Changes in the Affective Empathy of Osteopathic Students: a Longitudinal Study

Abstract

Background

Establishing an empathic bond of trust with patients is a characteristic that needs to be taught to medical students. Patients feel physicians are more caring if they sense their physician is empathetic. Yet, longitudinal studies have shown an erosion of affective empathy as allopathic medical students progress through their education. Although there are studies examining cognitive empathy among osteopathic students, there has not been a longitudinal study which has examined potential changes in affective empathy.

Methods

During orientation to the Campbell University Jerry M. Wallace School of Osteopathic Medicine (M1 timepoint), and at the beginning of each subsequent academic year (M2-M4 timepoints), and just before graduation (M4F timepoint) the graduating classes of 2017–2019 were asked to voluntarily participate in a longitudinal study by filling out the Balanced Emotional Empathy Scale (BEES), which measures affective empathy. Desired specialty choice and sex was also collected at each of the five timepoints. Specialty choice was divided into Core and Non-Core groups. Core specialties are “people-oriented” and have a large amount of patient contact and continuity of care and include Family and Internal Medicine, Ob/Gyn, Pediatrics and Psychiatry. Non-Core specialties are “technical- or procedure-oriented” and are those with little or no patient contact and/or continuity of care (e.g., Radiology, Surgery, Emergency Medicine, Anesthesiology).

Results

For men, BEES scores significantly dropped over the five timepoints (p < 0.001). While men selecting Non-Core specialties had significant drops in scores (p = 0.001); men who selected the Core specialties did not have a significant decrease. For women there was no significant drop in BEES scores, nor for women selecting Core or Non-Core specialties. Women always had larger BEES score averages than the men. Students selecting Core specialties better maintain their affective empathy than those who select Non-Core specialties.

Conclusion

The decline in affective empathy scores for osteopathic students has differences when compared to a similar longitudinal study of allopathic medical students.

Introduction

No one disputes that forming an empathic bond of trust with patients is an essential trait physicians need to possess [1, 2]. Patient satisfaction, compliance and outcomes are enhanced [3–9], and if a medical error occurs there is a lesser chance of being sued [10, 11]. Although there are myriad definitions for empathy [12], basically there are two different types that have been described: affective (vicarious) and cognitive (role-taking). Affective empathy is defined by Mehrabian and colleagues as “an individual’s vicarious emotional response to perceived emotional experiences of others” [13, 14]. Cognitive empathy, in relation to health professional education and patient care, is defined by Hojat and colleagues as “predominantly a cognitive (as opposed to affective or emotional) attribute that involves understanding (as opposed to feeling) of the patient's pain, experiences, concerns, and perspectives combined with a capacity to communicate this understanding and an intention to help” (italics and parenthetical statements by Hojat, et al.) [15].

Over the past several decades there has been an increased interest in determining the empathic nature of osteopathic and allopathic medical students and how their empathy changes as they progress through their undergraduate medical education, e.g., see refs. [16–21]. Many of these studies show an erosion of empathy after finishing the first year of the basic science curriculum and after the exposure to patients during the first year of clinical rotations [16, 21].

This study examines changes in osteopathic affective empathy that can be measured using the Balanced Emotional Empathy Scale (BEES) developed for the general population by Mehrabian [14]. The BEES has been used in the past to examine, in a cross-sectional or longitudinal fashion, changes in affective empathy among US allopathic medical students, [16] and in studies of allopathic medical students from Ethiopia or Poland [20, 22]. However, to date there have been no studies examining affective empathy changes among osteopathic students in a cross-sectional or longitudinal fashion. To fill this void, this longitudinal study was designed to examine affective empathy in the 2017–2019 graduating classes of osteopathic medical students. These data will be compared to affective empathy norms, as established by Mehrabian. [14]. (Changes in the cognitive empathy of this cohort has already been published [23].)

Like what has been seen with the drop in affective empathy scores in allopathic students [16], our hypothesis is that a very similar decrease in BEES scores will occur with the osteopathic students with significant drops after the completion of the first basic science year and after the first clinical rotation year. We also hypothesize that women will better maintain their affective empathy and that those men and women who enter Core specialties will better maintain their affective empathy than those students who enter Non-Core specialties.

