3 subscales: exhaustion (higher scores are worse), cynicism (higher scores are worse) and professional efficacy (higher scores are better).

RESULTS

The median JSE score at the end of the third academic year (PY3) was 110, with females scoring significantly higher (114.5 vs. 103.5; p<0.02). A majority of the 62 students reported burn out (82.3%), scoring in the highest category for either exhaustion (76%) or cynicism (55%). A majority (66%) also reported a low or moderate professional efficacy score, a negative finding. Measures of student burnout increased after the start of the program and remained at the higher level each subsequent year (p<0.0001). In the Spring of 2020, during the COVID-19 pandemic, nearly every student had moderate or high levels of emotional exhaustion (97%) and cynicism (78%) as measured by the MBI.

CONCLUSION

This interim data suggests high degrees of pharmacy student burnout. Empathy levels remained stable throughout the duration of the study. Pharmacy schools may need to focus on reform regarding well-being and prevention of burnout.

Variabilidad empática en estudiantes de odontología. Consecuencias aún no entendidas en América Latina

Introducción. La empatía es un atributo que permite a los odontólogos establecer una relación intersubjetiva con sus pacientes, lo que contribuye a un tratamiento exitoso, entre otros beneficios. Objetivo. Determinar si hay variabilidad en los niveles de empatía entre dos poblaciones de estudiantes de odontología y describir teóricamente las implicaciones generales de esta variabilidad en estrategias de intervención. Materiales y métodos. Estudio exploratorio transversal. La población de estudio consistió de estudiantes de odontología de 1er a 5to año de la Universidad Santiago de Cali, Colombia (n=610; N=647) y la Universidad San Sebastián, Chile (n=535; N=800). En ambos grupos, la empatía se midió con la Escala de Empatía de Jefferson (Versión S). Para el análisis de los datos se utilizó estadística descriptiva (media y desviación estándar). La consistencia interna de los datos se estimó mediante el alfa de Cronbach y el coeficiente de correlación intraclase. Se realizó un análisis de varianza factorial: tres factores estudiados: Universidad (U), Curso (C) y Sexo (S). El nivel de significancia estadística utilizado fue de α≤ 0.05 y β≤ 0.20. Resultados. Se observaron diferencias en el nivel de empatía y algunas de sus tres dimensiones entre los estudiantes de ambas universidades y entre los cursos (1er-5to año). No se observaron diferencias entre sexos. Conclusiones. Existe variabilidad en los niveles de empatía entre los estudiantes de ambas universidades. Para aumentar los niveles de empatía en esta población en Latinoamérica se requiere la implementación de estrategias específicas de intervención empática en cada programa de odontología ofrecido en la región.

A Pilot Study of the Impact of Virtually Embodying a Patient with a Terminal Illness

Compassionate end-of-life care matters deeply for patients and their caregivers, but studies continue to demonstrate ways in which physicians fall short. Despite specific training during medical school, many patients report lack of empathy in their providers with respect to end-of-life conversations. This is likely because empathy is simply hard to teach. Numerous activities have been tried to combat the decline in empathy during medical training with little to moderate success. However, virtual reality, which allows users to viscerally experience anything from another person's point of view, could be a game changer for building empathy within medicine. This type of perspective-taking has previously shown to improve understanding, reduce biases, facilitate empathy, and promote prosocial behaviors. In this pilot study, virtual reality was used to allow students to "become a patient" virtually embodying their daily activities, symptoms, and interactions with caregivers. Using the Embodied Labs modules, first-year medical students were able to experience first-hand having a terminal illness, being told no further treatments are available and witnessing loved ones' reactions. Data generated through surveys and reflections indicated a high level of place illusion, plausibility, and embodiment of users. This high level of immersion generated an increase in comfortability with talking about end-of-life issues, produced a better understanding of what patients and their families experience, and promoted a change in the way students would approach clinical skills. Analysis of reflections indicated a high level of empathy for the patient and his family members. Overall, the activity was highly received by students as a valuable learning activity. As such, we propose that virtual reality could be a useful pedagogical tool to facilitate empathy and clinical skills within medical education.

A validation study of the Korean version of the Toronto empathy questionnaire for the measurement of medical students' empathy

BACKGROUND

This study aimed to validate the Korean version of the Toronto Empathy Questionnaire (TEQ) and to determine its suitability for the measurement of empathy in medical students.

