Complex and novel determinants of empathy change in medical students

Empathy Levels Among Healthcare Professionals: An Asian Multi-professional Cross-Sectional Study

BACKGROUND

The aim of the study was to measure empathy in healthcare professionals in Singapore and to compare the scores between the different professions: doctors, nurses, and allied health professionals.

METHODS

An online survey questionnaire was conducted using the Jefferson Scale of Empathy (JSE) from July 2019 to January 2020. The total JSE score was calculated and compared among the different groups. Multiple linear regression was performed to assess predictors of total empathy scores for groups with statistically lower scores.

RESULTS

The survey was completed by 4,188 healthcare professionals (doctors (n=569, 13.6%), nurses (n=3032, 72.4%), and allied health professionals (n=587, 14.0%)) out of the 9,348-strong survey population, with a response rate of 44.8%. The study revealed a mean empathy score (SD) of 103.6 (15.6) for the cohort. The mean empathy score (SD) was 112.3 (14.7), 101.3 (15.2), and 107.0 (15.0), respectively for doctors, nurses, and allied health professionals. These were statistically significantly different among the groups (p< 0.0001), with nurses scoring significantly lower than either doctors (p< 0.0001) or allied health professionals (p< 0.0001). Multiple linear regression showed that age < 30 years old, male gender, Malay ethnicity, and working in a hospital setting were associated with significantly lower empathy scores in the nursing group.

CONCLUSION

Nurses in Singapore had significantly lower empathy scores compared to doctors and allied health professionals. Further research on the underlying causes should be undertaken and measures to improve empathy among Singapore nursing staff should be explored and implemented.

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).

Medical Humanities in Undergraduate Psychiatry Teaching: Learner Assessment and Mediators of Better Learning Outcomes

OBJECTIVES

Previous studies have found that the inclusion of medical humanities in medical education was associated with improvements in learner reflectivity and empathy. There is less data, however, on the impact of medical humanities on perceived patient care and mediators of learner outcomes. Our study aimed to determine the impact of medical humanities on perceived learner well-being and patient care, and the mediators of these outcomes in medical undergraduates undergoing psychiatric training.

METHODS

This cross-sectional study was conducted from August 2021 to December 2022 within undergraduate medical students undergoing psychiatry rotations and who attended sessions entitled "Humanities in Psychiatry." Both quantitative and qualitative data were obtained through anonymized online feedback forms. Path analysis was performed to examine the relationship between learners' perception of the medical humanities writing activity and its potential to improve their well-being, patient care, as well as mediators of these outcomes.

RESULTS

Overall, 97 medical undergraduates (response rate 67.4%) participated in the study and more than four-fifths reported improvements in listening, reflection, empathy, personal well-being, and perceived patient care. Males showed more interest in additional medical humanities sessions (mean rank 57.9 vs 42.5, P = .005) and greater improvements in personal well-being (mean rank 55.1 vs 44.5, P = .044). Path analysis showed that reflective capacity of learners mediated the relationship between reflective writing and perceived improvements in learner well-being (β = 0.596, 95% CI = 0.409-0.737) and patient care (β = 0.557, 95% CI = 0.379-0.702).

CONCLUSIONS

Our study found that the majority of learners responded positively to the medical humanities sessions, which suggests that its use could be beneficial in fostering empathy, reflection, learner well-being, and improved patient care. Using the PRISM model, we present practical implications for educators to consider when using medical humanities in relation to psychiatry training.

Psychometric properties of a French version of the Jefferson Scale of Empathy

OBJECTIVE

To assess the reliability and construct validity of a French version of the Jefferson Scale of Empathy-Students.

METHODS

A cross-sectional study was performed among undergraduate medical students in Tunisia. A total of 833 students completed a French version of the JSE-S using convenience sampling. To identify the internal consistency aspect of the reliability, Cronbach's alpha coefficient was computed. Moreover, to assess the construct validity, the sample was randomly divided into two groups. Data from the first group (n=415) were subjected to exploratory factor analysis (EFA), with principal axing factoring (PAF) and oblimin rotation, to re-examine the underlying factor structure of the scale. Data from the second group (n=419) were used for confirmatory factor analysis (CFA) to confirm its latent variable structure. Some goodness-of-fit indices were used to assess the hypothesized model. Gender groups were compared using a t-test to check the known-group validity.

RESULTS

Reliability analysis reported an acceptable level of internal consistency, with an overall Cronbach's alpha of 0.78 (95% CI [0.75,0.80]). EFA identified a two-factor structure, accounting for 27.4% of the total variance. The two-factor model produced good fit indices when item correlated errors were considered (χ²/df = 1.95, GFI = 0.92, CFI = 0.90, PCFI = 0.79, PGFI = 0.73 and RMSEA = 0.04). Female students had a statistically significant higher empathy scores than male students (t ₍₈₃₀₎ = - 4.16, p < .001).

CONCLUSIONS

The findings support the construct validity and reliability of a French version of the JSE for medical students. This instrument appears to be useful for investigating empathy among French-speaking populations.

