Empirical research on empathy in medicine-A critical review

Empathy Among Physicians and Nurses in Japan: A Nationwide Cross-sectional Study

BACKGROUND

Empathy with patients improves clinical outcomes. Although previous studies have shown no significant differences in empathy levels between physicians and nurses, investigations have not considered differences in cultural backgrounds and related factors of healthcare providers at the individual level.

OBJECTIVE

This study compares empathy between physicians and nurses in Japan and identifies relevant factors that contribute to these differences.

DESIGN

A cross-sectional survey design was used in the study. The online survey was conducted using the Nikkei Medical Online website.

PARTICIPANTS

A total of 5441 physicians and 965 nurses in Japan who were registered as members of Nikkei Medical Online were included.

MAIN MEASURES

Empathy was measured by the Jefferson Scale of Empathy (JSE).

KEY RESULTS

Cronbach's α was 0.89. The mean JSE score for Japanese physicians was significantly lower at 100.05 (SD = 15.75) than the mean score of 110.63 (SD = 12.25) for nurses (p<0.001). In related factors, higher age (increasing by one year) (+0.29; 95% CI 0.25 to 0.32; p<0.001), self-identified female gender (+5.45; 95% CI 4.40 to 6.49; p<0.001), having children (+1.20; 95% CI 0.30 to 2.10; p=0.009), and working at a hospital with 20-99 beds (+1.73; 95% CI 0.03 to 3.43; p=0.046) were significantly associated with higher scores, whereas those whose mother is a physician (-6.65; 95% CI -8.82 to -4.47; p<0.001) and father is a nurse (-9.53; 95% CI -16.54 to -2.52; p=0.008) or co-medical professional (-3.85; 95% CI -5.49 to -2.21; p<0.001) were significantly associated with lower scores.

CONCLUSIONS

Physicians had significantly lower scores on the JSE than nurses in Japan. Higher age, self-identified female gender, having children, working at a small hospital, having a mother who is a physician, and having a father who is a nurse or co-medical professional were factors associated with the level of empathy.

Lay Perspectives on Empathy in Patient-Physician Communication: An Online Experimental Study

Research indicates that patients consider empathy as a key factor contributing to the quality-of-care. However, ambiguities in the definition of this multidimensional construct complicate definite conclusions to-date. Addressing the challenges in the literature, and using a hypothetical physician-patient interaction which explored patient-perceived differences between expressions of affective empathy, cognitive empathy, compassion and no empathy, this study aimed to test whether lay participants' evaluations of the quality-of-care depend on the type of empathic physician behavior, and on the physician's gender. We conducted a randomized web-based experiment using a 4 (type of empathy) by 2 (physician gender) between-subjects design. Empathy was subdivided into three concepts: first, affective empathy (i.e. feeling with someone); second, cognitive empathy (i.e. understanding); and third, compassion (i.e. feeling for someone and offering support). Perceived quality-of-care was the primary outcome. Compared with non-empathic interactions, quality-of-care was rated higher when physicians reacted cognitively empathic or compassionate (d = 0.71; 0.43 to 1.00 and d = 0.68; 0.38 to 0.98). No significant difference was found between affective empathy and no empathy (d = 0.13; -0.14 to 0.42). The physician's gender was not related with quality-of-care. Aspects of participants' personality but not their age, gender or the number of physician visits were associated with quality-of-care. No interactions were observed. In showing that patients rated quality-of-care higher when physician reactions were described as cognitively empathic and compassionate, as compared with affectively empathic or non-empathic, our findings refine views about the kinds of empathy that are important in patient care with implications for clinical practice, education and communication trainings.

Physician Empathy and Chronic Pain Outcomes

Importance

Empathy is an aspect of the patient-physician relationship that may be particularly important in patients with chronic pain.

Objective

To measure the association of physician empathy with pain, function, and health-related quality of life (HRQOL) among patients with chronic low back pain.

Design, Setting, and Participants

This cohort study included adult enrollees from the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation national pain research registry. Study dates were from April 1, 2016, to July 25, 2023, with up to 12 months of follow-up.

Exposure

Physician empathy was assessed with the Consultation and Relational Empathy measure and dichotomized to yield very empathic physician and slightly empathic physician groups.

Main Outcomes and Measures

Main outcomes were patient-reported pain, function, and HRQOL measured with a numerical rating scale for low back pain intensity, the Roland-Morris Disability Questionnaire for back-related disability, and the Patient-Reported Outcomes Measurement Information System for HRQOL deficits pertaining to anxiety, depression, fatigue, sleep disturbance, and pain interference. Data were collected at 5 quarterly encounters from registry enrollment through 12 months and analyzed with generalized estimating equations, including multivariable models to measure temporal trends and to adjust for baseline and longitudinal covariates.

Results

Among the 1470 patients, the mean (SD) age was 53.1 (13.2) years, and 1093 (74.4%) were female. Patients completed 5943 encounters in which multivariable analyses demonstrated that greater physician empathy was inversely associated with pain intensity (β = -0.014; 95% CI, -0.022 to -0.006; P < .001), back-related disability (β = -0.062; 95% CI, -0.085 to -0.040; P < .001), and HRQOL deficits on each measure (eg, pain interference: β = -0.080; 95% CI, -0.111 to -0.049; P < .001). Correspondingly, compared with the slightly empathic physician group, the very empathic physician group reported lower mean pain intensity (6.3; 95% CI, 6.1-6.5 vs 6.7; 95% CI, 6.5-6.9; P < .001), less mean back-related disability (14.9; 95% CI, 14.2-15.6 vs 16.8; 95% CI, 16.0-17.6; P < .001), and fewer HRQOL deficits on each measure (eg, fatigue: 57.3; 95% CI, 56.1-58.5 vs 60.4; 95% CI, 59.0-61.7; P < .001). All physician empathy group differences were clinically relevant, with Cohen d statistics ranging from 0.21 for pain intensity to 0.30 for back-related disability, fatigue, and pain interference. Physician empathy was associated with more favorable outcomes than non-pharmacological treatments, opioid therapy, and lumbar spine surgery.

Conclusions and Relevance

In this cohort study of adult patients with chronic pain, physician empathy was associated with better outcomes over 12 months. Greater efforts to cultivate and improve physician empathy appear warranted.

A scoping review of empathy recognition in text using natural language processing

OBJECTIVE

To provide a scoping review of studies on empathy recognition in text using natural language processing (NLP) that can inform an approach to identifying physician empathic communication over patient portal messages.

MATERIALS AND METHODS

We searched 6 databases to identify relevant studies published through May 1, 2023. The study selection was conducted through a title screening, an abstract review, and a full-text review. Our process followed the PRISMA-ScR guidelines.

RESULTS

Of the 2446 publications identified from our searches, 39 studies were selected for the final review, which summarized: (1) definitions and context of empathy, (2) data sources and tested models, and (3) model performance. Definitions of empathy varied in their specificity to the context and setting of the study. The most common settings in which empathy was studied were reactions to news stories, health-related social media forums, and counseling sessions. We also observed an expected shift in methods used that coincided with the introduction of transformer-based models.

DISCUSSION

Aspects of the current approaches taken across various domains may be translatable to communication over a patient portal. However, the specific barriers to identifying empathic communication in this context are unclear. While modern NLP methods appear to be able to handle empathy-related tasks, challenges remain in precisely defining and measuring empathy in text.

CONCLUSION

Existing work that has attempted to measure empathy in text using NLP provides a useful basis for future studies of patient-physician asynchronous communication, but consideration for the conceptualization of empathy is needed.

On the proliferation of the empathy concept in healthcare and medical education research

OBJECTIVE

To offer a critique of empathy concept usage in healthcare and medical education research.

METHODS

Analysis of current usage and suggestions for authors and researchers.

