Evaluation of Dental Student Empathy Scores Using Cognitive and Effective Empathy Measures

ABSTRACT

Background

Empathy is stressed as an important component of patient‐centered practice and training within the dental profession, yet assessment of both cognitive and affective empathy among dental students in a US dental school model is sparse.

Aim

To determine if dental students’ cognitive and affective empathy differs by class year, gender, and age in a US dental school model.

Methods

This cross‐sectional study examined self‐reported empathy levels of first to fourth year dental students from a US dental school, using the Jefferson Scale of Empathy‐Health Profession Students (JSE‐HPS) and the Toronto Empathy Questionnaire (TEQ). Questions were scored using a 1‐7 Likert scale (1 = strongly disagree, 7 = strongly agree); associations were tested using ANOVA and two‐sample t‐tests.

Results

Two‐thirds of the dental students (66%) took the survey, n = 280. Most were female (50%), between 19 and 24 years old (52%), and in their first or second year of dental school (66%). The average JSE‐HPS score was 112 ± 11 and the average TEQ score was 91 ± 11. JSE‐HPS scores were significantly different between dental classes (p = 0.012). Fourth year students had significantly lower JSE‐HPS scores than the first and third year students (108 vs. 114 and 114; Tukey's p = 0.022 and 0.044). Females and students < 25 years demonstrated significantly higher empathy both JSE‐HP and TEQ. Cognitive and affective empathy measures were positively associated (Pearson r = 0.63, p < 0.001).

Conclusion

Dental educators should be aware of changes in student empathy levels during dental training to support and promote empathy development across class years within the US dental school model.

1. Introduction

Empathy is generally regarded as an essential element of person‐centered healthcare, and an important part of professional training in the healthcare field [1, 2, 3, 4]. Similarly, dentistry also emphasizes the importance of empathy within the dentist–patient relationship and the dental profession's commitment to service [5].

Historically, there has been a compartmentalization of empathy as either cognitive or affective [6, 7, 8]. Cognitive empathy is described as an “intellectual apprehension of another's emotional state,” whereas affective empathy is “an emotional reaction to another's emotional response” [9]. Within a healthcare context, empathy is regarded as a cognitive attribute, whereby healthcare providers develop “an uncritical understanding of a patient's inner feelings and experiences as a separate individual” [10]. The Jefferson Scale of Empathy (JSE) was developed in 2001 as an instrument to measure physician and medical student empathy, as previously no such population‐specific measure existed for medicine [10]. This scale was specifically designed as a measure of cognitive rather than affective empathy [6, 10]. A Health Professions Student version (JSE‐HPS) was subsequently adapted from the JSE, replacing the word “physician” with “healthcare provider” within the questionnaire items for wider use among students in other health disciplines [11]. Conversely, the Toronto Empathy Questionnaire (TEQ) was developed as a measure of affective empathy by Spreng et al. [9], who described the strength of the TEQ as a useful tool to complement other empathy evaluation approaches such as the JSE‐HPS.

1.1. Environmental Influences on Empathy

In recent years, the focus has shifted to acknowledging the complexity of empathy and its connection with socialization and environment. The differences in empathy observed when comparing health professions [4, 12], subspecialties [6, 13], age or academic year [14, 15], gender [7, 12], and culture [16, 17, 18] suggest that local environmental factors and socialization may influence self‐reported levels of empathy. It has been hypothesized that empathy is also influenced by factors such as stress and burnout [19, 20, 21, 22], educational demands [23, 24, 25], role modeling [15, 23, 25], and changes in self‐perception and professional persona [23, 24, 26]. Studies examining empathy levels in both medical and dental students have suggested that empathy declines throughout training, often coinciding with the introduction of clinical duties [14, 20, 27, 28]. However, several studies suggest that empathy is flexible and can be enhanced through training [2, 8, 29, 30]. There is a lack of studies within US dental schools to provide evidence regarding the effect of the US dental school environment on its students’ empathy.