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.

Development of student empathy during medical education: changes and the influence of context and training

PURPOSE

Empathy levels have been observed to often decrease when medical undergraduates move to the clinical years, particularly in the Western countries. However, empathy either remains similar or increases in many Asian medical schools. This study investigated the longitudinal empathy profile of medical students in Singapore.

METHODS

Two cohorts of medical students who enrolled in 2013 and 2014 to the National University of Singapore were tracked for 5 years. The Jefferson Scale of Empathy-student version was used. Analyses on the mean of the empathy level and individual factors, year-wise and gender comparison were conducted.

RESULTS

Average response rates for cohort 1 and 2 were 68.1% (n=181-263) and 55.4% (n=81-265), respectively. For both cohorts, there was no significant change across year of study in the mean empathy score. Average scores for both cohorts were 113.94 and 115.66. Though not significant, we observed mean empathy to be lowest at the end of year 5 (112.74) and highest in year 2 (114.72) for cohort 1 while for cohort 2, the lowest level of empathy was observed in year 5 (114.20) and highest in year 4 (118.42). Analysis of subcomponents of empathy only showed a significant difference for cohort one factor 1 (perspective taking) and factor 3 (standing in patients' shoes) across the study years.

CONCLUSION

No significant change in empathy score was observed during the transition from pre-clinical to clinical years, unlike many Western and Far-Eastern studies. This might be due to the curriculum and influence of the Asian values.

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.

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.

Finding Echoes: An Exploration of Empathy Among Physiotherapists and Physiotherapy Students in Singapore

Background

Empathy is an essential antecedent in motivating healthcare professionals to treat and care for their patients with compassion – few studies had explored empathy on healthcare workers. Currently, no data reported empathy amongst physiotherapists and physiotherapy students in Singapore.

Objectives

This study aims to: 1) measure and explore within- and between-group differences in empathy scores amongst physiotherapists and physiotherapy students in Singapore, and 2) compare the results with similar studies locally and overseas.

Methods

This cross-sectional survey recruited 187 participants (37 physiotherapists and 150 physiotherapy students) via convenience sampling. Participants completed the Jefferson Scale of Empathy (JSE) Health Professions (JSE-HP) and the JSE-Health Professions Students (JSE-HPS), correspondingly. The 20-item JSE-HP and JSE-HPS are validated self-reported questionnaires that measure clinical empathy using a 7-point Likert scale. Summed scores range from 20 to 140, with higher scores suggesting a higher level of empathy. Statistical analysis included descriptive statistics, independent-sample t-tests and one-way analyses of variance.

Results

The mean score of JSE-HP and JSE-HPS was 110.89±11.37 and 112.43±10.73, respectively. No statistically significant differences found between gender, physiotherapists and physiotherapy students, and years of study. However, physiotherapists scored significantly higher [5.08±1.24 (95% CI 4.67–5.49) vs 4.01±1.36 (95% CI 3.79–4.23), p < .001 ] in the JSE components ‘Walking in Patient's Shoes’.

Conclusion

Physiotherapists and physiotherapy students in Singapore have similar empathy scores to their counterparts locally and internationally. No statistically significant differences in empathy scores were found. However, physiotherapy students were less able to understand patients' perspectives. This warrants further exploration in developing this vital attribute amongst students.

Association between dispositional empathy and self-other distinction in Irish and Belgian medical students: a cross-sectional analysis

OBJECTIVE

Physicians' cognitive empathy is associated with improved diagnosis and better patient outcomes. The relationship between self-reported and performance-based measures of cognitive empathic processes is unclear.

DESIGN

Cross-sectional analysis of the association between medical students' empathy scale scores and their empathic performance in a visuospatial perspective-taking (VPT) task.

PARTICIPANTS

Undergraduate medical students across two European medical schools (n=194).

PRIMARY AND SECONDARY OUTCOME MEASURES

Two self-report empathy and one performance-based perspective-taking outcome: Jefferson Scale of Physician Empathy (JSPE); Empathy Quotient (EQ); Samson's level-1 VPT task.

RESULTS

Higher scores on the 'standing in patient's shoes' subscale of the JSPE were associated with a lower congruency effect (as well as lower egocentric and altercentric biases) in the VPT (B=-0.007, 95% CI=-0.013 to 0.002, p<0.05), which reflects an association with better capacity to manage conflicting self-other perspectives, also known as self-other distinction. Lower egocentric bias was also associated with higher scores on the 'social skills' EQ subscale (B=-10.17, 95% CI=-17.98 to 2.36, p<0.05). Additionally, selection of a 'technique-oriented' clinical specialty preference was associated with a higher self-perspective advantage in the VPT, reflecting greater attentional priority given to the self-perspective.

CONCLUSIONS

We show that self-assessment scores are associated with selected performance-based indices of perspective taking, providing a more fine-grained analysis of the cognitive domain of empathy assessed in medical student empathy scales. This analysis allows us to generate new critical hypotheses about the reasons why only certain self-report empathy measures (or their subscales) are associated with physicians' observed empathic ability.