RESULTS

Empathy is often undefined or inconsistently defined, and "empathy" as represented in research covers an unmanageably wide and varied range of intentions, attitudes, emotions, and behaviors. The ubiquitous use of "empathy" as a vague and often undefined umbrella term hinders comprehension and, therefore, scientific progress. Patients are rarely asked directly about empathy; instead, measures of so-called perceived empathy contain descriptive items that could as well be called quality of care, patient-centeredness, or patient satisfaction.

CONCLUSIONS

Although "empathy" in medical care is widely valued by researchers, educators, and practitioners, the empathy concept as used in the published literature is overused and unclear, and potentially damaging to scholarship, medical education, and ultimately healthcare. The vague term empathy should be replaced as much as possible with concrete descriptions of what is actually measured, experimentally manipulated, or taught.

PRACTICE IMPLICATIONS

Identifying patients' own empathy definitions will improve medical education and medical care through clarifying what clinical behaviors will best fulfill patients' needs and desires. This approach allows for greater specificity and personalized care delivery.

Impact of a longitudinal course on medical professionalism on the empathy of medical students

OBJECTIVE

Medical education should enhance empathy. We examined, using self-assessment instruments and standardized patients (SPs), the impact on empathy, of a multi-year intervention (years 4-6 of medical training) that uses reflective learning approaches.

METHODS

241 final-year medical students participated; 110 from the 2018 graduation class (non-intervention group) and 131 from the 2019 graduation class (intervention group). Participants completed two self-reported empathy questionnaires - the Jefferson Scale of Empathy-Students (JSE-S) and the Interpersonal Reactivity Index (IRI) - and a personality questionnaire, the NEO Five-Factor Inventory. Additionally, SPs in a simulated station assessed participants' empathy with two patient-reported instruments: the Consultation and Relational Empathy (CARE) scale and the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE).

RESULTS

Empathy scores were significantly higher in the intervention group compared to the non-intervention group when assessed by the SP (p < 0.001). No differences were found in self-reported questionnaires between the two groups.

CONCLUSION

A longitudinal, multi-year reflection-based intervention enhanced empathy amongst medical students as assessed by SPs, but not when assessed by student self-reported measures.

PRACTICE IMPLICATIONS

Multi-year reflective learning interventions during clinical training nurture empathy in medical students. Assessments completed by SPs or patients may enhance the evaluation of empathy.

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.

Narrative medicine workshops for emergency medicine residents: Effects on empathy and burnout

Background

Emergency medicine (EM) residents face unique affective challenges and barriers to interpersonal connection in their clinical environment which may contribute to decreased empathy and increased burnout. Narrative medicine (NM) might address these barriers and has had beneficial impacts in various populations but has never been studied in EM residents. In this study, we sought to evaluate the effect of NM workshops on burnout and empathy and to assess resident perceptions of the workshops.

Methods

We performed a quasi-experimental study at two EM residencies from June to October 2020. Residents at the intervention site participated in two NM workshops led by EM faculty that were composed of a close reading of a literary text, reflective writing, and group discussion. Residents were asked to complete the abbreviated Interpersonal Reactivity Index (IRI) and a single-item burnout measure pre- and postintervention. We fitted linear regression models to IRI subscores; we treated burnout as an ordinal variable and fitted a conditional logistic regression model. Residents completed a postintervention survey that we analyzed using summary statistics.

Results

A total of 46.7% of control (28/60) and 100% of intervention (48/48) residents responded (n = 76). While all respondents demonstrated worsening burnout with time (p = 0.001), residents at the intervention site exhibited less severe increases (interaction p < 0.001). Empathy remained unchanged. A total of 50% of intervention residents (24/48) responded to the postintervention survey; most (n = 20, 83.3%) agreed that the workshops should be a standard part of EM didactics.

Conclusions

These findings establish the feasibility and desirability of NM in residency education and offers a model for EM-centered narrative workshops. Additionally, while our outcomes are limited, we found that exposure to an NM curriculum may be protective against worsening burnout.

Clients' and genetic counselors' perceptions of empathy in Japan: A pilot study of simulated consultations of genetic counseling

The rapidly increasing availability of genetic testing is driving the acceleration of genetic counseling implementation. Empathy is important in medical encounters in general and forms a core component of a successful genetic counseling session; however, empirical evidence on empathy in genetic counseling is minimal. This study aimed to explore the perceptions of empathy in simulated genetic counseling consultations from the perspectives of clients and genetic counselors. Semi-structured interviews and interpersonal process recall were used with participants of simulated genetic counseling consultations to elicit their experiences of empathy. A constructivist grounded theory was used for data analysis. A total of 15 participants, including 10 clients and 5 genetic counselors, participated in 10 simulated counseling sessions. The genetic counselors attempted to demonstrate empathy and were sensitive toward detecting changes in clients. Meanwhile, the clients' perceptions represented their feelings and thoughts elicited through the counselors' empathic approaches. This was the first process study to examine empathy in simulated genetic counseling sessions. Our model of communication of empathy is a process in which counselors try to address implicit aspects of clients, and clients are provided with time and a safe place for introspection, which contributes to discussions on building good relationships with patients. There is also a suggestion of the utility of simulated consultations for healthcare providers to learn empathic communication.

Empathy Expression in Interpreted and Noninterpreted Care Conferences of Seriously Ill Children

BACKGROUND AND OBJECTIVES

Clinician empathy is associated with improved communication and clinical outcomes. We hypothesized that, when clinicians express empathy, families are more likely to deepen discussions, and that clinicians express less empathy in care conferences with language interpretation.

METHODS

Prospective, mixed methods cohort study of English and interpreted audio-recorded transcripts of care conferences for pediatric patients with serious illness hospitalized at a single urban, quaternary medical institution between January 2018 and January 2021. Directed content analysis identified empathic opportunities, clinician empathetic statements or missed opportunities, and family responses. Clinician empathic statements were "buried" if immediately followed by more clinician medical talk. Descriptive analyses summarized demographics and codes. χ2 analyses summarized differences among language interpretation and family responses.

RESULTS

Twenty-nine patient-family dyads participated. Twenty-two (81%) family members were female. Eleven (39%) used language interpretation (8 Spanish, 2 Vietnamese, 1 Somali). Families created 210 empathic opportunities. Clinicians responded with unburied empathy 80 times (38%, no differences for English versus interpreted care conferences, P = .88). When clinicians buried empathy or missed empathic opportunities, families responded with alliance (agreement, gratitude, or emotional deepening) 14% and 15% of the time, respectively. When clinicians responded with unburied empathy, families responded with alliance 83% of the time (P < .01).

CONCLUSIONS

Our study suggests that clinician empathic expression does not differ when language interpretation is used in pediatric care conferences. Clinicians often miss opportunities to express empathy, or they bury it by medical talk. Although unburied empathy created opportunities for relationship-building and family-sharing, buried empathy negatively impacted these domains similarly to no empathic expression.

Reconstructing the concept of empathy: an analysis of Japanese doctors' narratives of their experiences with illness

The ability of doctors to empathise with patients is a crucial concern in establishing humanistic medicine. Therefore, the cultivation of this ability has been discussed extensively in medical education. One theory suggests that the experience of patienthood can increase empathy among doctors. This theory is supported by previous research that published doctors' illness narratives. However, the concept of empathy has been ambiguously defined in academic fields, including medicine; therefore, analysing how doctors experience 'empathy' in their interactions with patients is difficult. Our research question is how doctors who became patients describe the relationship between their illness experiences and the interactions with patients after their illness. To this end, this paper initially tracks the debates on 'empathy' in medicine and other disciplines, to develop a lens for analysing doctors' illness narratives. Next, we conduct a narrative analysis of illness stories from 18 Japanese medical doctors who became patients. Our analysis supports the traditional idea that an illness can enable a doctor to become more empathetic. However, this is overly simplistic; how doctors experience and subsequently process their illness is more complex. Moreover, this notion can disregard doctors' suffering in these circumstances, and fail to represent the often-lengthy process of mastering 'empathy' based on their experiences. Therefore, our analysis deconstructed the concept of 'empathy', showing that it can appear in various ways. Further research is required to elucidate how empathy is cultivated during the process of transformation of doctors' illnesses, focusing on their communities and practices.