Methods

This longitudinal study was reviewed and approved by the Institutional Review Board of Campbell University (IRB #30). The BEES was voluntarily taken five times by the Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM) classes of 2017–2019 (n = 345/459; 75.2% of the graduates, consisting of 176 women (51%) and 169 men (49%). There were no missing data points for the osteopathic medical students who participated at all five timepoints. Students who did not complete the surveys for all five timepoints (n = 87) were not included in the analyses.

The BEES survey was given to the OMS I students during their orientation to medical school (M1 time-point on tables). This served as a baseline data point since the students had not yet taken any medical school classes. The OMS II-IV surveys were given during the first week of the sophomore, junior and senior years, respectively (M2-M4 time-points on tables and figure). Therefore, the M2 timepoint reflects any changes in empathy scores that occurred after finishing the first basic science year of the curriculum, the M3 timepoint reflects any changes that occurred during the second basic science year, etc. A final, fifth administration of the surveys was given several weeks before graduation (M4F time-point on tables and figure).

In addition to filling out the survey instrument, the students were asked to indicate their sex since the BEES is sex-sensitive with women having significantly higher scores than men [14, 16]. The students were also asked each time to choose which of 23 specialties they desired to enter. Each student was assigned a random ID number so their data could be tracked throughout their undergraduate medical education. The survey instruments were hand scored and the data entered into a password protected Excel spreadsheet.

Survey Instrument

The BEES consists of 30 positively or negatively worded items (15 in each category) measuring responses to fictional situations and particular life events. The survey uses a 9-point Likert scale ranging from + 4 (very strong agreement), 0 (neither agreement nor disagreement), to -4 (very strong disagreement). Higher scores reflect a greater capacity for an individual to be, e.g., altruistic, prosocial, pleasant, and tolerant [14]. BEES scores can range from + 120 to -120. The population norm is a score and s.d. of 45 ± 24; the male norm is 29 ± 28 and the female norm is 60 ± 21. Z-Scores range from ± 2.5 s.d. from the norm. The BEES Cronbach α coefficient is 0.87. Sample items include: “Unhappy movie endings haunt me for hours afterward”, and “I cannot feel much sorrow for those who are responsible for their own misery”.

Z-scores can be used to find what percentile a person or cohort is above or below a norm. These percentiles can be given a named designation, e.g., “slightly higher” or “extremely lower” than the norm. Z-Score designations by Dr. Mehrabian range from ± 2.5 s.d. from the norm and are in 0.5 s.d. increments (See ref. 25 for details of designations and percentiles). Z-scores are calculated by taking the BEES score of an individual (or cohort), subtracting the appropriate norm, and dividing this with the s.d. for that population norm, i.e., just males, just females or the combined population norm.

Like previous studies by the main author [16, 23–25], the 23 specialties were divided into five “Core” and 18 “Non-Core” specialties, with Core specialties representing those with a large amount of patient contact and/or continuity of care, i.e., “people-oriented”. Core specialties are defined as: Family and Internal Medicine, Ob/Gyn, Pediatrics and Psychiatry. Non-Core specialties are represented by specialties which are more “procedure- or technology-oriented” and have minimal or no patient contact or continuity of care. Examples of Non-Core specialties are Anesthesiology, Surgery, Diagnostic Radiology, Emergency Medicine, and Pathology.

Statistical Analysis

The longitudinal dataset was analyzed using IBM SPSS version 26.0 software. [26]. The dataset itself is comprised of both categorical (DO Program Year, Class, Sex, Specialty Choice, and Core vs Non-Core) and numerical variables (BEES scores). By examining the values for skewness and kurtosis, it was determined that the BEES data could be viewed as normally distributed. Therefore, parametric methods were appropriate to use for analysis and thus provide the foundation for the results that follow. These tests include ANOVA, Levene’s Test of Equality of Variances, Independent Samples t-test for Equality of Means, Mann–Whitney U Test and the 2-Tailed Pearson Correlation. Before the data were analyzed, a post-hoc analysis using Tukey’s Honestly Significant Difference (HSD) was conducted to determine true significant differences.

Results

The BEES empathy scores for the three matriculating classes were combined at each timepoint since there were no significant differences in the averaged scores for the entering osteopathic students.