Assessing empathy in final-year medical students using the Persian version of the Jefferson Scale of Physician Empathy

BACKGROUND

A doctor-patient relationship built on the concept of empathy is so essential to attain the best clinical outcomes in medicine. Since empathy has a positive role in interpersonal relationships and medical outcomes, its assessment is highly crucial. The aim of this study was to assess the empathy in last-year medical students using the Persian version of the Jefferson Scale of Physician Empathy (JSPE) and correlate empathy scores with demographic features.

MATERIALS AND METHODS

In this cross-sectional study, last-year medical students at Shiraz Medical School, Shiraz, Iran, were recruited for this study. In this research, we used the Persian version of JSPE. The validity and reliability of the Persian version of this tool were confirmed in the previous research. For the analysis of data, we employed descriptive statistics and the independent sample t-test.

RESULTS

One hundred and eighty-five final-year medical students were included in this study. The maximum score of the questionnaire was 140, and the total mean score of empathy was 98.15 ± 13.29. The females' total mean score (102.05 ± 11.89) was higher than the males' score (93.57 ± 13.46). The difference between the mean score of gender and empathy was significant (P value <.001), but there was no significant difference between empathy and the two other demographic factors (P > 0.05).

CONCLUSIONS

Although physicians would gain the essential characteristics of empathy during their career, attending professors and other responsible policymakers in medical education should focus more on the factors related to physicians' empathy to train better and more professional physicians.

Impact of an aging simulation workshop with different debrief methods on the development of empathy in pharmacy undergraduates

INTRODUCTION

This study aimed to investigate a workshop's impact on empathy development, compare potential differences in effects among different workshop debrief methods, and identify if any demographic factors predict empathy development.

METHODS

Participants were first randomly divided to receive either a didactic lecture, a jigsaw approach, or a fishbowl approach for the debrief method. In their respective arms, participants experienced simulation stations followed by their assigned debrief. Of 167 year-two National University of Singapore pharmacy undergraduates, 130 participated in the study and completed the Jefferson Scale of Empathy-Health Professions Student (JSE-HPS) version before and after the workshop.

RESULTS

The JSE-HPS scores were significantly increased post-workshop; however, no significant differences in pre-post workshop score changes were observed among the three approaches. Overall, no demographic factor was identified to have significantly influenced empathy development.

CONCLUSIONS

The study demonstrated that the simulation workshop developed empathy among pharmacy students regardless of the debrief method employed within the workshop. Future work would be necessary to assess if there are long-term impacts of different debrief methods on empathy development.

Medical students' preclinical service-learning experience and its effects on empathy in clinical training

BACKGROUND

Service learning (SL) is an educational methodology presumed to help medical students be more empathetic and compassionate. We longitudinally investigated the level of empathy in medical students and how preclinical SL experience was related to their level of empathy in their clinical clerkships.

METHODS

Our cohort comprised fifth-year medical students engaged in clerkships as part of a 7-year medical programme at one medical school in Taiwan. Surveys were conducted at the beginning of the clerkship in September 2015 (T1) to collect data on the medical students' preclinical SL experience in curriculum-based service teams (CBSTs) and extracurricular service teams (ECSTs) and their SL self-efficacy, demographic characteristics, and empathy level. Subsequently, three follow-up surveys were conducted once every 3 months to determine the empathy level of the students during their clinical clerkships (T2-T4). Seventy students who returned the written informed consent and completed the baseline (T1) and two or more follow-up surveys (T2-T4) were included in our analysis with the response rate of 34%. In total, 247 responses across the 1-year clerkship were analysed. Descriptive statistics, paired t tests, and generalised estimating equations were employed.

RESULTS

Our study revealed that changes in empathy level in the dimensions of perspective taking, compassionate care, and standing in patients' shoes in their clinical clerkships. Relative to that at T1, their empathy decreased in perspective taking and compassionate care at T2-T4 but increased in standing in patients' shoes at T3. Additionally, our study verified the positive effect of medical students' preclinical SL experience in CBSTs and ECSTs on empathy in terms of compassionate care and perspective taking, respectively, but not on that of standing in patients' shoes.

CONCLUSIONS

Separate investigations into subconstructs of empathy, such as perspective taking, compassionate care, and standing in patients' shoes, in medical students may be necessary for exploring the various driving forces or barriers to developing empathy in medical students. Moreover, SL experience through both CBSTs and ECSTs at medical academies may have positive effects on medical students' empathy in their clinical clerkships and should be promoted at medical schools.

Empathy amongst dental students: An institutional cross-sectional survey in Poland and Croatia

AIM

To determine and compare levels of empathy and its dimensions in Polish and Croatian dental students.

METHODS

Fourth- and fifth-year dental students (N = 193) at the University of Rijeka and University of Silesia completed questionnaires to determine levels of overall empathy and its dimensions: compassionate care (CC), perspective taking (PT) and ability to stand in someone else's shoes (ASSES). Total empathy and its dimensions were analysed depending on the country of origin, year of study and gender of the participants. The HPS version of the Jefferson Scale of Physician Empathy was used to conduct the research. Statistical analysis was performed using the Mann-Whitney U test.