Physician empathy in Korean clinical contexts: developing a conceptual framework and exploring influencing factors

PURPOSE

Despite its well-known clinical importance, physician empathy (PE) has been variably defined and its concepts among cultures are yet to be studied. This study aimed to develop a conceptual framework of PE and explore influencing factors on physicians' empathetic behavior in the Korean clinical context.

METHODS

Forty-two faculty members and 67 residents participated in the two-round Delphi survey to arrive at a consensus regarding the conceptual framework of PE in 2019. To explore individual and external factors affecting physicians' empathetic behavior, a Likert scale questionnaire based on an initial free-text response was administered to the same participants.

RESULTS

The conceptual framework of PE among Korean doctors consisted of basic communication skills and attitudes, cognitively understanding of patients' thoughts and emotions, and communicating the doctors' understandings to patients. Individual attributes and system- and patient-factors were revealed as influencing factors for PE in real practice. The former included communication ability, self-awareness and management, humanism, clinical competence, and good personality traits. Excessive workload, time constraints, aggressive attitudes, and negative preconceptions towards doctors were perceived as inhibiting or hindering empathy in patient care.

CONCLUSION

PE in the Korean clinical context comprised behavioral and cognitive components. Individual attributes, as well as external factors including system- and patient-factors were identified to affect PE in clinical settings. Further studies are needed to enhance the conceptual clarity of PE and identify how to promote doctors' empathetic practice even in less favorable healthcare environments.

Communication skills training for improving the communicative abilities of student social workers

Background

Good communication is central to effective social work practice, helping to develop constructive working relationships and improve the outcomes of people in receipt of social work services. There is strong consensus that the teaching and learning of communication skills for social work students is an essential component of social work qualifying courses. However, the variation in communication skills training and its components is significant. There is a sizeable body of evidence relating to communication skills training therefore a review of the findings helps to clarify what we know about this important topic in social work education. We conducted this systematic review to determine whether communication skills training for social work students works and which types of communication skills training, if any, were more effective and lead to the most positive outcomes.

Objectives

This systematic review aimed to critically evaluate all studies which have investigated the effectiveness of communication skills training programmes for social work students. The research question which the review posed is: 'What is the effectiveness of communication skills training for improving the communicative abilities of social work students?' It was intended that the review would provide a robust evaluation of communication skills training for social work students and help explain variations in practice to support educators and policy-makers to make evidence-based decisions in social work education, practice and policy.

Search Methods

We conducted a search for published and unpublished studies using a comprehensive search strategy that included multiple electronic databases, research registers, grey literature sources, and reference lists of prior reviews and relevant studies.

Selection Criteria

Study selection was based on the following characteristics: Participants were social work students on generic (as opposed to client specific) qualifying courses; Interventions included any form of communication skills training; eligible studies were required to have an appropriate comparator such as no intervention or an alternative intervention; and outcomes included changes in knowledge, attitudes, skills and behaviours. Study selection was not restricted by geography, language, publication date or publication type.

Data Collection and Analysis

The search strategy was developed using the terms featuring in existing knowledge and practice reviews and in consultation with social work researchers, academics and the review advisory panel, to ensure that a broad range of terminology was included. One reviewer conducted the database searches, removing duplicates and irrelevant records, after which each record was screened by title and abstract by both reviewers to ensure robustness. Any studies deemed to be potentially eligible were retrieved in full text and screened by both reviewers.

Main Results

Fifteen studies met the inclusion criteria. Overall, findings indicate that communication skills training including empathy can be learnt, and that the systematic training of social work students results in some identifiable improvements in their communication skills. However, the evidence is dated, methodological rigour is weak, risk of bias is moderate to high/serious or incomplete, and extreme heterogeneity exists between the primary studies and the interventions they evaluated. As a result, data from the included studies were incomplete, inconsistent, and lacked validity, limiting the findings of this review, whilst identifying that further research is required.

Authors’ Conclusions

This review aimed to examine effects of communication skills training on a range of outcomes in social work education. With the exception of skill acquisition, there was insufficient evidence available to offer firm conclusions on other outcomes. For social work educators, our understanding of how communication skills and empathy are taught and learnt remain limited, due to a lack of empirical research and comprehensive discussion. Despite the limitations and variations in educational culture, the findings are still useful, and suggest that communication skills training is likely to be beneficial. One important implication for practice appears to be that the teaching and learning of communication skills in social work education should provide opportunities for students to practice skills in a simulated (or real) environment. For researchers, it is clear that further rigorous research is required. This should include using validated research measures, using research designs which include appropriate counterfactuals, alongside more careful and consistent reporting. The development of the theoretical underpinnings of the interventions used for the teaching and learning of communication skills in social work education is another area that researchers should address.

Empathy is not so perfect! -For a descriptive and wide conception of empathy

Physician empathy is considered essential for good clinical care. Empirical evidence shows that it correlates with better patient satisfaction, compliance, and clinical outcomes. These data have nevertheless been criticized because of a lack of consistency and reliability. In this paper, we claim that these issues partly stem from the widespread idealization of empathy: we mistakenly assume that physician empathy always contributes to good care. This has prevented us from agreeing on a definition of empathy, from understanding the effects of its different components and from exploring its limits. This is problematic because physicians' ignorance of the risks of empathy and of strategies to manage them can impact their work and wellbeing negatively. To address this problem, we explore the effects of the potential components of empathy and argue that it should be conceived as a purely descriptive and wide term. We end by discussing implications for medical education.

A Pan-Canadian Perspective on Education and Training Priorities for Physiotherapists. Part 2: Professional Interactions and Context of Practice

Purpose: Canadian physiotherapists who participated in the Physio Moves Canada (PMC) project of 2017 identified the state of training programmes as a threat facing professional growth of the discipline. One purpose of the project was to identify priority areas for physiotherapist training programmes as identified by academics and clinicians across Canada. Method: The PMC project included a series of interviews and focus groups conducted across clinical sites in every Canadian province and in Yukon Territory. Data were interpreted using descriptive thematic analysis; identified sub-themes were returned to participants for reflection. Results: Overall, 116 physiotherapists and 1 physiotherapy assistant participated in 10 focus groups and 26 semi-structured interviews. Results are presented using the curriculum guidelines of the time for organization. Here we describe two themes: Physiotherapy Professional Interactions, further defined by interpersonal and interprofessional competencies, and Context of Practice further defined by advocacy, leadership, community awareness, and business competencies. Conclusions: Participants appear to express a desire for programmes to train reflexive and adaptable primary health care practitioners with strong foundational knowledge and clinical expertise, complemented by interpersonal and interprofessional skills to empower physiotherapists to effectively care and advocate for patients, to lead health care teams, and to share ideas to inspire change towards a future of physiotherapy practice.

Empathy as a silent art-A doctor´s daily balancing act: A qualitative study of senior doctors' experiences of empathy

Empathy in the doctor-patient relationship is of great importance and has long been considered a true professional virtue for doctors. Despite the general agreement concerning the importance of empathy, there is no consensus regarding the definition of empathy in medical research. While several quantitative studies, measuring empathy as an individual trait, show a decline in empathy among medical students, other studies have shown that empathy is influenced by contextual factors as well as the availability of role models. Therefore, further studies about the transition from medical school to clinical work also including the perspective of senior doctors are needed. The study presented in this article aims to better understand the clinical conditions for empathy through interviews with senior doctors about their lived experience of empathy. Twelve senior doctors, from different specialities were interviewed using a semi-structured approach. The data was analysed using content analysis. The analysis resulted in the main theme: Empathy as a silent art-a doctor`s daily balancing act. This main theme comprised three categories: "A tacit, yet language-dependent process", "A daily balancing act" and "An unsupported path towards mastery". Doctors face many challenges in their daily balancing act between individual and structural conditions that may affect empathy. In order to maintain and further develop empathy, doctors need working conditions allowing for collegial reflection and conversations that promote empathy.