METHODS

The study sample was Year 1 and 2 medical students at two medical schools on six-year undergraduate medical programs in South Korea. The study participants completed the Korean TEQ, which has a single factor structure and consists of 16 items; responses are scored using a 5-point Likert scale, giving a maximum possible score of 64. Psychometric validation of the questionnaire was performed by exploratory and confirmatory factor analyses and the goodness of fit test. Average variance extracted was calculated to establish convergent validity, and associations between factors and construct reliability were analyzed to establish discriminant validity. Cronbach's alpha values were utilized for reliability analysis.

RESULTS

A total of 279 students completed and returned the questionnaire (a 96.2% response rate). Participant empathy scores ranged from 20 to 60 (M = 44.6, SD = 7.36). Empathy scores were higher for females than males (p < .05). The cumulative variance of the Korean TEQ was 32%, indicating that its explanatory power was rather weak. Consequently, goodness-of-fit testing was performed on four hypothetical models, among which a three-factorial structure consisting of 14 items demonstrated satisfactory fit indices and explained 55% of the variance. Reliability estimates of the three subscales were also satisfactory (Cronbach's α = .71-.81). This three-factorial model was validated by confirmatory factor analysis and demonstrated adequate convergent and discriminant validity.

CONCLUSIONS

This study demonstrated psychometric validation of the Korean TEQ for measuring medical students' empathy. We suggest a modified 14-item model with a three-factorial structure, which demonstrated better psychometric properties than the original scale.

The Development of Empathy and Associated Factors during Medical Education: A Longitudinal Study

PURPOSE

In this longitudinal study, we investigated the development of empathy during medical education and assessed potential predictors of empathy at different time points in the course of medical studies.

METHODS

In our longitudinal study, starting in 2011, we surveyed medical students at Lübeck Medical School, Germany at the beginning of their course of study and after 2, 4, and 6 years (t0-t3) using standard instruments for empathy (Jefferson Scale of Empathy, Student Version, JSE-S), anxiety and depression (Hospital Anxiety and Depression Scale, HADS), stress (Perceived Medical School Stress scale), and behavior and experience patterns (Arbeitsbezogene Verhaltens- und Erlebensmuster [Work-related Behavior and Experience Patterns]).

RESULTS

A total of 43 students completed all surveys. The cross-sectional samples for the different survey time points comprised between n = 220 and 658 students. We observed a slight, but statistically significant, increase of empathy scores from t0 to t3 (t(43) = -3.09, P < .01). Across all analyses, a preference for a people-oriented specialty was associated with a higher JSE-S sum score, as well as being female, whereas we saw a negative association between HADS depression and JSE-S scores.

CONCLUSION

In our study, empathy scores were shown to be relatively stable during medical education with a tendency to increase. In line with previous research, individuals preferring a people-oriented specialty and women showed higher empathy scores.

Searching for the erosion of empathy in medical undergraduate students: a longitudinal study

OBJECTIVE

To analyse the trajectory of empathy throughout the degree programme of medicine in a Spanish school of medicine.

DESIGN

Longitudinal, prospective 5-year study, between October 2014 and June 2019.

SETTING

Students from a Spanish university of medicine.

PARTICIPANTS

Two voluntary cohorts of undergraduate medical students from two different school years were invited to participate (n=135 (cohort 1, C1) and 106 (cohort 2, C2) per school year). Finally, a total number of 174 students (102 (C1, 71.6% women) and 72 (C2, 70.8% women) students, respectively) were monitored for 5 years. Each cohort was divided in two subcohorts of paired and unpaired students that were analysed to check possible social desirability bias.

PRIMARY OUTCOME MEASURE

The Jefferson Scale of Empathy (JSE).

RESULTS

The cohort of 102 students (C1) monitored between their first and fifth years of study (71.6% women) showed an improvement among paired women of 2.15 points in total JSE score (p=0.01) and 2.39 points in cognitive empathy (p=0.01); in the unpaired female cohort the increase was of 2.32 points (cognitive empathy) (p=0.02). The cohort of 72 students (C2) monitored between their second and sixth years of study (70.8% women) displayed a cognitive empathy increase of 2.32 points (p=0.04) in the paired group of women. There were no significant differences between paired and unpaired results for either cohort. Empathy scores among men did not decrease.