RESULTS

The analysis showed no significant differences in total empathy level between Polish and Croatian students (P = .838). However, separate analysis of empathy items showed significant differences between the two groups. Croatian students obtained significantly higher average PT values (P = .021), whilst Polish students had significantly higher CC scores (P < .001). Analysis of Croatian respondents revealed significantly higher ASSES scores in the fourth- and fifth-year students (P = .047). Analysis in the Polish group demonstrated an increase in PT scores from the fourth to the fifth year of study (P = .008).

CONCLUSION

Croatian students scored higher on items associated with cognitive empathy, whilst Polish students displayed higher values in the aspect of emotional empathy. The present results demonstrated an increase in cognitive empathy level in Polish students, whilst in their Croatian colleagues, the level of cognitive empathy decreased with the progression of the academic programme.

A systematic review of psychometric assessment of the Jefferson Scale of Empathy using the COSMIN Risk of Bias checklist

INTRODUCTION

Empathic communication in health care may enhance positive patient and health care professional relationships, patient satisfaction and can buffer professional burnout. The Jefferson Scale of Empathy (JSE) was developed based on the need to quantitatively measure levels of empathy, particularly in health care settings. Evaluating the utility of empathy is underpinned by the psychometric rigour of the instruments used to measure it. The aim of this study was to critically evaluate the current evidence on the measurement properties of the JSE.

METHODS

Two reviewers independently searched six databases for papers describing psychometric assessment of the JSE from January 2000 to July 2018 inclusive. The studies were independently assessed for methodological quality using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist.

RESULTS

The search strategy resulted in the retrieval of 985 papers, of which 59 were included in this study. The majority of papers reported on measures of structural validity and internal consistency, and it was in these areas which the highest quality of reporting was demonstrated. Additionally, there was a generally very good quality in reporting of convergent validity. Reliability, measurement error, cross-cultural validity were reported with less than optimum quality.

CONCLUSION

The JSE demonstrates robust structural validity, internal consistency, and convergent validity. These measurement properties are generally well reported in the literature in studies of good methodological quality, and thus may be interpreted with relative confidence when used in empathy research. However, current evidence is limited for the properties of reliability, measurement error, and cross-cultural validity. Thus, a degree of caution should be considered in drawing conclusions when using the JSE with regard to these properties. It is recommended that future examinations of the JSE refer to the COSMIN guidelines to ensure complete and well-reported psychometric data are included.

Positive impact of COVID-19 on career choice in pediatric medical students: a longitudinal study

BACKGROUND

On March 11^th, 2020, the WHO made the assessment that coronavirus disease 2019 (COVID-19) could be characterized as a pandemic. Medical students experienced a greater degree of anxiety and psychological stress than during previous pandemics. Negative emotions were related to decreased medical career interest, increased career choice regret and dropout rates in medical students, which affected academic and professional development. The goal of this study was to investigate the impact of the current COVID-19 outbreak on the career preferences of pediatric medical students and to explore the underlying factors contributing to it.

METHODS

A prospective, longitudinal study was conducted among all 120 pediatric medical students from Shanghai Medical College of Fudan University on November 23^rd, 2019, and February 21^st, 2020 using a 7-item online questionnaire about career choice.

RESULTS

A total of 106 (41 male and 65 female) students with a mean age of 21 years consented to participate in this study. The response rate was 100% in November 2019 and 98.1% in February 2020. Since the outbreak, career choices to practice medicine or pediatrics did not drop significantly, decreasing by only 4.3% and 2.2%, respectively. There was a positive impact of the COVID-19 outbreak on strengthening 66.7% of students' beliefs and choices to become good pediatricians (P<0.001). Only 14 students (13.5%) thought that COVID-19 had a negative impact on their career choices, but the majority of them were in the 3^rd (28.6%) and 4^th (64.3%) years of medical education and had insufficient knowledge about the hospital environment and clinics.

CONCLUSIONS

The outbreak of COVID-19 might have an overall positive impact on career choice by strengthening students' belief and choice to become good doctors and may decrease the choice regret and drop rates of the next generation of doctors. Special attention should be paid to students with insufficient clinical experience. Good protection for students, sharing outstanding stories regarding fighting the pandemic, and innovations of needs-based curriculum could be helpful during this pandemic. Future studies are warranted to confirm these findings.

A multi-institutional and cross-sectional study on empathy in Chinese medical students: differences by student cadre or not, future career preference, and father's education status

BACKGROUND

The aims of this study were to examine the factor structure of the Chinese version of the Jefferson Scale of Empathy for medical students (JSE-S) and investigate differences in empathy scores among Chinese medical students according to gender, student cadre or not, future career preference, and parents' education.

METHODS

Medical students from three universities completed an online questionnaire containing the JSE-S. Exploratory factor analysis was conducted to determine the factor structure, and group comparisons of empathy scores were examined via t-tests and analysis of variance.