Evaluation of pharmacy student empathy scores before and after a geriatrics advanced pharmacy practice experience (APPE)

INTRODUCTION

Empathy from healthcare providers is associated with improved patient care and satisfaction, resulting in increased emphasis on empathy in pharmacy school curricula. Previous studies showed improvement in pharmacy student empathy after older adult-specific simulation activities in the didactic setting, but no such data exist for the practice environment. This study's purpose was to evaluate the impact of a geriatrics advanced pharmacy practice experience (APPE) on pharmacy student empathy toward older adults.

METHODS

All fourth-year pharmacy students in a geriatrics APPE at one of four participating sites were offered to participate in the study at the beginning of the rotation. Empathy was measured at baseline and end of the rotation using the Kiersma-Chen Empathy Scale (KCES). Wilcoxon matched-pairs signed-ranks test was used to test differences from pre- to post-rotation.

RESULTS

Fifty-four of the 110 eligible students opted to participate in the study, and 46 completed both the pre- and post-surveys. Most students were female (55.6%), and the average age was 27.3 years. Mean empathy scores for all students increased significantly by 4.89 points (z = 4.17, P < .001, d = 0.97). Specific KCES items related to handling other's feelings and viewing another person's perspective also significantly improved.

CONCLUSIONS

Empathy is a key component to professional development in healthcare students, and a geriatrics APPE provides an opportunity for students to grow this soft skill. Although further study is warranted, older adult focused rotations may be considered by schools of pharmacy to aid in preparing "graduate-ready" pharmacists.

Understanding of empathetic communication in acute hospital settings: a scoping review

OBJECTIVE

Empathy and empathy education have been reviewed a number of times through systematic reviews and meta-analyses; however, the topic of 'empathetic communication' remains poorly understood when considering engaging in hospital-based research. Therefore, this scoping review aimed to explore the existing literature concerning empathetic communication in hospital settings and to evaluate the definitions presented.

DESIGN

Scoping review.

DATA SOURCES

Systematic searches of the PubMed, CINAHL, Cochrane, PsycINFO, and PsycArticles databases were conducted.

STUDY SELECTION

All English studies in which empathetic communication in hospital settings were explored. The search terms used included empathy, communication, hospital settings, providers, and consumers.

DATA EXTRACTION

Data were assessed through the use of a pre-set analysis tool.

RESULTS

After conducting the searches, 419 articles were identified, of which 26 were included in this review. No single article specifically defined the term 'empathetic communication'; however, 33 unique definitions of 'empathy' were identified, of which 23 considered communication to be a component of empathy. There was a considerable lack of consistency between the empathy definitions, with some classifying communication in empathy as an ability and others classifying it as a dynamic process.

CONCLUSION

Future and contextually focused research is needed to develop a consistent and clear definition of empathetic communication and empathy within a hospital setting to better build positive healthcare cultures.

PRACTICE IMPLICATIONS

Inconsistencies between definitions of empathy in empathetic communication research could reduce the efficacy of future research gains and impact the translation of research findings into clinical practice.

Consistency Analysis in Medical Empathy Intervention Research

Various studies have examined the effectiveness of interventions to increase empathy in medical professionals. However, inconsistencies may exist in the definitions, interventions, and assessments of empathy. Inconsistencies jeopardize the internal validity and generalization of the research findings. The main purpose of this study was to examine the internal consistency among the definitions, interventions, and assessments of empathy in medical empathy intervention studies. We also examined the interventions and assessments in terms of the knowledge-attitude-behavior aspects. We conducted a literature search for medical empathy intervention studies with a design of randomized controlled trials and categorized each study according to the dimensions of empathy and knowledge-attitude-behavior aspects. The consistencies among the definitions, interventions, and assessments were calculated. A total of 13 studies were included in this study. No studies were fully consistent in their definitions, interventions, and assessments of empathy. Only four studies were partially consistent. In terms of knowledge-attitude-behavior aspects, four studies were fully consistent, two studies were partially consistent, and seven studies were inconsistent. Most medical empathy intervention studies are inconsistent in their definitions, interventions, and assessments of empathy, as well as the knowledge-attitude-behavior aspects between interventions and assessments. These inconsistencies may have affected the internal validity and generalization of the research results.

Physicians, emotion, and the clinical encounter: A survey of physicians' experiences

OBJECTIVES

Training in emotion management is not a standard part of medical education. This study's objective was to understand physicians' challenges navigating emotion (their own and their patients') and identify areas for intervention to support physician wellness and enhance patient care.

METHODS

In 2019, we surveyed 103 physicians in emergency medicine, internal medicine, family medicine, and neurology. Participants quantitatively reported emotion training, emotions that were challenging, and barriers to addressing emotion. They provided qualitative examples of emotion challenges and successes that we analyzed using an inductive thematic analysis.

RESULTS

There were no significant differences in responses by specialty. Only 10% reported receiving emotion management training, with no evidence that more recently trained physicians received more. Those who had received training on emotion reported greater comfort in dealing with patients' emotions and were more likely to engage in teaching on emotion. There were gender and career stage differences regarding which emotions physicians found most challenging. The authors identified central themes of emotion-related challenges and successes.

CONCLUSIONS

Targeted educational initiatives are needed to advance physicians' ability to navigate emotion in clinical encounters.

PRACTICE IMPLICATIONS

Developing strategies for managing patients' emotions may better prepare physicians for navigating the emotional demands of practicing medicine.

Optimising planned medical education strategies to develop learners' person-centredness: A realist review

CONTEXT

Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful.

METHODS

A realist review was conducted with a search of Medline, Embase, HMIC and ERIC databases and the grey literature using the terms 'medical education' and 'person-centred' and related synonyms. Studies that involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focused on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness.

RESULTS

Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome configuration (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focused on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness.

CONCLUSION

Our findings offer explanations as to why communication skills-based interventions may be insufficient to develop learners' person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policymakers testable theory to inform the development of medical education strategies that aim to support person-centredness.

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.

Medical students' experiences when empathizing with patients' emotional issues during a medical interview - a qualitative study

BACKGROUND

There is evidence that empathy decreases as medical students go through clinical training. However, there are few in-depth studies investigating the students' own experiences when trying to empathize in concrete clinical encounters. We therefore wanted to explore medical students' perceptions, experiences, and reflections when empathizing with patients expressing emotional issues.

METHODS

A qualitative content analysis of semi-structured interviews with third year medical students (N = 11) was conducted using video-stimulated recall from their own medical interview with a simulated chronically ill patient. Students were led to believe that the patient was real.

RESULTS

Five themes which may influence student empathy during history-taking were identified through analysis of interview data: (1) Giving priority to medical history taking, (2) Interpreting the patient's worry as lack of medical information, (3) Conflict between perspectives, (4) Technical communication skill rather than authentic and heart-felt and (5) The distant professional role.

CONCLUSIONS

The participating students described conflicts between a medical agenda, rules and norms for professional conduct and the students' own judgments when trying to empathize with the patient. To our knowledge, this is the first study ever to document the students' own perspective in concrete situations as well as how these reported experiences and reflections affect their empathy towards patients. Since we now know more about what is likely to hinder medical students' empathy, educators should actively encourage group reflection and discussion in order to avoid these negative effects of history taking both inside and outside of the clinical setting.