1.2. Empathy in Dental Professional Training

Empathy within medical training has been extensively examined in the literature [20, 28, 31]. However, less attention has been paid to empathy within dental training, particularly within the US given its predoctoral education model [2, 4, 32, 33]. Haddad et al. suggest empathy training has been overlooked in dentistry due to the numerous technical skills that must be taught in a limited time frame [25]. An ever‐expanding dental curriculum leaves little time for the training and development of pro‐social skills such as empathy.

Typically, these prior studies examine only dental student cognitive empathy and are cross‐sectional in design, using self‐report measures to quantify empathy levels via the JSE‐HPS. There have been numerous prior studies of cognitive empathy focused solely on dental student programs from outside the US, including Europe [2, 18, 25, 34], Africa [13, 35], Asia [3, 16, 24, 36, 37, 38], Canada [39], and Central and Latin America [15, 17, 40, 41, 42]. However, there are only two reported studies that included US dental students [4, 27] utilizing the JSE‐HPS and only one was focused solely on dental students [27]. Dental education program models outside the US and Canada are typically a post‐secondary undergraduate program that includes a 4 to 6 year Bachelor of Dental Science (BDS) degree. These programs may have integrated and/or subsequent internships or possible additional graduate training (MS and PhD) [43, 44, 45]. Programs such as those will typically enroll younger students with less prior educational experience than students in US professional school dental programs, Doctor of Dental Surgery program (DDS), or Doctor of Dental Medicine (DMD), which generally require a bachelor's degree prior to enrollment. Given the likely influence of local environmental factors on empathy, enrollee and programmatic differences within the US, as compared to international models, could affect dental student empathy in US‐based programs.

Regarding the measurement of affective empathy, only two studies measured affective empathy in dental student populations. Rosenzweig et al. evaluated both affective and cognitive empathy to assess the effectiveness of a person‐centered care course on empathy in fourth‐year French dental students, as compared with a non‐intervention control group [2]. No statistically significant improvement was found in the treatment group, but a decline was noted in the control group. Ghaus et al. examined affective empathy levels before and after the COVID‐19 pandemic at two Pakistani dental schools and found an increase in the mean post‐test empathy scores [37]. To the authors’ knowledge, no studies have evaluated affective empathy in US dental students.

This study aimed to examine the cognitive and affective empathy of dental students from a US dental school model by class year, gender, and age and to assess if there is a relationship between cognitive and affective empathy.

2. Materials and Methods

2.1. Ethical Review

The study protocol was reviewed by the University of Missouri‐Kansas City Institutional Review Board and determined exempt following Federal Regulations 45 CFR Part 46.101(b) (IRB Protocol #19‐064). The reviewing IRB determined that written or verbal consent would be waived for this study, as the consent form would be the only identifier linking the participant to their responses. To ensure participant anonymity, an IRB‐approved information script was read to all potential participants immediately prior to survey administration in lieu of written or verbal consent.

2.2. Study Design and Sampling

This cross‐sectional, observational study was conducted at a dental school in the Midwestern United States. The study participants were students in their first to fourth year of predoctoral dental education; each member of the first (n = 106), second (n = 108), third (n = 104), and fourth (n = 105) year dental school class was invited to take the survey during the spring term of the academic year. Participants did not receive course credit for completing the survey, nor were there any repercussions for declining to participate. Limited demographic information was collected in the IRB‐approved survey to ensure anonymity for the participants.

Data were collected via anonymous paper surveys and recruitment was standardized by a verbal information script presented to students by study personnel in each dental school year during a class period in the spring semester prior to survey administration. Voluntary completion of the survey was considered as consent to participate in the study. To maintain anonymity, each survey was returned to a slot in the collection box away from the view of the distributors whether complete or not. To ensure confidentiality, identifiers that would link students’ responses back to the specific student were not used.

2.3. Survey Instrument

Permission was obtained to use two scales to measure dental student empathy: the JSE‐HPS which was designed to measure cognitive empathy in health professional students and TEQ that measures affective empathy [9, 10]. The survey had a total of 36 empathy‐related questions and three demographic questions, taking approximately 5–10 min to complete. Survey questions 1–20 correspond with the JSE‐HPS and questions 21–36 with the TEQ (Supporting Information S1).