RESULTS

Four factors emerged from the factor analysis: "perspective taking," "compassionate care," "standing in the patient's shoes," and an uninterpretable factor. The results indicated that students who were female, held positions as student cadres, preferred to become a doctor, and whose fathers had a high school education or below tended to have more empathy.

CONCLUSIONS

Overall, the findings provide information on the dimensions of empathy applicable to Chinese medical students and confirm the factors found in the original measure. The dimensions have implications for developing empathy among medical students throughout the world. Educators can use the information to design interventions to foster empathy among students in the context of medical education reform in many countries, including China.

Medical Students' Empathy Level Differences by Medical Year, Gender, and Specialty Interest in Akdeniz University

BACKGROUND

As an important feature in patient-physician communication for both primary and clinical care, empathy is one of the basic competencies that physicians should possess. The primary aim of this study was to evaluate the level of empathy among medical students in all years of medical training using two different instruments: the Jefferson Scale of Physician Empathy (for clinical empathy level) and the Toronto Empathy Questionnaire (for general empathy level).

MATERIALS AND METHODS

This study is a cross-sectional descriptive study conducted in 2017-2018 academic year with students studying at Akdeniz University Faculty of Medicine. Data collection form, Toronto Empathy Questionnaire (TEQ) and Jefferson Scale of Physician Empathy (JSPE) was applied to the students by the researchers. The statistical analysis was carried out by using IBM-SPSS version 23 for Mac OS. T-test, ANOVA test, Spearman and Pearson correlation analysis were used for comparisons.

RESULTS

The mean TEQ score of the students was 52.8/65 and the JSPE-S score was 80.3/100. TEQ scores of students increased up to 4th year and then decreased, but the difference between the years was not statistically significant. The third year students' JSPE-S scores were significantly higher than that of the sixth year students.

CONCLUSION

While the clinical empathy levels of medical students decreased significantly after 3rd year, the general empathy levels decreased less. This result shows us that we should review our medical education curriculum and educational environment, and should initiate initiatives, and devote more time to empathy education in order to prevent the decrease in empathy level and increase empathy during medical education.

Cultura, ensino e aprendizagem da empatia na educação médica: scoping review

Este estudo teve o objetivo de identificar, na literatura, como a empatia é influenciada pelos diferentes fatores culturais no contexto de ensino e aprendizagem em saúde. Realizado por meio de scoping review , conforme a proposta de Joanna Briggs Institute (JBI), a busca foi realizada nas bases de dados PubMed, Lilacs, Scopus e Web of Science e executada entre o período de dezembro de 2017 a janeiro de 2018. Observou-se, pelas pesquisas, que os estudantes ocidentais têm maior nível de empatia quando comparados aos estudantes orientais. Além disso, há diferença na empatia entre diferentes etnias, raças, sexo e religião. Sua avaliação dá-se por meio de diferentes instrumentos. Assim, entre os fatores que influenciam a empatia, identificou-se a cultura como sendo um deles. São necessários novos estudos a fim de compreender da melhor forma a empatia entre as diversas profissões da saúde.

Differences and changes in the empathy of Korean medical students according to gender and vocational aptitude, before and after clerkship

PURPOSE

The purpose of this study is to determine whether there is any change in the empathy scores of third-year medical graduate students after they have taken a clerkship and have begun gaining more opportunities to meet patients through the clerkship.

METHODS

The participants were 109 third-year students in 2014 and 110 fourth-year students in 2015 at Kyungpook National University, School of Medicine. The author measured empathy using a modified and expanded version of the Korean version of the Jefferson Scale of Empathy of Physician Empathy-Student version and used the Holland-III aptitude test-S to assess vocational aptitude.

RESULTS

As a results, male students in their third year exhibited higher scores, but there was no significant difference in the fourth year. The empathy score increased slightly when third-year students became fourth-year students, but the difference was not statistically significant. There was no statistically significant change in the scores of both male and female students between the 2 years. The results of the vocational aptitude test showed that students who preferred person-oriented specialties had higher empathy scores when they entered their fourth academic year compared to objectively-oriented students.

CONCLUSION

In this study, male students showed higher empathy scores than female students, an atypical finding that was inconsistent with the results of previous studies. However, the distribution of scores among male students was wider than that of female students, a finding consistent with previous studies. As such, individual differences need to be considered when developing curriculum in order to improve the empathy of medical students.

Civic-Mindedness Sustains Empathy in a Cohort of Physical Therapy Students: A Pilot Cohort Study

Background:

Empathy is critical to patient-centered care and thus is a valued trait in graduate health-care students. The relationship between empathy and civic-mindedness in health professions has not previously been explored.

Objectives:

(a) To determine whether significant differences occurred on the Jefferson Scale for Empathy–Health Professions Student Version (JSE-HPS) and Civic-Minded Professional scale (CMP) and its subscales across the curriculum, (b) to explore a potential relationship between civic-mindedness and empathy in a cohort of graduate physical therapy (PT) students at regular intervals, and (c) to explore the predictive ability of civic-mindedness on empathy scores.