The Intricate Relationship Between Client Perceptions of Physician Empathy and Physician Self-Assessment: Lessons for Reforming Clinical Practice

Objectives: Clinical empathy is an important predictor of patient outcomes. Several factors affect physician’s empathy and client perceptions. We aimed to assess the association between physician and client perception of clinical empathy, accounting for client, physician, and health system factors. Methods: We conducted a hospital-based cross-sectional study in 3 departments (family medicine, internal medicine, and surgery) of King Saud Medical City in Riyadh, Saudi Arabia. We interviewed 30 physicians and 390 clients from 3 departments. Physicians completed the Jefferson Scale of Empathy (JSE) and the clients responded to the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). We used a hierarchical multilevel generalized structural equation approach to model factors associated with JSE and JSPPPE and their inter-relationship. Results: Mean (SD) score of client-rated physician empathy was 26.6 (6) and that of physician self-rated was 111 (12.8). We found no association between the 2 (b  =  0.06; 95% confidence intervals CI: −0.1, 0.21), even after adjusting for client, physician, and health system factors. Physician's nationality (0.49; 0.12, 0.85), adequate consultation time (1.05; 0.72, 1.38), and trust (1.33; 0.9, 1.75) were positively associated whereas chronic disease (−0.32; −0.56, −0.07) and higher waiting times (−0.26; −0.47, −0.05) were negatively associated. Conclusion: A physician's self-assessed empathy does not correlate with clients’ perception. We recommend training and monitoring to enhance clinical empathy.

Empathetic, persistent and female: A snapshot of oral health therapy students in Australia and New Zealand

INTRODUCTION

Dental therapists, hygienists and oral health therapists constitute up to a third of the dental workforce in Australia and New Zealand. Personality is often explored in health professions to provide insights into traits that are conducive to workforce retention and to assist in planning and training. This study aimed to investigate the current demographic and personality characteristics of oral health students in Australia and New Zealand.

MATERIALS AND METHODS

Students in years one to three of all eight undergraduate Bachelor of Oral Health programs in Australia and New Zealand were invited to complete an online survey. The survey measured activities prior to entering into oral health, career intentions and included a personality questionnaire, the Temperament and Character Inventory (TCI).

RESULTS

Three quarters of participants (n = 336; 30% response rate; females = 90%) were single, from an urban area and 20-29 years of age. Oral health students overall portrayed high trait levels of Persistence and Cooperativeness. Cluster analysis of TCI traits identified three groups. Groups of students with high Persistence and Cooperativeness tended to be older, were working in non-dental and dental careers prior to their degree and were interested in working in regional areas after graduation.

CONCLUSIONS

Students with high levels of persistence and cooperativeness were interested in working in regional areas after graduation, highlighting the importance of industriousness and persistence in overcoming barriers to practicing in regional areas. Further research is warranted to investigate barriers and enablers in recruitment and retention of males in a primarily female dominated profession.

Empathic Validation in Physician-Patient Communication: An Approach to Conveying Empathy for Problems With Uncertain Solutions

Interest in systematic approaches to improving clinical empathy has increased. However, conceptualizations of empathy are inconsistent and difficult to operationalize. Drawing on video recordings of primary care visits with older adults, I describe one particular communication strategy for conveying empathy-empathic validation. Using conversation analysis, I show that the design of empathic validations and the context in which they are delivered are critical to positive patient responses. Effective empathic validations must (a) demonstrate shared understanding and (b) support the patient's position. Physicians provided empathic validation when there was no medical solution to offer and within this context, for three purposes: (1) normalizing changes in health, (2) acknowledging individual difficulty, and (3) recognizing actions or choices. Empathic validation is a useful approach because it does not rely on patients' ability to create an "empathic opportunity" and has particular relevance for older adults.

The relationship between medical students' empathy and burnout levels by gender and study years

OBJECTIVE

To investigate the multifaceted factors affecting empathy in medical students.

METHODS

1293 medical students from 15 South Korean medical schools participated in an online survey. Affective empathy was measured with the 'empathy concern' and 'personal distress' dimensions from the Interpersonal Reactivity Index for Medical Students (IRI-MS). Cognitive empathy was assessed with IRI-MS' 'perspective taking' and Jefferson Scales for Physician Empathy for Student (JSPE-S). Maslach Burnout Inventory for Medical Students (MBI-MS) assessed the burnout levels of the participants.

RESULTS

A significant gender difference in affective and cognitive empathy was found using JSPE-S. Different patterns were seen in the empathy dimensions between the study years and genders. Burnout scores showed no gender differences, while exhaustion and cynicism increased, and academic efficacy decreased with seniority. Academic efficacy was a consistently influential factor for both affective and cognitive empathy in both genders, all study years and the three domains of burnout.

CONCLUSION

Academic efficacy was a significant factor influencing both affective and cognitive empathy.

PRACTICAL IMPLICATIONS

The comprehensive nature of empathy in medical students may be better investigated by applying multi-dimensional empathy measurement tools and by analyzing multiple factors such as gender, study year and burnout.

Empathy, an important but problematic concept

The concept of empathy as it is used in scholarly discourse has been challenged for over 50 years, yet the same ambiguities and controversies associated with the concept persist and, indeed, have accelerated with the accumulation of definitions, subconstructs that are included under the empathy umbrella, and measuring instruments. In this article we address the following interrelated problems: many definitions, authors not offering definitions, authors using instruments that do not match their definitions, authors not specifying definitions and measurements in cited studies, the jingle-jangle problem, and the persistent need for more construct validity research. In this Special Issue on empathy and its problems, authors bring new theoretical insights, creative research designs, and a critical focus on the empathy concept itself.

Challenging the clinically-situated emotion-deficient version of empathy within medicine and medical education research

In this paper, we argue that the notion of a clinically-situated empathy (e.g. physician empathy), is potentially problematic as it perpetuates an emotion-deficient version of empathy within medicine and medicine education research. Utilizing classic and contemporary empathy theory from various social science disciplines, we discuss how empathy in the general sense differs conceptually from clinically-situated empathy-paying particular attention to the role of emotional contagion. To highlight this contrast, we draw upon Hojat et al.'s model of physician empathy and how this body of work reflects broader medical-cultural norms that problematize the role and impact of emotions within the clinical encounter. Alternatively, we present a more encompassing model of empathy drawing upon the fields of social-psychology and social-neuroscience in order to bring the notion of "feeling with" and emotional contagion more specifically, into medical education, medical education research, and medicine more generally.

Medical students' expressions of empathy: A qualitative study of verbal interactions with patients expressing emotional issues in a medical interview

OBJECTIVE

Explore medical students' verbal responses to patients expressing emotional issues in a medical interview.

METHODS

Eleven third-year students were instructed to conduct a medical interview with a simulated chronically ill patient while being videotaped (but were led to believe that the patient was real). An interaction analysis system (VR-CoDES) was used to identify patient utterances containing emotional expressions as well as student utterances responding to these emotional expressions. A qualitative content analysis of student utterances was then conducted.

RESULTS

Four categories that depicted student responses were identified: (1) questions focusing on a medico-professional agenda, (2) allowing disclosure of emotions without explicit acknowledgment of emotions, (3) attempts at reassurance, and (4) explicit recognition of emotions, but most often on a factual and descriptive level.

CONCLUSIONS

Our analysis indicate that these students gave priority to medico-professional tasks and responsibilities in their responses. They demonstrated some interest in the patient's emotional experiences whilst most often leaving out their own personal perspectives.

PRACTICE IMPLICATIONS

Communication skills curricula should address how the medical interview affects empathy and interaction with patients and encourage discussion and reflection on how to retrieve medical information while paying adequate attention to the patient's and own emotions, experiences, and perspectives.

Empathy in Medical Education: Its Nature and Nurture - a Qualitative Study of the Views of Students and Tutors

CONTEXT

Medical education is committed to teaching patient centred communication and empathy. However, quantitative research suggests empathy scores tend to decline as students progress through medical school. In qualitative terms, there is a need to better understand how students and tutors view the practice and teaching of clinical empathy and the phenomenon of empathic erosion.

METHODS

Working within a constructivist paradigm, researchers thematically analysed the individual interview data from a purposive sample of 13 senior students and 9 tutors.