Figure 1 shows the steady decline in affective empathy scores as the osteopathic students progressed through their undergraduate medical education. Overall, as expected, women have larger BEES scores than men [14], regardless if they enter Core or Non-Core specialties. Therefore, women better maintain their affective empathy than men. The combined women BEES score upon entering medical school (M1 timepoint; 55.91 ± 27.81) is slightly lower than the female population norm (60 ± 21), while the combined male BEES score (31.63 ± 24.73) is slightly larger than the male population norm (29 ± 28). Neither of the M1 BEES scores were significantly different from the female and male population norms. Women selecting Non-Core specialties showed a rebound in BEES scores after completing their second year of clinical rotations (M4F timepoint; 9.1% increase) that very closely approached the female Non-Core M1 timepoint. Men showed a steady decline in BEES scores but, unlike the women, there was no rebound in the Non-Core male BEES scores just before graduation. For either sex, the largest drop in BEES scores occurred after finishing the second year of basic science courses (M3 timepoint; 15.7% and 5.0% for men and women, respectively, compared to the M2 timepoint). Numerical details are shown in Tables 1–4; degrees of significance are discussed below.

Fig. 1.

Average BEES scores for DO students selecting Core or Non-Core specialties in the 2017-2019 cohorts

Table 1.

Average M1-M4F male, female, and total BEES scores for DO 2017–2019 cohorts

Survey Timepoint*	BEES
	Male			Female			Total
	N	Mean	Std. Dev	N	Mean	Std. Dev	N	Mean	Std. Dev
M1	169	31.63	24.73	176	55.91	27.81	345	44.02	28.98
M2	169	30.25	24.69	176	53.03	27.05	345	41.87	28.28
M3	169	25.49	28.93	176	50.39	27.89	345	38.19	30.98
M4	169	22.56	28.61	176	48.77	28.43	345	35.93	31.35
M4F	169	20.14	29.66	176	49.57	28.99	345	35.15	32.78
Total	845	26.02	27.69	880	51.53	28.10	1725	39.03	30.67

^*M1 = survey at start of medical school. M2 -M4 = surveys at start of second, third and fourth years, respectively. M4F = survey just before graduation. So, M2 survey reflects the change in BEES scores after finishing the first year of medical school, etc.

Table 4.

Average M1-M4F Female Core vs. Non-Core BEES scores for DO 2017–2019 cohorts

Survey Timepoint*	BEES Female Core			BEES Female Non-Core			BEES Female Total
	N	Mean	Std. Dev	N	Mean	Std. Dev	N	Mean	Std. Dev
M1	91	60.62	25.18	85	50.87	29.69	176	55.91	27.81
M2	97	55.76	26.61	79	49.67	27.38	176	53.03	27.05
M3	110	55.41	24.88	66	42.02	30.69	176	50.39	27.89
M4	128	51.77	28.48	48	40.77	26.99	176	48.77	28.43
M4F	129	51.29	30.03	47	44.85	25.66	176	49.57	28.99
Total	555	54.53	27.43	325	46.42	28.53	880	51.53	28.10

^*M1 = survey at start of medical school. M2 -M4 = surveys at start of second, third and fourth years, respectively. M4F = survey just before graduation. So, M2 survey reflects the change in BEES scores after finishing the first year of medical school, etc.

The male population norm for a BEES score is 29 ± 28; the female norm is twice as large at 60 ± 21; the BEES score norm for the combined population is 45 ± 24. [14]. Table 1 shows the average M1-M4F male and female BEES scores for the three matriculating classes. The male M1 score, obtained during orientation to medical school, was 31.63 ± 24.73, which is not significantly different from the male norm (t = 1.384, p = 0.168). This score steadily dropped during the four years to 20.14 ± 29.66 just before graduation (M4F timepoint). This represents a 36.3% decrease, which is statistically significant at the 0.001 level (t = -3.882, p < 0.001), with a 95% confidence interval for the mean difference of (-13.36, -4.35).

The female M1 BEES score was 55.91 ± 27.81, which is not significantly different (t = -1.952, p = 0.053) than the female population norm (60 ± 21). The female BEES scores steadily dropped until the M4 timepoint (48.77 ± 28.43) with a slight rebound just before graduation (49.57 ± 28.99). Compared to men, the female M1 – M4F scores showed an 11.4% drop which is only one-third the decrease seen in male BEES scores and does not represent a statistically significant decline (F = 1.914, p = 0.106). Compared to the BEES population norm of the combined male and female population ( 45 ± 24) [14], the overall CUSOM combined cohort mean of 39.03 ± 31 is statistically significantly lower (t = -8.08, p < 0.001) with the 95% confidence interval for the mean difference (-7.42, -4.52).