CONCLUSIONS

The empathy of medical students at our school did not decline along grade years. In fact, it improved slightly, particularly cognitive empathy, among women. This paper contributes to enlarge data from Europe, where longitudinal studies are scarce. It supports the idea that there may be global geo-sociocultural differences; however, more studies comparing different school settings are needed.

Virtually Walking in a Patient's Shoes-the Path to Empathy?

Empathy is the basis of a patient-physician relationship; however, this is being lost by students throughout medical training. Immersive virtual reality that allows individuals to viscerally experience anything from another person's point of view has the potential to reverse the erosion of empathy and improve clinical practices.

Empathy trajectories throughout medical school: relationships with personality and motives for studying medicine

Empathy remains a widely discussed topic within medical education research. Studies on empathy changes among medical students are not univocal: empathy may decline, remain stable or increase. A largely unexplored research question regards inter-individual variability in empathy change, namely if different longitudinal trajectories of empathy exist. Evidence on the association of empathy trajectories with personality and motives for studying medicine is also scarce. Here, latent growth modeling examined empathy (measured with the Jefferson Scale of Empathy) among 201 medical students (M_age = 20.74, 57% females) across three assessments: at entry year (Year 1) and during the first two clinical years (Years 4 and 5). Associations between empathy trajectories, personality in Year 1 and motives for studying medicine in Years 4 and 5 were tested. We identified two empathy trajectory groups: lower and decreasing (n = 59; 29%) and higher and stable (n = 142; 71%). Regression analyses indicated that higher openness in Year 1 was associated with an increased probability of higher and stable group membership (controlling for motives in Year 1). The effect of openness disappeared controlling for motives in Years 4 and 5 while caring for patients (in Years 4 and 5) and altruism (in Year 4) were positively associated with an increased probability of higher and stable group membership. In sum, we observed that empathy remains stable in most medical students and declines in fewer; openness and patients-oriented motives for studying medicine are associated with higher and stable empathy. Encouraging medical students' patients-oriented motives from preclinical throughout clinical years may prevent empathy decline.

Decline of Empathy after the First Internship: Towards a More Functional Empathy?

Research has shown a decline in empathy as medical studies progress. Among various hypotheses, an explanation track evoked is the first contact with the internship.

Objectives This quasi-experimental study was designed to examine the impact of the first internship in medical students. Our research question was: “to what extent the first internship may decreased the empathy’s scores of our 3d year medical students?”

Methods We measured the empathy of 220 third year medical students before and after their first internship (3 weeks) in family medicine. Using online surveys methodology, we collected data about empathy (“Interpersonal Reactivity Index”: IRI), epidemiology, professional orientation choices.

Results Statistical analyses revealed a small but significant decrease in IRI’s “fantasy,” “empathic concern” and “personal distress” subscales.

Conclusion These results suggest a potential impact of the first internship on empathic skills. The fact that the students’ score for the “personal distress” subscale (which characterizes a difficulty in managing their emotions) decreases is actually a rather good thing. These data raise the question of the “function” of this loss of empathy. The fact that this score decreases after first internship, may indicate a positive change for these medical students: towards better emotional regulation and more functional affective empathy.

Increases in loneliness during medical school are associated with increases in individuals' likelihood of mislabeling emotions as negative

Expressions of emotion represent an important and unique source of information about the states of others. Being able to effectively understand expressions of emotions to make inferences about others' internal mental states and use these inferences to guide decision-making and behavior is critical to navigating social relationships. Loneliness, the perception that one lacks social connection, has important functional consequences for how individuals attend to signals of emotions in others. However, it is less clear whether loneliness changes how individuals recognize emotions in others. In medical practitioners, being able to accurately recognize emotional cues from patients is critical to effectively diagnosing and reacting with care to those patients. The current study examines the relationship between changes in loneliness during medical school and students' recognition of emotion in others. Measures of loneliness and emotion recognition were collected from 122 medical students during their first 3 years of medical school at the beginning and end of each academic year. Changes in loneliness were related to changes in emotion detection, with increases in loneliness being associated with decreases in the probability of accurately discriminating sad and angry faces from other expressions, decreases in the probability of mislabeling emotion expressions as happy, and increases in the probability of mislabeling other emotional expressions as pained and angry. This study suggests that changes in loneliness during medical school are associated with increases in students' labeling emotional expressions as negative, possibly by shifting attention to cues of negative emotion and away from cues of positive emotion. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-Institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools

PURPOSE

To examine differences in students' empathy in different years of medical school in a nationwide study of students of U.S. DO-granting medical schools.