RESULTS

The four major themes were as follows: (1) 'the nature of empathy', including the concept of the innate empathy that students already possess at the beginning of medical school; (2) 'beyond the formal curriculum' and the central importance of role modelling; (3) 'the formal curriculum and the tick-box influence of assessments'; and (4) the 'durability of empathy', including ethical erosion and resilience. A garden model of empathy development is proposed - beginning with the innate seeds of empathy that students bring to medical school, the flowering of empathy is a fragile process, subject to both enablers and barriers in the formal, informal, and hidden curricula.

CONCLUSION

This study provides insights into empathic erosion in medical school, including the problems of negative role modelling and the limitations of an assessment system that rewards 'tick-box' representations of empathy, rather than true acts of compassion. It also identifies factors that should enable the flowering of empathy, such as new pedagogical approaches to resilience and a role for the arts and humanities.

What is your empathy scale not measuring? The convergent, discriminant, and predictive validity of five empathy scales

Recent reviews of the emapthy literature have revealed that nearly half of the published studies on empathy employed an empathy measure that did not align precisely with the theoretical definition the author provided. This may occur because researchers might not know what each published empathy scale actually measures. The present research begins to address this problem by reporting a large set of correlates for five different empathy scales to enable researchers to review the interpersonal traits and abilities each scale predicted. Participants (N = 182) completed the Davis IRI and the empirically derived Hogan Empathy Scale (HES). Each empathy scale produced its own unique pattern of correlates with empathy related traits that more or less supported each scale's description. However, none of the five scales reliably predicted empathy related abilities. We discuss the importance of examining a scale's predictive validity over its reliability, face-validity, popularity, or name.

Physician empathy according to physicians: A multi-specialty qualitative analysis

OBJECTIVES

To explore how physicians in neurology, family medicine, internal medicine, and emergency medicine characterize clinical empathy.

METHODS

Physicians (N = 94) were asked to describe up to 10 examples of empathic physician behavior. Data were analyzed using template analysis.

RESULTS

Physicians' descriptions of clinical empathy patterned into three themes: Clinical Performance and Professionalism, Interpersonal Communication, and Clinician Orientation. Clinical Performance and Professionalism subthemes included physician competency and accessibility; intersection with institutional resources; and spending/making/taking time with patients. Interpersonal Communication subthemes involved information sharing; verbal and nonverbal approaches; interpersonal sensitivity; physician self-disclosure; and attention to emotion. Clinician Orientation encompassed general physician demeanor and internal thoughts and feelings that might be unobservable by patients. Physicians varied widely in the themes they mentioned in their definition of empathy.

CONCLUSION

Physicians hold diverse notions of clinical empathy. These extend beyond traditional affective and cognitive empathy definitions to include structural elements like team-based care and accessibility after hours. Communication behaviors were perceived as important for demonstrating empathy. Some physician descriptions of empathy may not be perceptible to patients.

PRACTICE IMPLICATIONS

Training physicians to engage in behaviors that both they and patients perceive as empathic may lead to higher patient and physician satisfaction.

Differences in empathy toward patients between medical and nonmedical students: an fMRI study

There is growing concern about a potential decline in empathy among medical students over time. Despite the importance of empathy toward patients in medicine, it remains unclear the nature of the changes in empathy among medical students. Thus, we systematically investigated affective and cognitive empathy for patients among medical students using neuroscientific approach. Nineteen medical students who completed their fifth-year medical curriculum and 23 age- and sex-matched nonmedical students participated in a functional magnetic resonance imaging study. Inside a brain scanner, all participants read empathy-eliciting scenarios while adopting either the patient or doctor perspective. Brain activation and self-reported ratings during the experience of empathy were obtained. Behavioral results indicated that all participants reported greater emotional negativity and empathic concern in association with the patient perspective condition than with the doctor perspective condition. Functional brain imaging results indicated that neural activity in the posterior superior temporal region implicated in goal-relevant attention reorienting was overall increased under the patient perspective than the doctor perspective condition. Relative to nonmedical students, medical students showed decreased activity in the temporoparietal region implicated in mentalizing under the patient perspective versus doctor perspective condition. Notably, this same region showed increased activity under the doctor versus patient condition in medical students relative to nonmedical students. This study is among the first to investigate the neural mechanisms of empathy among medical students and the current findings point to the cognitive empathy system as the locus of the primary brain differences associated with empathy toward patients.

The relationship between empathy and altruistic motivations in nursing studies: a multi-method study

BACKGROUND

The efficient management of relational competences in healthcare professionals is crucial to ensuring that a patient's treatment and care process is conducted positively. Empathy is a major component of the relational skills expected of health professionals. Knowledge of undergraduate healthcare students' empathic abilities is important for educators in designing specific and efficient educational programmes aimed at supporting or enhancing such competences. In this study, we measured first-year undergraduate nursing students' attitudes towards professional empathy in clinical encounters. The students' motivations for entering nursing education were also evaluated. This study takes a multi-method approach based on the use of qualitative and quantitative tools to examine the association between students' positive attitudes towards the value of empathy in health professionals and their prosocial and altruistic motivations in choosing to engage in nursing studies.

METHODS

A multi-method study was performed with 77 first-year nursing students. The Jefferson Scale of Empathy (JSE) - Health Professions Student Version was administered. Students' motivations for choosing nursing studies were detected through an open question and thematically analysed. Using explorative factor analysis and principal component analysis, a dimensional reduction was conducted to identify subjects with prosocial and altruistic motivations. Finally, linear models were tested to examine specific associations between motivation and empathy.

RESULTS

Seven distinct themes distinguishing internal and external motivational factors were identified through a thematic analysis of students' answers regarding their decision to enter a nursing degree course. Female students gained higher scores on the empathy scale than male ones. When students' age was considered, this difference was only observed for younger students, with young females' total scores being higher than young males'. High empathy scores were positively associated with altruistic motivational factors. A negative correlation was found between external motivational factors and the scores of the Compassionate Care subscale of the JSE.

CONCLUSIONS

Knowing the level of nursing students' empathy and their motivational factors for entering nursing studies is important for educators to implement training paths that enhance students' relational attitudes and skills and promote the positive motivational aspects that are central to this profession.

Ignitions of empathy. Medical students feel touched and shaken by interacting with patients with chronic conditions in communication skills training

OBJECTIVE

To explore what and how medical students learn from patients with chronic conditions in the context of communication skills training.

METHODS

Semi-structured interviews and focus groups with 32 medical students. Interviews were recorded, transcribed, analyzed inductively and organized into four main narrative themes.

RESULTS

Learning from patients provided medical students opportunities to see the world through the patients' eyes, understand the diversity of patients' needs, and recognize the importance of matching patients' and doctors' perspectives. Consequently, students expressed emotional responses on challenges in interactions with the patients related to performing the role as 'medical expert'. Difficulty empathizing became visible in the students' interaction with patients.

CONCLUSION

The patients' authentic contributions provided the students with unique opportunities to engage with their own emotions and capacity for empathy. However, for students to benefit from this affective practical training, they need guidance to balance professional and personal aspects in encounters. There is a need to introduce the 'doctor as person' in medical education.

PRACTICE IMPLICATIONS

Patients with chronic conditions strengthen students' learning of empathy as part of transformative learning. Doing so with patients is a challenging way of learning. Thus, faculty and educators must provide explicit guidance for students to benefit.