When combining both sexes and looking at the total BEES scores, the overall decline in both males and females shows an overall significant difference in BEES scores (M1-M4F decrease of 20.2%; F = 5.398, p < 0.001). A post-hoc analysis using Tukey’s Honestly Significant Difference (HSD) was conducted to determine between which years the declines were significant in the model. The M4F BEES scores were significantly lower than both M1 and M2 scores (p = 0.001, 0.032, respectively) and the M4 BEES scores were significantly lower than the M1 BEES scores (p = 0.005).

When examining each individual year, the Z-scores for the combined male and female BEES scores were all designated as “average”, i.e., 50th percentile, when compared to the combined male and female population norms established by Mehrabian [14] and decreased from a Z-score of -0.04 to -0.41 at the M1 and M4F timepoints, respectively. (See ref. 25 for an explanation of Mehrabian designations and Z-scores.)

BEES Scores of All Students Selecting Core vs. Non-Core Specialties

In Table 2, a total of 234/345 students (67.83%) selected a Core specialty at the end of their senior year (101/234 men (43.16%) and 133/234 women (56.84%)). A total of 111/345 students (32.17%) selected a Non-Core specialty at the end of their senior year (68/111 men (61.26%) and 43/111 women (38.74%)). Although the data is not shown, the number of male and female graduates entering the Core specialties, in descending order of popularity, were Internal Medicine (n = 93), Family Medicine (n = 77), Pediatrics (n = 31), Psychiatry (n = 19), and Ob/Gyn (n = 14). The most popular Non-Core specialties were Emergency Medicine (n = 28), General Surgery (n = 21), and 11 each for Anesthesiology and Orthopedic Surgery.

Table 2.

Average M1-M4F Core vs. Non-Core BEES scores for DO 2017–2019 cohorts

Survey Timepoint*	Core vs. Non-Core
	Core			Non-Core			Total
	N	Mean	Std. Dev	N	Mean	Std. Dev	N	Mean	Std. Dev
M1	152	50.88	27.48	193	38.61	29.05	345	44.02	28.98
M2	166	46.75	27.49	179	37.35	28.33	345	41.87	28.28
M3	193	44.73	28.64	152	29.89	31.93	345	38.19	30.98
M4	211	42.43	29.83	134	25.69	31.06	345	35.93	31.35
M4F	218	40.35	32.20	127	26.23	31.94	345	35.15	32.78
Total	940	44.55	29.55	785	32.43	30.71	1725	39.03	30.67

^*M1 = survey at start of medical school. M2 -M4 = surveys at start of second, third and fourth years, respectively. M4F = survey just before graduation. So, M2 survey reflects the change in BEES scores after finishing the first year of medical school, etc.

Table 2 shows students selecting a Core residency had a steady decline in M1 – M4F BEES scores from 50.88 ± 27.48 to 40.35 ± 32.20 (20.7% decrease). The overall ANOVA model examining mean differences in Core BEES scores across the five timepoints is significant (F = 3.382, p = 0.009), with the only pairwise significant difference being between M1 and M4F with a p = 0.007 for Tukey’s HSD. Students who selected Non-Core specialties also showed a steady decline in BEES scores from 38.61 ± 29.05 to 26.23 ± 31.94 (32.1%). The overall ANOVA model examining mean differences in non-core BEES scores across the five timepoints is also significant (F = 6.443, p < 0.001). Both M1 and M2 scores are statistically significantly different from M4 and M4F scores, respectively, using Tukey’s HSD (M1 vs. M4, M4F: p = 0.002, p = 0.003; M2 vs. M4, M4F: p = 0.007, p = 0.014).

These data also show that those students who select Core specialties have larger BEES scores than those selecting Non-Core specialties. This difference is seen at each of the five timepoints with M1 Core BEES scores (50.88 ± 27.48) being 24.2% larger than the M1 Non-Core score (38.61 ± 29.05), and M4F Core BEES score (40.35 ± 32.20) being 35.0% larger than the M4F Non-Core BEES score (26.23 ± 31.94). The biggest difference in Core vs. Non-Core BEES scores was at the M4 timepoint (39.5%) that occurs after the students finish their first year of clinical rotations, indicating the students selecting Core specialties better maintained their affective empathy vs. those who selected the technical-/procedure-oriented, Non-Core specialties.