METHOD

Participants in this cross-sectional study included 10,751 students enrolled in 41 of 48 campuses of DO-granting medical schools in the United States (3,616 first-year, 2,764 second-year, 2,413 third-year, and 1,958 fourth-year students). They completed a web-based survey at the end of the 2017-2018 academic year that included the Jefferson Scale of Empathy and the Infrequency Scale of the Zuckerman-Kuhlman Personality Questionnaire for measuring "good impression" response bias. Comparisons were made on empathy scores among students in different years of medical school using analysis of covariance, controlling for the effect of "good impression" response bias. Also, comparisons were made with preexisting data from students of U.S. MD-granting medical schools.

RESULTS

A statistically significant decline in empathy scores was observed when comparing students in the preclinical (years 1 and 2) and the clinical (years 3 and 4) phases of medical school (P < .001); however, the magnitude of the decline was negligible (effect size =0.13). Comparison of findings with MD students showed that while the pattern of empathy decline was similar, the magnitude of the decline was less pronounced in DO students.

CONCLUSIONS

Differences in DO-granting and MD-granting medical education systems, such as emphasis on provision of holistic care, hands-on approaches to diagnosis and treatment, and patient-centered care, provide plausible explanations for disparity in the magnitude of empathy decline in DO compared with MD students. More research is needed to examine changes in empathy in longitudinal study and explore reasons for changes to avert erosion of empathy in medical school.

The Effectiveness of Teaching Clinical Empathy to Medical Students: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

Clinical empathy is a necessary trait to provide effective patient care, despite differences in how it is defined and constructed. The aim of this study was to examine whether empathy interventions in medical students are effective and how confounding factors potentially moderate this effect.

METHOD

The authors performed a systematic review and meta-analysis. They searched the literature published between 1948 and 2018 for randomized controlled trials that examined empathy interventions in medical students. The search (database searching, citation tracking, hand-searching relevant journals) yielded 380 studies, which they culled to 16 that met the inclusion criteria. For the meta-analysis, they used a random effects model to produce a pooled estimate of the standardized mean difference (SMD), then completed subgroup analyses.

RESULTS

The authors found evidence of the possibility of response and reporting bias. The pooled SMD was 0.68 (95% confidence interval 0.43, 0.93), indicating a moderately positive effect of students developing empathy after an intervention compared with those in the control groups. There was no evidence of publication bias, but heterogeneity was significantly high (I = 88.5%, P < .01). Subgroup analyses indicated that significant moderating factors for developing empathy were age, country, scope of empathy measurement, type of empathy intervention, and presence of rehearsal. Moderating factors with limited evidence were sex, study quality, journal impact factor, and intervention characteristics.

CONCLUSIONS

Despite heterogeneity and biases, empathy interventions in medical students are effective. These findings reinforce arguments in the literature and add considerable rigor from the meta-analysis. The authors propose a conceptual model for educators to follow when designing empathy interventions in medical students.

Empathy in Action in Healthcare (EACH): A mixed methods study of nurses' and therapists' empathy

BACKGROUND

Despite a plethora of research on empathy and its associated constructs, there is little evidence exploring clinicians' perceptions of their empathy and its impact on service level outcomes.

METHODS

The aim of this single centre mixed methods study was to investigate nurses' and therapists' empathy levels and explore their views regarding its impact on clinical decision making at a national specialist orthopaedic centre. Data were collected from 126 respondents using an online validated empathy scale (Jefferson scale) supplemented by interviews with a convenience sample of 20 respondents. Questionnaire data were analysed using descriptive and inferential statistics. Qualitative interview data were subjected to a standard process of inductive thematic analysis prior to seeking relationships between the two datasets.

RESULTS

There was a statistically significant difference in empathy levels between nurses and therapists (p = 0.031), with nurses scoring lower than therapists. Interview findings identified four key themes; displaying empathy, therapeutic use of self, influences and impacts, and learning. Differences between empathy scores and participants' subjective accounts of empathy were apparent.

CONCLUSION

Empathy is an important construct built upon personal and professional experiences. Previous research reports empathy as a positive tool, however, our data suggest that its inappropriate use might also have a negative impact on service delivery and health outcomes.

[Can empathy be taught to caregivers?]