Heart and Head: Profiles and Predictors of Self-Assessed Cognitive and Affective Empathy in a Sample of Medical and Health Professional Students

For medical and health professions, students learning to respond to others' distress with well-regulated empathy is an important developmental skill linked to positive health outcomes and professionalism. Our study aimed to investigate the sociodemographic, psychological, and psychosocial differences between medical (MS) and health professional (HPS) students and their empathic abilities, since both populations share common stressors, namely, dealing with suffering people. Additionally, we were interested in assessing the psychological and psychosocial predictors of empathy of MS compared to HPS. One hundred thirty MS and 86 HPS were administered the Patient Health Questionnaire-9, Interpersonal Reactivity Index, Integrative Hope Scale, and UCLA Loneliness Scale. The two groups showed differences in their contextual characteristics, with the HPS group having larger families, lower parents' education levels, and lower family income compared to the MS group. In both groups, ~15% of students reported previous contact for psychological problems. A higher proportion of HPS (23.3%) reported depressive symptoms than MS (10%), and female HPS reported more intense feelings of loneliness than other subgroups of students. No differences were found between the two groups in self-assessed cognitive and affective empathy. In both groups, women showed greater affective scores than men and, at the same time, seemed to be particularly prone to personal distress. The cognitive empathic dimension of “perspective taking” was predicted by young age (OR, 612; 95% CI, 1.395–15.242) and the overall socioeconomic status (OR, 3.175; 95% CI, 1.154–8.734) of the HPS. Self-assessed affective competence was predicted by female gender (OR, 3.112; 95% CI, 1.328–7.288), depressive symptomatology (OR, 2.777; 95% CI, 1.004–7.681), higher mother's level of education (OR, 2.764; 95% CI, 1.147–6.659), and feeling of hope related to social relationships (OR, 1.367; 95% CI, 1.152–1.622). Risk factors for poor self-assessed affective emphatic skills were previous contact for psychological problems (OR, 3.263; 95% CI, 1.238–8.601) and feelings of loneliness (OR, 1.18; 95% CI, 1.09–1.276). Our findings emphasize the need to test psychosocial models to better understand empathic skills.

What is clinical empathy? Perspectives of community members, university students, cancer patients, and physicians

OBJECTIVES

To explore what undergraduates, community members, oncology patients, and physicians consider empathic behavior in a physician.

METHODS

150 undergraduates, 152 community members, 95 physicians, and 89 oncology patients rated 49 hypothetical physician behaviors for how well they fit their personal definition of physician empathy. Dimensions of empathy were explored and compared across groups.

RESULTS

Three dimensions of empathy were Conscientious and Reassuring, Relationship Oriented, and Emotionally Involved. Relationship Oriented was the most strongly endorsed, followed by Emotionally Involved, with Conscientious and Reassuring coming in last. There were no group differences for Conscientious and Reassuring, but the Relationship Oriented factor was more endorsed by the clinical groups (physicians and patients) than the non-clinical groups. The Emotionally Involved factor was endorsed by physicians notably more than by patients.

CONCLUSION

What is considered clinical empathy is not the same across individuals and stakeholder groups.

PRACTICE IMPLICATIONS

Physicians and patients differ in how much they include the physicians' emotionality and emotion-related actions in their definition of empathy. Communication training for physicians that emphasizes behaviors associated with empathy (listening, understanding a person's feelings and perspectives, and showing interest in and concern for the whole person) may enhance patients' perception of clinical empathy.

Exploring relational and moral features in medical students

OBJECTIVES

We aimed to explore empathy, moral competencies, callous traits, and temperament in a sample of medical students. Furthermore, we aimed to investigate differences in our variables across the 1st and 5th years of medical education and possible correlations between them.

METHODS

This was a cross-sectional study with 138 medical students. We resorted to self-reported instruments that were given at the end of classes: Barrett-Lennard Relational Inventory, Temperament Evaluation of Memphis, Pisa and San Diego Auto-questionnaire, Inventory of Callous-Unemotional Traits, and Moral Competence Test. For the statistical analysis, we resorted to descriptive and inferential statistics, using non-parametric tests when data didn't follow a normal distribution.

RESULTS

We found no statistical difference between empathy scores in 1st (N=104, Mean=41.42, SD=22.48) and 5th year students (N=34, Mean=37.35, SD=23.35), t₍₁₃₆₎=0.908, p=0.366. Callous traits were negatively correlated with empathy (r₍₁₃₆₎=-0.444, p=0.000) and no correlation between moral competences and empathy (r₍₉₆₎=0.029, p=0.779) was observed. We found a negative correlation between empathy and cyclothymic, anxious and irritable temperaments (r₍₁₃₆₎=-0.334, p=0.000, r₍₁₃₆₎=-0.281, p=0.001, r₍₁₃₆₎=-0.400, p=0.000).

CONCLUSIONS

Our scores corroborate previous evidence that medical students are empathic, have good moral standards and low callous traits. We saw no differences in empathy scores between the two years and future studies could explore the particulars of medical curriculums impacting this variable. In our study, empathy was negatively correlated with callous traits and linked with specific temperaments. Considering these variables at admission to medical school as well as preserving and improving them in medical education might offer better standards of care.

How medical school alters empathy: Student love and break up letters to empathy for patients

INTRODUCTION

Medical education is committed to promoting empathic communication. Despite this, much research indicates that empathy actually decreases as students progress through medical school. In qualitative terms, relatively little is known about this changing student relationship with the concept of empathy for patients and how teaching affects it. This study explores that knowledge gap.

METHODS

Adopting a constructivist paradigm, we utilised a research approach new to medical education: Love and Breakup Letter Methodology. A purposive sample of 20 medical students were asked to write love and break up letters to 'empathy for patients'. The letters were prompts for the focus group discussions that followed. Forty letters and three focus group discussions were thematically analysed.

RESULTS

The three major themes were: art and artifice; empathic burden; and empathy as a virtue. Students were uncomfortable with the common practice of faking empathic statements, a problem exacerbated by the need to 'tick the empathy box' during examinations. Students evolved their own empathic style, progressing from rote empathic statements towards phrases which suited their individual communication practice. They also learned non-verbal empathy from positive clinician role-modelling. Students reported considerable empathic burden. Significant barriers to empathy were reported within the hidden curriculum, including negative role-modelling that socialises students into having less compassion for difficult patients. Students strongly associated empathy with virtue.

CONCLUSIONS

Medical education should address the problem of inauthentic empathy, including faking empathic s in assessments. Educators should remember the value of non-verbal compassionate communication. The problems of empathic burden, negative role modelling and of finding empathy difficult for challenging patients may account for some of the empathy decline reported in quantitative research. Framing empathy as a virtue may help students utilise empathy more readily when faced with patients they perceive as challenging and may promote a more authentic empathic practice.

How do laypeople define empathy?

The term "empathy" is popular, yet fuzzy. How laypeople define it has not been investigated. In Study 1, we analyzed 99 participants' free narratives describing their personal definition, and in Study 1 (N = 191) and Study 2 (N = 351), we asked participants to rate a list of specific behaviors and tendencies for how well each one matched their personal definition. Out of 10 coded components, perspective taking was mentioned most often and personal distress (anxious reactivity in emotional situations) was never mentioned. Item ratings revealed four Empathy Concept factors: Prosocial Emotional Response, Interpersonal Perceptiveness, Other Perspective, and Anxious Reactivity. Other Perspective and Prosocial Emotional Response were most highly endorsed while Anxious Reactivity showed the lowest endorsement. Individuals varied widely in their endorsements of the factors. These results demonstrate that laypeople hold a multifactorial set of definitions of empathy and differ widely from one another in which ones they endorse.

Balint groups and narrative medicine compared to a control condition in promoting students' empathy

BACKGROUND

The perceived importance of clinical empathy may decline among students during medical training. Several interventions have been shown to be effective in promoting or preserving medical students' empathic abilities, such as empathy skills training or Balint groups. Although narrative medicine training shares some features with these interventions, no randomized study to date examined the efficacy of narrative medicine training. This study aimed to assess the effects of Balint groups and narrative medicine training on clinical empathy measured by the self-rated Jefferson's School Empathy Scale - Medical Student (JSPE-MS©) among fourth-year medical students.