Methods:

This study was a convenience sample of a cohort of 48 PT students who completed both the JSE-HPS and the CMP at 4 points of a service-learning intensive curriculum. Statistical analysis included descriptive statistics, a Friedman’s analysis of variance with Wilcoxon signed-ranks post hoc testing, and Spearman correlations with stepwise linear regressions.

Results:

Statistically significant differences were not found for the JSE-HPS. Civic-Minded Professional scores increased across the curriculum. The JSE-HPS, the CMP, and various CMP subscales were significantly correlated. The JSE-HPS pretest scores were predictive of the year 1 and 2 posttest JSE-HPS scores.

Conclusion:

This study’s findings indicate that service-learning and the resulting development of civic-mindedness supports empathy. Programs could use JSE-HPS pretests to identify individual graduate students need for empathy mentorship upon program entrance or as one admission criterion.

Understanding medical students' empathy based on Enneagram personality types

PURPOSE

High self-awareness can promote communication and empathy. The Enneagram is a well-known personality tool to enhance self-awareness. We evaluated differences in empathy among medical students using the Enneagram typology.

METHODS

This cross-sectional study included first and second grade students at the Inje University College of Medicine. The Jefferson Scale of Empathy was used to measure empathy and the Korean Enneagram Personality Type Indicator was used for examining personality characteristics. Empathy scores were analyzed according to the Triads, Hornevian group, Harmonic group, and each Enneagram type.

RESULTS

The Instinctive triad, the Withdrawns, and the Positive outlook group were the most common, and the Feeling triad, the Assertives, and the Emotional realness group were the least common. Students in the Feeling triad and the Dutifuls had higher compassionate care (CC) scores as compared to their counterparts. Type 2 and 6 students showed the two highest empathy and CC scores. The empathy score of type 3 students was the lowest. Type 7 had the lowest CC score but the highest perspective taking score.

CONCLUSION

These differences in empathy according to Enneagram personality types can be applied to medical education to maintain and improve medical students' empathy.

Empathy assessment in healthcare students is highly heterogeneous: A systematic review and meta-analysis (2012-2016)

BACKGROUND

Clinical empathy leads to improved patient satisfaction and better clinical outcomes. Currently, there are multiple empathy scales with minimal or no efforts to produce an integrated definition of clinical empathy which can be assessed sufficiently by only a few scales. Moreover, there is an unclear overall reliability of these empathy scales, hence limiting comparative evaluation.

AIM

To examine which empathy scales have been used in healthcare students and to estimate their overall internal consistency.

METHODS

A systematic review was performed with inclusion criteria any empirical study with quantitative data examining empathy of healthcare students toward patients between 2012 and 2016. A random effects model was used to produce a pooled estimate of the Cronbach’s alphas. The Hakstian-Whalen transformation was used for analyses based on the Rodriguez-Maeda method. Heterogeneity was quantified using the I² statistic and further investigated with subgroup analysis and meta-regression. Publication bias was assessed using funnel plots, Egger’s test, Begg’s test, and the trim and fill analysis.

RESULTS

Thirteen scales have been used to assess clinical empathy in healthcare students from forty nine studies with total sample size 49384 students. The most frequently used scale is the Jefferson Scale of Physician Empathy followed by Davis’ Interpersonal Reactivity Index. The overall reliability was 0.805 (95%CI 0.786-0.823), which is acceptable, but there was heterogeneity and publication bias. Some heterogeneity was explained by the different countries of the studies under investigation and student types but most heterogeneity remained unexplained.

CONCLUSION

The results indicate that scales have satisfactory internal consistency but there are a multitude of scales, definitions and empathy components. Future research should focus on standardizing scales and creating consensus statements regarding the definition of empathy and use of appropriate scales.

Changing characteristics of the empathic communication network after empathy-enhancement program for medical students

The Empathy-Enhancement Program for Medical Students (EEPMS) comprises five consecutive weekly sessions and aims to improve medical students' empathic ability, an essential component of humanistic medical professionalism. Using a graph theory approach for the Ising network (based on l1-regularized logistic regression) comprising emotional regulation, empathic understanding of others' emotion, and emotional expressivity, this study aimed to identify the central components or hubs of empathic communication and the changed profile of integration among these hubs after the EEPMS. Forty medical students participated in the EEPMS and completed the Depression Anxiety Stress Scale-21, the Empathy Quotient-Short Form, the Jefferson Scale of Empathy, and the Emotional Expressiveness Scale at baseline and after the EEPMS. The Ising model-based network of empathic communication was retrieved separately at two time points. Agitation, self-efficacy for predicting others' feelings, emotional concealment, active emotional expression, and emotional leakage ranked in the top 20% in terms of nodal strength and betweenness and closeness centralities, and they became hubs. After the EEPMS, the 'intentional emotional expressivity' component became less locally segregated (P = 0.014) and more directly integrated into those five hubs. This study shows how to quantitatively describe the qualitative item-level effects of the EEPMS. The key role of agitation in the network highlights the importance of stress management in preserving the capacity for empathic communication. The training effect of EEPMS, shown by the reduced local segregation and enhanced integration of 'intentional emotional expressivity' with hubs, suggests that the EEPMS could enable medical students to develop competency in emotional expression, which is an essential component of empathic communication.