The concepts of empathy and care are the subject of numerous publications that testify to a surge in interest in the subject. What are the possibilities of teaching empathy to medical and nursing students? A proposed definition and a literature review can be developed to identify the effects of empathy in care and the opportunities for teaching empathy to students and practicing professionals.

Associations of emotional intelligence and gratitude with empathy in medical students

BACKGROUND

Empathy is an essential quality for physicians and medical trainees. This study aimed to examine the associations of emotional intelligence (EI) and gratitude with empathy in medical students.

METHODS

We conducted this cross-sectional study at three medical schools in China. A pack of self-reported questionnaires, consisting of the Interpersonal Reactivity Index (IRI), the Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF), the Gratitude Questionnaire-6 (GQ-6), and demographic section were distributed to the students.

RESULTS

A pool of 1392 students became the final participants. After adjustment for the demographics, trait EI and gratitude were positively related to Perspective Taking and Empathic Concern, accounting for 33.1 and 22.7% of their variance, respectively. While trait EI was strongly and negatively associated with Personal Distress, gratitude was modestly and positively associated with it, and they collectively explained 29.1% of its variance.

CONCLUSIONS

Trait EI and gratitude could be vital psychological constructs for understanding empathy in medical students. The positive roles they may play could be considered when intervention strategies and programs are designed to enhance the professional competencies in medical students.

Revisiting the trajectory of medical students' empathy, and impact of gender, specialty preferences and nationality: a systematic review

BACKGROUND

Empathy allows a physician to understand the patient's situation and feelings and respond appropriately. Consequently, empathy gives rise to better diagnostics and clinical outcomes. This systematic review investigates the level of empathy among medical students across the number of educational years and how this level relates to gender, specialty preferences, and nationality.

METHOD

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors conducted a systematic search of studies published between February 2010 and March 2019 investigating the level of empathy among medical students. The databases PubMed, EMBASE, and PsycINFO were searched. Studies employing quantitative methodologies and published in English or Scandinavian language and examining medical students exclusively were included.

RESULTS

Thirty studies were included of which 24 had a cross-sectional and 6 a longitudinal study design. In 14 studies, significantly lower levels of empathy were reported by increase in the number of educational years. The remaining 16 studies identified both higher, mixed and unchanged levels. In 18 out of 27 studies it was reported that females had higher empathy scores than males. Only three out of nine studies found an association between empathy scores and specialty preferences. Nine out of 30 studies reported a propensity towards lower mean empathy scores in non-Western compared to Western countries.

CONCLUSION

The results revealed equivocal findings concerning how the empathy level among medical students develops among medical students across numbers of educational years and how empathy levels are associated with gender, specialty preferences, and nationality. Future research might benefit from focusing on how students' empathy is displayed in clinical settings, e.g. in clinical encounters with patients, peers and other health professionals.

Challenges in promoting clinical empathy skills in medical students: A content analysis study

Background: Empathy is a key clinical skill in the medical profession, and many studies have reported a decline in it among medical students during their years of education; especially, in the clinical stage, and this affective decline persists in the physician-hood. This study aimed to explore the participants' perceptions about challenges for promoting clinical empathy in training stages. Methods: A qualitative design using content analysis was applied. Semi-structured interviews were applied to obtain data. Individual interviews were conducted with 14 interns and six clinical professors. The data were analyzed through conventional content analysis and the credibility, trustworthiness, and conformability of the data were confirmed. Results: Data analysis led to the extraction of two main categories, including overt and covert challenges, and also four categories and nine sub-categories. Conclusion: Resolving clinical empathy challenges in medical students requires financial and human resources, and training on the principles of effective doctor-patient interactions. Furthermore, professionalism should be strengthened in professors, and both official and hidden curricula should be revised accordingly.

Empathic decline and training in nursing students

ABSTRACT Objective The objective of this article is to examine whether the levels of empathy fit the concept of empathic decline. Method This was a non-experimental and cross-sectional study. Two populations of nursing students in two nursing programs were studied: Universidad San Sebastián (Santiago, Chile) and Universidad Mayor (Temuco, Chile). The original data on empathy, assessed by the Jefferson Scale of Empathy, were combined into a single data base. They were then analyzed by means of normality tests and homoscedasticity, Cronbach’s alpha, analysis of variance; the standard deviation of the dependent outcome measure (Sy.x) and the coefficient of determination (R2) were estimated. Results The sample sizes from the two programs were 479 and 277, respectively. It was found that the distributions of the averages over the course of study for empathy (and its components) were constant, and in some cases increased. Conclusion It was found that the distribution of the means of empathy in the nursing students analyzed did not conform to the classical empathic decline observed in other studies. Therefore, it is inferred that the traditional factors identified as causes of empathic erosion were not operating in the same way in the studied context.