METHODS

Students who gave their consent to participate were randomly allocated in equal proportion to Balint groups, narrative medicine training or to the control group. Participants in the intervention groups received either seven sessions of 1.5-h Balint groups or a 2-h lecture and five sessions of 1.5-h narrative medicine training from October 2015 to December 2015. The main outcome was the change in JSPE-MS© score from baseline to one week after the last session.

RESULTS

Data from 362 out of 392 participants were analyzed: 117 in the control group, 125 in the Balint group and 120 in the narrative medicine group. The change in JSPE-MS© score from baseline to follow-up was significantly higher in the Balint group than in the control group [mean (SD): 0.27 (8.00) vs. -2,36 (11.41), t = 2.086, P = 0.038]. The change in JSPE-MS© score in the narrative medicine group [mean (SD): - 0.57 (8.76)] did not significantly differ from the changes in the control group (t = 1.355, P = 0.18) or the Balint group (t = 0.784, P = 0.43). Adjusting for participants' characteristics at baseline, Balint groups remained associated with better outcomes compared to the control group (β = 2.673, P = 0.030).

CONCLUSIONS

Balint groups may promote clinical empathy to some extent among medical students, at least in the short run.

Focusing: A new challenger for improving the empathy skills of medical students

OBJECTIVES

Studies of empathy among medical students reported an alarming significant decline during medical education. Some authors identified the third year of education as the most problematic one: empathy decreased significantly when the curriculum was shifting to patient-care activities. Scientists have tried to address the means and methods for improving empathy skills (e.g., by improving communication abilities), but investigations on this topic are missing. Based on the Damasio's hypothesis and scientific studies, we assume that Focusing (i.e., an embodied practice where one attends to a bodily felt sense and uses it to understand the self and situations) would be significantly and positively linked to empathy.

METHOD

After their clinical internships, we selected third-year medical students (N = 121) and asked them to complete three questionnaires assessing empathy, Focusing, and social desirability.

RESULTS

By controlling social desirability, findings confirmed that Focusing (especially the "having access to the felt body" component) was significantly and positively linked with empathy (i.e., Fantasy & Perspective-Taking), and positively predicted Fantasy, Perspective-Taking, and Empathic Concern.

CONCLUSIONS

These preliminary results suggest that the felt body plays a role in increasing empathy (mainly on cognitive empathy). Few scientific studies have described constructs that significantly promote cognitive empathy and empathic concern (a deeply anchored trait of empathy), which suggests new avenues of investigation.

'I'm sorry to hear that'-Empathy and Empathic Dissonance: the Perspectives of PA Students

CONTEXT

Our understanding of clinical empathy could be enhanced through qualitative research-research currently under-represented in the field. Physician associates within the UK undergo an intensive 2-year postgraduate medical education. As a new group of health professionals, they represent a fresh pair of eyes through which to examine clinical empathy, its nature and teaching.

METHODS

Working with a constructivist paradigm, utilising grounded theory methodology, researchers studied 19 purposively sampled physician associate students in two UK medical schools. One-to-one semi-structured interviews were transcribed verbatim. Data were analysed using a grounded theory approach.

RESULTS

The global themes were the pathways to empathy, empathy modifiers and empathic dissonance a novel term to describe the discomfort students experience when pressurised into making empathic statements they don't sincerely feel. Students preferred using non-verbal over verbal expressions of empathy. A conceptual model is proposed. The more substantial empathic pathway, affective empathy, involves input from the heart. An alternative empathy, more constrained, comes from the head: cognitive empathy was considered a solution to time pressure and emotional burden. Formal teaching establishes empathic dissonance, a problem which stems from over-reliance on the empathic statement as the means to deliver clinical empathy.

CONCLUSIONS

This study furthers our understanding of the construct and teaching of empathy. It identifies empathic barriers, especially time pressure. It proposes a novel concept-empathic dissonance-a concept that challenges medical educationalists to reframe future empathy teaching.

Embodying empathy: A phenomenological study of physician touch

CONTEXT

Empathic physician behaviour is associated with improved patient outcomes. One way to demonstrate empathy is through the use of non-verbal communication (NVC) including touch. To date, research on NVC, and specifically touch, has been relatively limited in medicine, which is surprising given the central role it plays in conveying affective and empathic messages. To inform curriculum development on NVC, this study aimed to examine physicians' experiences of communicating by touch.

METHODS

We conducted an interpretative phenomenological study. A total of 15 physicians (seven women and eight men) from different specialties, including both recent graduates and experienced doctors, described in detail specific instances of touch drawn from their clinical practices. Interview prompts encouraged participants to recall exact details such as the context, their relationship with the patient they touched and their physical experience of touching. Interviews (45-100 minutes) were analysed with template analysis, followed by a process of dialectic questioning, moving back and forth between the data and researchers' personal reflections on them, drawing on phenomenological literature to synthesise a final interpretation.

RESULTS

Participants described two dimensions of the experience of touch: 'choosing and inviting touch' and 'expressing empathy.' Touch was a personal and fragile process. Participants interpreted non-verbal patient cues in order to determine whether or not touch was appropriate. They interpreted facial expressions and body language in the present to make meaning of patients' experiences. They used touch to share emotions, and to demonstrate empathy and presence. Participants' experiences of touch framed it as a form of embodied empathic communication.

CONCLUSIONS

Touch is a powerful form of NVC that can establish human connection. Phenomenological accounts of empathy, which emphasise its embodied intersubjective nature, can be used to theoretically enrich pedagogical approaches to touch in medical education and to deepen our understanding of empathy.

Assessing the effects of an empathy education program using psychometric instruments and brain fMRI

This study aimed to (1) evaluate the effects of an empathy education program, and (2) explore functional magnetic resonance imaging (fMRI) as a potential empathy assessment tool. An empathy enhancement program for premedical students was developed. The Korean version of the Jefferson Scale of Empathy-Student version (JSE-S) and Interpersonal Reactivity Index (K-IRI) were used to measure self-assessed changes in empathy. Clinical vignettes demonstrating empathy tasks were presented to participants undergoing fMRI, to assess regional changes in the brain. Self-reported empathy scores and brain activity signals using fMRI from before and after the program were compared. The JSE-S total and perspective taking scores significantly increased after the program. Data from the fMRI revealed noticeable differences in cognitive regions associated with empathy, namely the right superior medial frontal gyrus and left precentral gyrus. This study results support the prior evidence of positive impact of empathy education. In addition, the authors suggest that brain fMRI might be used in measuring the effectiveness of empathy education.

Improving Patient Experience by Teaching Empathic Touch and Eye Gaze: A Randomized Controlled Trial of Medical Students

Background

Empathy is critical for optimal patient experience with health-care providers. Verbal empathy is routinely taught to medical students, but nonverbal empathy, including touch, less so. Our objective was to determine whether instruction encouraging empathic touch and eye gaze at exit can impact behaviors and change patient-perceived empathy.

Materials

A randomized, controlled, double-blinded trial of 34 first-year medical students was conducted during standardized patient (SP) interviews. A video either encouraging empathic touch and eye gaze at exit or demonstrating proper hand hygiene (control) was shown. Encounter videos were analyzed for touch and eye gaze at exit. The Jefferson Scale of Patient Perceptions of Physician Empathy was used to measure correlations. Intervention students were surveyed regarding patient touch.

Results

Of this, 23.5% of intervention students touched the SP versus zero controls; 88.2% of intervention students demonstrated eye gaze at exit. Eye gaze at exit positively impacted patient-perceived empathy (correlation = 0.48, P > .001). Survey responses revealed specific barriers to touch.

Conclusion

Medical students may increase perceived empathy using eye gaze at exit. Instruction on empathic touch and sustained eye gaze at exit at the medical school level may be useful in promoting empathic nonverbal communication. Medical educators should consider providing specific instructions on how to appropriately touch patients during history-taking. This is one of the few studies to explore touch with patients and the first ever to report the positive correlation of a health provider's sustained eye gaze at exit with the patient's perceived empathy. Further studies are needed to explore barriers to empathic touch.