An Epidemiological Study on Empathy and its Correlates: A Cross-sectional Assessment among Medical Students of a Government Medical College of India

BACKGROUND

Empathy is a desirable quality in every clinician. It is a crucial determinant of patient-physician communication and relation. There are very few existent Indian studies on empathy of medical students and its correlates.

AIM

The aim of the study was to assess empathy level of medical students and its correlates.

METHODOLOGY

It was a cross-sectional, hospital-based, analytical observational study conducted from July to November 2017. In total, 249 undergraduate medical students of a medical college of Kolkata were interviewed with a structured schedule. The schedule comprised of the sociodemographic questionnaire, career satisfaction, future career choice, and Jefferson Scale of Empathy.

RESULTS

The mean empathy score was 98.5 ± 12.5. Third-semester students had higher empathy scores (102.4 ± 12.4) compared to fifth (97.2 ± 12.9) and seventh semester (95.0 ± 10.9) students. The difference between the mean scores of different semesters was statistically significant. Female students were more empathic than male students. In the multivariable linear regression model, sex, semester, residence, career satisfaction, future career choice, and current place of living were significant predictors of empathy scores.

CONCLUSION

Empathy level of medical students of our study was quite low compared to other studies conducted outside India. Empathy eroded with semester, which supports earlier pieces of evidence in this regard.

Understanding Medical Students' Experience with Stress and Its Related Constructs: A Focus Group Study from Singapore

OBJECTIVE

In order to protect medical students from burnout and its untoward psychiatric effects, it is imperative to understand their stress, burnout, coping, and resilience experiences. This study aimed to derive collective definitions from the medical student perspective, to identify common themes of students' experiences, and to distinguish pre-clinical and clinical year students' experiences relating to these four constructs.

METHODS

The authors conducted focus groups of medical students in Singapore across 4 years using a semi-structured question guide. Participants shared their understanding, experiences, and the relationships between stress, burnout, coping, and resilience. Coders independently evaluated construct definitions and derived common themes through an iterative process, and compared transcripts of pre-clinical and clinical year students to determine differences in experience over time.

RESULTS

Nine focus groups (54 students, 28 females, mean age 24.3) were conducted. Students identified common definitions for each construct. Nine themes emerged within three domains: (1) relating constructs to personal experience, (2) interrelating stress, burnout, coping, and resilience, and (3) understanding the necessity of stress. Compared to clinical students, pre-clinical students reported theory-based rather than reality-based experiences and exam-induced stress, defined constructs using present rather than future situations, and described constructs as independent rather than interrelated.

CONCLUSIONS

This sample of medical students in Singapore shares a common understanding of stress, burnout, coping, and resilience, but experiences these uniquely. They perceive a positive role for stress. These findings build upon prior literature, suggesting an interrelationship between stress and its related constructs and adding the novel perspective of students from an Asian country.

Empathy and burnout: a study on residents from a Singapore institution

INTRODUCTION

Empathy and burnout are two entities that are important in a physician's career. They are likely to relate to each other and can be heavily influenced by surrounding factors, such as medical education, local practices and cultural expectations. To our knowledge, empathy and burnout studies have not been performed in Singapore. This study was designed to evaluate empathy and burnout levels using the Jefferson Scale of Physician Empathy (JSPE) and Maslach Burnout Inventory (MBI) among residents in Singapore, and compare them with the United States (US) literature.

METHODS

The JSPE, MBI and a self-designed questionnaire were completed by 446 trainees at a residency-sponsoring institution in Singapore.

RESULTS

Residents in Singapore had lower empathy and higher rates of burnout compared to US literature. Physician empathy was associated with burnout: residents with higher empathy scores had higher personal accomplishment (p < 0.001, r = 0.477, r² = 0.200); and lower emotional exhaustion (p < 0.001, r = 0.187, r² = 0.035) and depersonalisation (p < 0.001, r = 0.321, r² = 0.103) scores.

CONCLUSION

Residents in Singapore had lower empathy and higher burnout scores compared to the US literature. Further research into the underlying cause is imperative to guide intervention.

Emotional intelligence and academic performance of medical undergraduates: a cross-sectional study in a selected university in Sri Lanka

BACKGROUND

Emotional intelligence (EI) has been linked with academic and professional success. Such data are scarce in Sri Lanka. This study was conducted to describe the pattern of EI, to determine its predictors and to determine the effect of EI on academic performance at the final MBBS examination, in medical undergraduates of a Sri Lankan university.

METHODS

This is a cross-sectional study in a selected university, involving those who did final MBBS examination in 2016. Consecutive sampling was done. EI was assessed with self-administered Genos Emotional Intelligence Full Version (7 domains; 70 questions equally weighted; total score 350). Socio-demographic data were obtained using a self-administered questionnaire. Academic performance was assessed with final MBBS results in the first attempt.