An Exploration of Knowledge and Attitudes of Medical Students and Rheumatologists to Placebo and Nocebo Effects: Threshold Concepts in Clinical Practice

INTRODUCTION

Understanding placebo and nocebo responses (context/meaning effects [CMEs]) is fundamental to physician agency. Specific instruction in CMEs is often lacking in medical education. Patient-practitioner interactions may challenge medical students' understanding of biomedical causality and the nexus between this, practical ethics and professionalism across various conceptual and applied aspects of CMEs. This study compared the corpus of knowledge and phronesis related to CMEs between Australian graduate medical students and rheumatologists to gain a sophisticated understanding of this relationship to inform curriculum development.

METHOD

In 2013 and 2014, the authors surveyed third-year medical students undertaking a graduate programme in an Australian medical school and Australian rheumatologists to ascertain their understanding of placebo and nocebo responses. The survey ascertained (1) the alignment of the respondents' understanding of CMEs with accepted facts and concepts; (2) opinions on the ethical status of CMEs; and (3) responses to 2 scenarios designed to explore matters of biomedical causality, practical ethics and professionalism.

RESULTS

There were 88 completed surveys returned, 53 rheumatologists and 35 students. Similar proportions within each group identified CMEs, with most (n = 79/88 [89.8%]) correctly recognising a placebo (rheumatologists: 50 [94.3%], students: 29 [82.9%]) and approximately three-quarters (n = 65/88 [73.9%]) correctly recognising nocebo effects (rheumatologists: 39 [73.6%], students: 26 [74.3%]). Statistically significant differences between practitioners and students were observed in relation to the following: placebo responders and placebo responsiveness; placebos as a 'diagnostic tool'; placebos usage in clinical practice and research, and nocebo effects.

CONCLUSIONS

Physicians require an awareness of CMEs and the fact that they arise from and influence the effective agency of health care professionals. Curricular emphasis is needed to permit an honest assessment of the components that influence when, how and why patient outcomes arise, and how one's agency might have neutral or negative effects but could be inclined towards positive and away from negative patient outcomes.

How does medical education affect empathy and compassion in medical students? A meta-ethnography: BEME Guide No. 57

Background: Empathy and compassion are important in healthcare delivery, and are necessary qualities in medical students. Aims: To explore medical students', patients' and educators' perceptions of what affects empathy and the expression of compassion; and to address gaps in knowledge, attitudes and skills on how education affects empathy and the expression of compassion in medical students. Methods: The seven steps by Noblit and Hare were used for this meta-ethnography. Databases were searched for studies in English, published from 2007 to 2017 with outcomes of empathy and compassion. Key themes and concepts were identified, and accounts from the studies were used to build interpretations. Findings: Thirty-three qualitative studies were included and four main themes were derived: seeing the patient as a person; appreciating the elements of empathy and compassion; navigating in the training environment; and being guided by ideals. Interactions between the patient, the medical student and training environment which affect the development of empathy and compassion are illustrated in a conceptual model. Conclusions: This meta-ethnography extends our understanding of how medical education affects the expression of empathy and compassion in medical students. The results provide important considerations for medical educators and faculty developers in further developing and improving medical curricula.

Curricula for empathy and compassion training in medical education: A systematic review

Background

Empathy and compassion are vital components of health care quality; however, physicians frequently miss opportunities for empathy and compassion in patient care. Despite evidence that empathy and compassion training can be effective, the specific behaviors that should be taught remain unclear. We synthesized the biomedical literature on empathy and compassion training in medical education to find the specific curricula components (skills and behaviors) demonstrated to be effective.

Methods

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL using a previously published comprehensive search strategy. We screened reference lists of the articles meeting inclusion criteria to identify additional studies for potential inclusion. Study inclusion criteria were: (1) intervention arm in which subjects underwent an educational curriculum aimed at enhancing empathy and/or compassion; (2) clearly defined control arm in which subjects did not receive the curriculum; (3) curriculum was tested on physicians (or physicians-in-training); and (4) outcome measure assessing the effect of the curriculum on physician empathy and/or compassion. We performed a qualitative analysis to collate and tabulate effects of tested curricula according to recommended methodology from the Cochrane Handbook. We used the Cochrane Collaboration’s tool for assessing risk of bias.