Male vs. Female BEES Scores for Students Selecting Core vs. Non-Core Specialties

Table 3 shows the differences in BEES scores for men who select either Core or Non-Core specialties. The number of men selecting Core specialties steadily increased each year from an n = 61 during orientation to n = 89 at the M4F time point (a 31% increase); conversely, the Non-Core numbers steadily dropped from n = 108 to n = 80 (a 26% drop). The decrease is twice as large for the women who showed a M1-M4F 55.3% drop in those that selected a Non-Core specialty (Table 4). A possible explanation for this change is that a realization occurs among some of the students when they determine they are not competitive for being selected into some of the more competitive Non-Core specialties they initially desired, e.g., Orthopedics, Diagnostic Radiology, or Dermatology, and switch to a Core specialty choice. In addition, straightforward, fact-based conversations with their clinical advisors solidifies their realization they are not competitive for some specialties. (Personal communications with the clinical advisors by the authors). Another explanation for students changing from a Non-Core to a Core specialty, is that during their medical education they find they desire to have more patient contact that occurs with the Core “people-oriented” specialties vs. the procedure/technical-oriented Non-Core specialties that have little or no patient contact and continuity of care.

Table 3.

Average M1-M4F Male Core vs. Non-Core BEES scores for DO 2017–2019 cohorts

Survey Timepoint*	BEES Male Core			BEES Male Non-Core			BEES Male Total
	N	Mean	Std. Dev	N	Mean	Std. Dev	N	Mean	Std. Dev
M1	61	36.36	24.32	108	28.96	24.67	169	31.63	24.73
M2	69	34.09	23.56	100	27.61	25.21	169	30.25	24.69
M3	83	30.58	27.23	86	20.58	29.82	169	25.49	28.93
M4	83	28.04	26.03	86	17.28	30.11	169	22.56	28.61
M4F	89	24.51	28.57	80	15.29	30.27	169	20.14	29.66
Total	385	30.17	26.42	460	22.54	28.28	845	26.02	27.69

^*M1 = survey at start of medical school. M2 -M4 = surveys at start of second, third and fourth years, respectively. M4F = survey just before graduation. So, M2 survey reflects the change in BEES scores after finishing the first year of medical school, etc.

Table 3 also shows there was a steady decline in BEES scores for men selecting Core specialties from a high of 36.36 ± 24.32 during orientation to 24.52 ± 28.54 just before graduation. While this represents a 32.5% drop in BEES scores, the overall ANOVA model comparing means across the five timepoints is statistically significant (F = 2.414, p = 0.049). However, post-hoc analysis with Tukey’s HSD fails to detect a statistically significant difference between any of the five timepoints. Those men selecting Non-Core specialties also showed a steady decline in BEES scores with an M1 score of 28.96 ± 24.67, and an M4F score of 15.29 ± 30.27, representing a significant 47.2% drop in BEES scores. The overall ANOVA model does indicate differences in mean BEES scores across the five timepoints (F = 4.493, p = 0.001), with the M1-M4F mean difference showing the largest statistically significant difference at the p = 0.008 level, again using Tukey’s HSD for post-hoc analysis.

Total Male BEES Z-scores steadily declined over the five timepoints from -0.09 to -0.32, all of which are considered within the “average” range of a normal male population, i.e., 50th percentile, according to Mehrabian [14]. Core males had Z-scores which dropped from + 0.26 to -0.16; both of which are considered as “average” for the male population norm. Non-Core males had Z-scores which dropped from 0.00 to -0.49, which resulted in “average” BEES scores, with the M4F timepoint barely missing a “slightly low” Z-score (i.e., -0.50; 31st percentile) for the male population norm.

Table 4 shows the differences in BEES scores for women who select either Core or Non-Core specialties. The number of women selecting Core specialties steadily increased each year from an n = 91 during orientation to n = 129 at the M4F time point (a 29.5% increase); conversely, the Non-Core numbers steadily dropped from n = 85 to n = 47 (a 44.7% decrease). Once again, these data show a shift from Non-Core to Core specialties as the women progressed through their undergraduate osteopathic education. There was a steady decline in BEES scores for women selecting Core specialties from a high of 60.62 ± 25.18 during orientation to 51.29 ± 30.03 just before graduation, representing a 15.4% decline in female Core BEES scores. The ANOVA model testing the null hypothesis of equality of means across all five timepoints is not statistically significant (F = 1.987, p = 0.095). Those women selecting Non-Core specialties also showed a steady decline in BEES scores with an M1 score of 50.87 ± 29.69, and an M4F score of 44.85 ± 25.66, representing a 11.8% drop in BEES scores, and is also not statistically significant in the overall ANOVA model (F = 1.687, p = 0.153).