RESULTS

Of 148 eligible students 130 responded (response rate-88%); 61.5% were females; mean age was 26.3 ± 1 years. Mean total EI score was 241.5 (females-245.5, males-235.1; p = 0.045).Among different domains, mean score was highest for Emotional Self-Awareness (36.8/50) and lowest for Emotional Expression (32.6/50). Multiple linear regression analysis indicated that having good family support (p = 0.002), socializing well in university (p = 0.024) and being satisfied with facilities available for learning (p = 0.002), were independent predictors of EI. At the final MBBS examination 51.6% obtained classes, 31.5% passed the examination without classes and 16.9% got repeated. Females had better academic performance than males (p = 0.009). Mean EI of second-class upper division, second-class lower division, pass and repeat groups were 249.4, 246.6, 240.2 and 226.9, respectively (with one-way ANOVA p = 0.015). After adjusting for gender, ordinal regression analysis indicated that, total EI score was an independent predictor of final MBBS results [β-0.018 (95% CI 0.005-0.031); p = 0.006].

CONCLUSIONS

In the study population, both EI and academic performance were higher among females. Independent of gender, academic performance was better in those who were more emotionally intelligent. Several psychosocial factors were found to be independent predictors of EI. These results suggest that emotional skills development might enhance academic performance of medical undergraduates in Sri Lanka. Further research is needed in this under-explored area.

The mediating effect of calling on the relationship between medical school students' academic burnout and empathy

PURPOSE

This study is aimed at identifying the relationships between medical school students' academic burnout, empathy, and calling, and determining whether their calling has a mediating effect on the relationship between academic burnout and empathy.

METHODS

A mixed method study was conducted. One hundred twenty-seven medical students completed a survey. Scales measuring academic burnout, medical students' empathy, and calling were utilized. For statistical analysis, correlation analysis, descriptive statistics analysis, and hierarchical multiple regression analyses were conducted. For qualitative approach, eight medical students participated in a focus group interview.

RESULTS

The study found that empathy has a statistically significant, negative correlation with academic burnout, while having a significant, positive correlation with calling. Sense of calling proved to be an effective mediator of the relationship between academic burnout and empathy.

CONCLUSION

This result demonstrates that calling is a key variable that mediates the relationship between medical students' academic burnout and empathy. As such, this study provides baseline data for an education that could improve medical students' empathy skills.

Research trends in studies of medical students' characteristics: a scoping review

The purpose of this study is to investigate domestic and international research trends in studies of medical students' characteristics by using the scoping review methods. This study adopted the scoping review to assess papers on the characteristics of medical students. The procedure of research was carried out according to the five steps of the scoping review. The full texts of 100 papers are obtained and are read closely, after which suitable 88 papers are extracted by us for this research. The review is mapped by the year of the study, source, location, author, research design, research subject, objective, and key results. The frequency is analyzed by using Microsoft Excel and SPSS. We found 70 papers (79.5%) on a single medical school, 15 (17.0%) on multiple medical schools, and three (3.4%) on mixed schools, including medical and nonmedical schools. Sixty-nine (79.5%) were cross-sectional studies and 18 (20.5%) were longitudinal studies. Eighty-two papers (93.2%) adopted questionnaire surveys. We summarized research trends of studies on medical students in Korea and overseas by topic, and mapped them into physical health, mental health, psychological characteristics, cognitive characteristics, social characteristics, and career. This study provides insights into the future directions of research for the characteristics of medical students.

Ethical erosion in newly qualified doctors: perceptions of empathy decline

OBJECTIVES

This study sought to understand whether UK Foundation doctors perceived the phenomena of ethical erosion and empathy decline during their initial period of clinical practice, and if so, why this occurred.

METHODS

This qualitative study used semi-structured interviews with nine doctors in their first year of clinical practice at Royal Bolton Hospital, UK. Participants were invited to discuss the definition of empathy, how individuals acquire and maintain empathic ability, perceptions of ethical erosion in the self and others, and how clinical experiences have influenced their empathic ability. The interviews were transcribed, and analysed to identify emergent themes.

RESULTS

Each participant reported a conscious acknowledgement of empathy decline in their own and their colleagues' early clinical experiences as doctors. Stressful working environments, the prioritisation of patients' physical rather than psychological well-being, and the attitudes of senior colleagues were all suggested as possible causes. Some doctors believed that specialties with reduced patient contact had a culture which precluded empathy, and influenced their own practice. In addition, some described how their value judgements of patients had affected their ability to empathise. However, all doctors perceived that empathy skills were desirable in senior clinicians, and some believed that educational interventions may be useful in arresting ethical erosion.

CONCLUSIONS

Newly qualified doctors are aware of ethical erosion in themselves and their colleagues as they begin clinical practice. This has serious implications for patient care. Improving working conditions may reverse this trend. Empathy skills training within undergraduate and postgraduate curricula may be a useful intervention.