Results

Fifty-two studies (total n = 5,316) met inclusion criteria. Most (75%) studies found that the tested curricula improved physician empathy and/or compassion on at least one outcome measure. We identified the following key behaviors to be effective: (1) sitting (versus standing) during the interview; (2) detecting patients’ non-verbal cues of emotion; (3) recognizing and responding to opportunities for compassion; (4) non-verbal communication of caring (e.g. eye contact); and (5) verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perception of physician empathy and/or compassion.

Conclusion

Evidence suggests that training can enhance physician empathy and compassion. Training curricula should incorporate the specific behaviors identified in this report.

Medical students' empathy positively predicts charitable donation behavior

Empathy is known to motivate prosocial behavior. This relationship, however is complex and influenced by the social context and the type of prosocial behavior. Additionally, empathy is a complex psychological capacity, making it important to examine how different components of empathy influence different prosocial behaviors. The current study uses a unique longitudinal sample to assess how changes in cognitive and affective components of empathy relate to charitable giving. Measures of empathy were collected from medical students in the fall and spring of students' first three years of medical school. After this time, students had the opportunity to donate to charity. Positive changes in students' cognitive empathy predicted their charitable giving, with students who demonstrated greater increases in cognitive empathy giving more money. This study points to an important role for cognitive empathy in certain prosocial behaviors, and suggests that long term changes in empathy influence individual differences in prosocial behavior.

Navigating Tensions of Efficiency and Caring in Clerkship: A Qualitative Study

Phenomenon: Clerkship is a challenging transition during which medical students must learn to navigate the responsibilities of medical school and clinical medicine. We explored how clerks understand their roles as both medical learners and developing professionals and some of the tensionss that arise therein. Understanding how the clinical learning environment shapes the clerkship role can help educators foster compassionate care. Approach: We conducted 5 focus groups and 1 interview with 3rd-year medical students (n = 14) at University of Toronto between January and June 2016 regarding the perceived role of the clerk, compassionate care, assessment and feedback. Data were analyzed thematically. Findings: In addition to transitioning to a new learning environment, clerkship students assume different roles in response to complex and often competing expectations from preceptors. We identified three main themes: learning to impress preceptors with varying expectations, providing compassionate care-sometimes supported by preceptors, other times being secondary to efficiency-and passing assessments that required a different skill set than simply being a "good clerk." Insights: Clerks perceive their role as providing compassionate care to patients and balance this with fulfilling the (sometimes) competing roles of being a student and developing medical professional. In a system where efficiency is often prioritized, medical students are afforded an opportunity to help satisfy the demand for greater compassion in patient-centered care.

Is empathy change in medical school geo-socioculturally influenced?

CONTEXT

There is convincing evidence that physician empathy leads to better patient care. As a result, there has been considerable research interest in investigating how empathy changes during undergraduate medical studies. Early (generally North American) studies raised concerns that medical training causes a decline in empathy. More recent studies (conducted around the world) have begun to suggest that either a slight increase or decrease in empathy occurs during undergraduate medical training, which has led some to argue that empathy changes indiscriminately (with no discernible pattern). This paper explores whether there is evidence to suggest that empathy changes indiscriminately or with a discernible geo-sociocultural pattern during undergraduate medical training.

METHODS

Literature that investigated change in empathy during undergraduate medical training was reviewed. Cross-sectional and longitudinal studies were tabulated separately according to their respective geographical locations. The tabulated results were analysed to investigate whether empathy changed similarly or differently within different geographical locations.

RESULTS

The studies reviewed indicate similar patterns of empathy change within approximate geo-sociocultural clusters. Whereas US studies predominantly show small but significant decreases in empathy, Far Eastern studies mostly show small but significant increases in empathy as undergraduates progress through the medical course.

CONCLUSIONS

These results suggest that change in empathy during undergraduate medical education is not as indiscriminate (patternless) as once thought. Additionally, these results support the notion that empathy is a locally construed global construct.