Core females had Z-scores which dropped from + 0.03 to -0.41 in the M1 and M4F timepoints, respectively. Both Z-scores are considered as “average” when compared to the female population norm [14]. Non-Core females had Z-scores which dropped from -0.43 to-0.72, which resulted in “average” BEES scores dropping to a “slightly low” designation at the M4F timepoint (31st percentile). Total female BEES Z-scores had a steady decline over the first four timepoints with a slight rebound just before graduation. The scores ranged from -0.19 (M1 timepoint) to -0.53 and -0.50 at the M4 and M4F time points, respectively. These last two Z-scores are considered “slightly low” when compared to a normal female population.

When comparing the Z-scores of men vs. women selecting Core specialties, despite the significant drop in male BEES scores, all the Z-scores were in the “average” range for their respective population norms with women showing a lower Z-score than men (-0.41 vs. -0.16, respectively). The biggest difference in Z-scores occurred among men and women selecting Non-Core specialties. The M1 male Non-Core Z-score had a -0.04 numerical difference off the male population norm (28.96 vs. 29.00, respectively) but dropped to -0.49 at the M4F timepoint. Female Non-Core Z-scores were much lower than those for the men, and the female M1 Z-score was -0.43 and dropped to -0.72 at the M4F timepoint. The female Non-Core M1 Z-score is considered “average” but entered the “slightly low” designation (31st percentile) at the M4F timepoint. Therefore, women selecting Non-Core specialties, from the start of their medical education, had smaller overall affective empathy scores when compared to the men entering the Non-Core specialties.

When examining the extremes of BEES scores right before graduation (M4F timepoint), there were two men and one woman who had “extremely high” BEES scores (Z-score of 2.00 – 2.49; 98th percentile); and two women, but no men, who had “very extremely high” BEES scores (Z-score ≥ 2.50; 99.4 percentile). These five students account for 1.4% of the graduating cohort. Conversely, there were five men and six women who had “extremely low” BEES scores (Z-score of -2.00 to -2.49; 2nd percentile); and seven men and 13 women who had “very extremely low” BEES scores (Z-score ≤ -2.50; 0.6 percentile). So, 31 graduating students (9% of the cohort) had extremely low or very extremely low affective empathy scores.

When converting the decline in BEES scores to percentages from entrance to medical school to just before graduation (M1 and M4F timepoints, respectively), the drop for all male students was three-times larger than the drop seen for the female students (35.8% vs. 11.3%, respectively) Males selecting Core specialties had a drop just over double the female decrease (32.6% vs. 15.4%, respectively). The drop in male Non-Core BEES scores was over four-times greater than the decrease seen for women (47.2% vs. 11.8%, respectively). Therefore, the women better maintained their BEES scores, and presumedly their affective empathy, as compared to the men.

Discussion

To the author’s knowledge, there are no osteopathic data concerning affective empathy, other than the previous studies by the authors and colleagues [25, 27]. Other studies have shown patients perceive differences in how osteopathic vs. allopathic physicians interact with their patients regarding empathic behavior, communication style, interpersonal mannerisms and health outcomes [28, 29]. Because of these perceived differences by patients, and the paucity of osteopathic affective empathy data, the results in the current study are compared to an equivalent longitudinal study by Newton and colleagues of how affective empathy changes in allopathic students during medical school [16].

There are numerous studies that have examined cognitive empathy (via the Jefferson Scale of Empathy) in allopathic and osteopathic schools [e.g., see refs. 21, 23, 30, 31]. In many of these studies the greatest decline in cognitive empathy scores occurred after the completion of the first year of clinical rotations [21, 23, 32, 33]. As these studies show, the decline is greatest for those students who desire to enter Non-Core, technical/procedure-oriented specialties for their residencies [21, 25].

Comparison of Allopathic and Osteopathic Longitudinal Studies

It should be noted that the longitudinal allopathic study did not collect BEES scores just before graduation [16]. Therefore, comparisons of BEES scores between the two schools can only be made up to the M4 timepoint which reflects any changes in affective empathy after finishing the first year of clinical rotations.