Investigating the relation between self-assessment and patients' assessments of physicians-in-training empathy: a multicentric, observational, cross-sectional study in three teaching hospitals in Brazil

OBJECTIVES

This study investigated the associations between self-assessed empathy levels by physicians in training and empathy levels as perceived by their patients after clinical encounters. The authors also examined whether patient assessments were valid and reliable tools to measure empathy in physicians in training.

DESIGN

A multicentric, observational, cross-sectional study.

SETTING

This study was conducted in three public teaching hospitals in Brazil.

PARTICIPANTS

From the 668 patients invited to participate in this research, 566 (84.7%) agreed. Of these, 238 (42%) were male and 328 (58%) were female. From the invited 112 physicians in training, 86 (76.8%) agreed. Of the 86 physicians in training, 35 (41%) were final-year medical students and 51 (59%) were residents from clinical and surgical specialties. The gender distribution was 39 (45%) males and 47 (51%) females.

PRIMARY AND SECONDARY OUTCOME MEASURES

Physicians in training filled the Jefferson Scale of Physician Empathy (JSE) and the Interpersonal Reactivity Index. Patients answered the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE) and the Consultation and Relational Empathy Scale (CARE).

RESULTS

This study found non-significant correlations between patient and physicians-in-training self-assessments, except for a weak correlation (0.241, p<0.01) between the JSPPPE score and the JSE compassionate care subscore. CARE and JSPPPE scales proved to be valid and reliable instruments.

CONCLUSIONS

Physicians-in-training self-assessments of empathy differ from patient assessments. Knowledge about empathy derived from self-assessment studies probably does not capture the perspective of the patients, who are key stakeholders in patient-centred care. Future research on the development of physician empathy or on outcomes of educational interventions to foster empathy should include patient perspectives.

Medical students' individual and social empathy: A follow-up study

Background: The Social Empathy Index (SEI) measures self-reported empathy for individuals and for vulnerable groups. In a previous study, we published first-year medical students' SEI scores before and after completing a course on the social determinants of health. We re-administered the SEI to the original student cohort entering their 4th year. Methods: Survey data were analyzed for individual and social empathy components using repeated measures ANOVA. Associations of demographic data and the latest scores were analyzed using either two sample t-test or ANOVA. Results: Of 130 4th-year eligible medical students, 76 (58%) completed all three surveys. The mean "Affective Mentalizing" score increased by 0.15 points from the first to fourth year of medical school, p < 0.05. A concomitant decline was observed in "Emotional Regulation" decreasing 0.68 points, p < 0.001. "Contextual Understanding of Systemic Barriers" (CU) increased in mean score by 0.26 points, p = 0.006. Discussion: Our findings support promoting interventions to combat a decline of emotional regulation in their clinical years. The consistent increase in CU at each follow-up testing point may indicate a need to focus on students' sense of self-efficacy in addressing the social determinants of health. Social empathy scores might predict which students are likely to choose primary care specialties.

Medical students' empathy and attitudes towards professionalism: Relationship with personality, specialty preference and medical programme

Background

Existing research has suggested that self-reported empathy in medical students is moderated by personality traits and diverse demographic and educational factors including age, gender, nationality, career aspirations, as well as year of curriculum. It is unclear how empathy, personality, and background factors might impact on students’ attitudes towards professionalism in medicine.

Methods

A cross-sectional questionnaire-based study was conducted in first and final year medical students at an Irish medical school. The following instruments were administered: (a) Jefferson Scale of Empathy; (b) NEO Five-Factor Inventory (NEO-FFI-3); (c) Attitudes towards Professionalism Scale. Demographic and educational variables were also measured. Descriptive and correlational analysis was conducted to examine the association between empathy, personality, professionalism-related attitudes and additional measures. Regression analysis was used to examine determinants of attitudes towards professional behaviour.

Results

Both selected NEO-FFI personality traits and empathy were independently associated with distinct categories of professional behaviour. Specifically, Openness to Experience was associated with higher empathy scores, and higher ‘Social responsibility’. Extraversion was linked with higher scores on the “Personal characteristics” and “Interactions with team” categories, while Conscientiousness was also positively associated with “Personal characteristics”. In agreement with previous studies, the personality traits most associated empathy were Agreeableness and Openness to Experience. Empathy did not vary according to programme year or career specialty preference.

Conclusions

This study is the first to show that empathy and personality factors may act as determinants of students’ attitudes towards medical professionalism in a manner which is dependent upon category of professional behaviour.