In the longitudinal allopathic study, there is a significant drop in BEES scores after the completion of the first year of the basic science curriculum (M2 timepoint) and after the completion of the first year of clinical rotations (M4 timepoint) [16]. Whereas, for the osteopathic students, the largest drop in BEES scores occurred after completion of the second year of study (M3 timepoint). The data also reveals that the allopathic classes of 2001–2004 had entering men and women with larger BEES scores than entering osteopathic men and women in 2017–2019. Like the significant overall drop in total male and female allopathic BEES scores (32.0% and 12.8%, respectively) [16], the male and female osteopathic BEES scores also significantly dropped during their medical school education at the M4 timepoint (28.1% and 12.8%, respectively), with the women having a slight rebound in BEES scores just before graduation (11.8% decrease; M4F timepoint).

When the data are broken down into those students who selected Core or Non-Core specialties at each of the four timepoints, there are differences between allopathic and osteopathic students. For women selecting Core specialties, there was a slightly larger decrease in the osteopathic BEES score vs. the allopathic score after students finished their first basic science year of medical school. After finishing the first year of clinical rotations, allopathic women selecting Core specialties had a larger decrease in BEES scores than the osteopathic students.

The biggest difference between the osteopathic and allopathic students occurred for those women selecting Non-Core specialties. The osteopathic women selecting Non-Core specialties had a BEES score that was stable after finishing the first year of medical school but showed a large drop in after finishing the second year of basic science courses (M2 vs. M3 timepoint). In contrast, the Non-Core allopathic women showed their dramatic drop in BEES scores after finishing the first year of medical school while their BEES score stabilized after finishing the second basic science year.

It is unknown at this time why the drop in BEES scores occurred after finishing different years of the basic science curriculum, since both schools had a “traditional” didactic curriculum for the first two years. Furthermore, after women selecting Non-Core specialties finished the first year of clinical rotations, the allopathic decrease in the BEES score was seven-times greater than the decease seen for osteopathic women (M4 timepoint; -8.79 vs. -1.25 points, respectively). One explanation may be when it became known that most studies showed affective and cognitive student empathy was decreasing during medical school [16, 33, 34], this may have caused medical school administrators to have faculty put an increased emphasis on exposing students to the concepts of empathy during their didactic education and standardized patient encounters, as well as having attending clinicians to practice and promote empathic behavior for their students on rotations.

When examining the overall percentage drop in osteopathic student BEES scores from entrance to medical school to just after finishing the first year of clinical rotations (M1-M4 timepoints, respectively) male Core students have a drop 1.6 times greater than the female Core decrease (22.9% vs. 14.6%, respectively). Allopathic M1-M4 male and female Core scores had decreases, but the male decrease was twice as large as the female Core decrease (25.8% vs.13.0%, respectively). The drop in osteopathic male Non-Core BEES scores was three-times greater than the decrease seen for women (40.3% vs.12.8%, respectively). Allopathic male and female Non-Core scores also decreased, but the male decrease was much less at only 1.3 times as large as the female Non-Core decrease (38.7% vs. 29.3%, respectively). Most likely, the decline in empathy for either sex, and at both types of medical schools, may be attributed to the longer work/study hours, depersonalization/burnout, deidealization, increased cynicism, the hidden curriculum [35–38], and pressures of finally treating actual patients. This can be exacerbated with the realities of clinical year experiences by the student doctors who are subordinate to their attendings and have little or no real authority.

In summary, allopathic students selecting Core or Non-Core specialties see sharp declines in BEES scores after finishing the first and third years of study, whereas only the osteopathic male students selecting Non-Core, but not Core, specialties show a decline after finishing the second year of medical school. Declines for Core men and Non-Core women osteopathic students is not as great as the decreases seen for the corresponding allopathic students, but the Non-Core men and Core women had larger decreases than the allopathic students.

These comparisons of the differing times of the declines in allopathic and osteopathic affective empathy scores does not suggest the stage of their four-year medical education plays a large role in why patients view these two types of physicians differently [28, 29]. However, since women have greater amounts of affective, as well as cognitive, empathy it may be that the greater numbers of female DOs that enter primary care vs. their allopathic counterparts [23–25], combined with the rebound of female DO affective empathy scores after finishing the final year of clinical rotations upon graduation, may be a reason for the DOs as being perceived by patients as having better empathic communication skills than the MDs. Yet, affective empathy scores in the high and, especially, the low extremes may not be advantageous.

Affective Empathy Extremes

Those students who have extremely high (Z-score of 2.00 – 2.49; higher than 98% of a normal population) or very extremely high (Z-score of ≥ 2.50; higher than 99.4% of a normal population) BEES scores are at a greater risk of suffering from job burnout vs. those students who have more moderate affective empathy scores [39–42]. This is due to the cognitive effort it takes to control these affective responses [43, 44]. These overly empathic individuals may not be able to separate their own vicarious emotions when encountering an emotionally charged patient situation which can lead to less effective patient care [12]. Considering there were only five graduating medical students (two men and three women; 1.4% of the cohort) who fell into these categories, this may not be a major concern for the 2017–2019 graduating classes.

However, those 31 graduating students (9% of cohort; 12 men and 19 women) who had extremely low (Z-score of -2.00 to -2.49; lowest 2% of a normal population) or very extremely low (Z-score ≤ -2.50; lowest 0.6% of a normal population) BEES scores are a cause for concern. These individuals may be very competent in their diagnostic and clinical skills but may be lacking in the ability to form an empathic bond of trust with their patients who may feel their physician is distant and uncaring. Studies have shown that the lack of a good “bedside manner” can hamper the relationship with the patient [44–47]; whereas the converse results in better patient satisfaction and outcomes. [8, 9, 48]. This very low amount of affective empathy can be emotionally protective for the physician who has learned to not let patient suffering, or pain they may be inducing on the patient, to negatively impact their use of painful procedural treatments on a patient. In this regard, studies have shown that physicians who, by necessity, must perform a painful procedure on a patient, rate the pain they are inducing as less than individuals who are not physicians [49]. Also, previous research has shown that those male or female graduates who desire to enter residencies that are more procedure-oriented, e.g., various surgical specialties, have lower BEES scores than those who enter people-oriented, primary care specialties [24, 25].

To help those students with extremely low BEES scores, it is important to have excellent role models who can teach, by example, how to communicate with patients and form an empathic bond of trust, as well as introducing into the curriculum how to teach/enhance empathic behavior. [1, 21, 50, 51]. However, it must be mentioned that other studies show that when patients select physicians, many rate their technical expertise above a “good” bedside manner [52, 53].

Limitations

One limitation of this study is that it was performed at a single osteopathic medical school. As mentioned earlier, an unavoidable limitation is the comparison of the longitudinal osteopathic data (classes of 2017–2019) to the only longitudinal study of allopathic student affective empathy (classes of 2001–2004). Although both Universities had a “traditional” medical school curriculum with two years of basic sciences followed by two clinical rotation years, the 13-year difference in the comparison of the graduating classes needs to be considered since the cohorts may have had varied undergraduate experiences. Note, the CUSOM data were gathered before the COVID epidemic changed how the curriculum was delivered.

Conclusions

These data show that affective empathy, via BEES scores, significantly drop for male students from the time they enter medical school (M1 timepoint) until just before graduation (M4F timepoint), but not for female students where there is no significant decline in BEES scores. To a degree, this may be advantageous, since blunting a very large affective empathic response to an emotionally charged interaction with a patient may allow for a physician to treat the patient more effectively vs. being concerned about their own emotions [12, 33, 54].

Overall, male BEES scores have larger decreases as compared to female scores. Those selecting Non-Core, more technical specialties, have larger drops in BEES scores than those students selecting Core, people-oriented, specialties. This osteopathic trend is somewhat similar to what was seen in longitudinal allopathic studies [16]. However, the only significant decline in osteopathic BEES scores was for men who selected Non-Core specialties, whereas allopathic BEES scores significantly declined for both men and women in Core or Non-Core specialties. The hypothesis that the osteopathic students would have significant drops in BEES scores after finishing the first and third years of medical school was not supported. The hypotheses that women would have larger BEES scores than men and that students selecting Core specialties would have higher BEES scores than those selecting to enter Non-Core specialties were supported.

Author Contributions

Drs. Newton and Vaskalis provided substantial contributions to the conception and design of the study, acquisition of data, and analysis and interpretation of data. The article was written by Dr. Newton and edited and approved for submission by Dr. Vaskalis.

Funding

No funding was received for conducting this study.

Declarations

Ethical Approval

The questionnaire and methodology for this study was approved by the Human Research Ethics committee of Campbell University (IRB #30).

Informed Consent

All participants provided written informed consent prior to participation.

Conflict of Interest

The authors have no relevant financial or non-financial interests to disclose that are relevant to the content of this manuscript.