The JSE‐HPS and the TEQ are validated instruments for the measurement of empathy [9, 27]. The assessment of each of the 36 empathy‐related questions was scored using a 1–7 Likert scale (1 = strongly disagree, 7 = strongly agree). Both instruments were individually scored by summing the responses. To make the survey questions more consistent and easier to complete for the respondents, the TEQ's scale was converted from a 1–5 to a 1–7 Likert scale assessing strength of agreement to match that of the JSE‐HPS. In both the JSE‐HPS and TEQ, negatively phrased questions were reverse‐scored. Scores for the JSE‐HPS can range from 20 to 140 and scores for the TEQ can range from 16 to 112.

Demographic information collected included participant gender (male or female), year in DDS program (first year through fourth year), and age. Age was collected categorically with responses consisting of age in 3‐year ranges (19–21, 22–24, … 49–51, > 51). To ensure that each age category had a sufficiently large sample size for analysis, we created a binary age variable with two categories: those under 25 years old and those 25 years old or older. At the time of survey development, the use of the term “gender” rather than “sex” to distinguish male and female participants was determined by the authors to be more culturally appropriate. To maintain consistency with the original survey, the authors have continued use of the term “gender” within this report. As the survey was intended to be anonymous, a minimal number of demographic variables were collected to limit the potential for re‐identification of responses. The characteristics of the dental student population at the University of Missouri‐Kanas City School of Dentistry would have allowed for individual identification if additional variables were to be collected.

2.4. Data Analysis

Surveys were classified as “complete” and included in the analysis if the survey had 80% completion for the questions on JSE‐HPS (16 of 20 questions answered) and 81% of the questions answered on the TEQ (13 of 16 questions answered). Age was categorized into two groups (< 25 years of age, 25 years and older) for final analysis. Associations between empathy scores for both JSE‐HPS and TEQ with class year were analyzed using one‐way ANOVA with Tukey's post hoc test. Associations for both JSE‐HPS and TEQ scores with gender and age were assessed using two sample t‐tests with equal variance. Stratified associations between JSE‐HPSs and TEQ scores and demographic variables within gender were tested using a two‐sample t‐test with equal variance (age) and using a one‐way ANOVA and Tukey's post hoc (class year). Significance was set a priori to α = 0.05.

3. Results

There were 280 dental students who completed the survey, a response rate of 66% (Table 1). The majority of participants were female (50%), between 19 and 24 years old (52%), and in their first or second year of dental school (66%). The mean score for the results of the JSE‐HPS was 112 ± 11 with a range of 81–140. For the TEQ, the mean score was 91 ± 11 and scores ranged from 56 to 112 (Table 1).

TABLE 1.

Total sample characteristics.

	N = 280
	N (%)
Age (years)
<25 years old	146 (52%)
≥25 years old	133 (47%)
Missing	1 (1%)
Class year
First year	97 (35%)
Second year	87 (31%)
Third year	45 (16%)
Fourth year	51 (18%)
Gender
Female	141 (51%)
Male	130 (46%)
Unidentified	9 (3%)

There was a significant difference in JSE‐HPS scores between dental student class years (p = 0.012) (Table 2). The fourth year students had significantly lower scores than the first and third year students (Tukey's post hoc p = 0.022 and 0.044, respectively). Female participants scored significantly higher on the JSE‐HPS than male participants (p < 0.001). Participants under the age of 25 scored significantly higher than those over the age of 25 on the JSE‐HPS (p = 0.005) (Table 2).

TABLE 2.

Associations between Jefferson Scale of Empathy and Toronto Empathy Questionnaire and demographic variables.

		JSE‐HPS		TEQ
	N	Mean (SD)	p‐value	Mean (SD)	p‐value
Age (years)			0.005 *		0.032 *
<25 Years	146	113.4 (10.1)		92.7 (10.7)
≥25 Years	133	109.7 (12)		89.9 (11.3)
Class Year			0.012 **		0.121 **
First year	97	113.6 (10.1)		92.0 (10.9)
Second year	87	110.6 (11.6)		91.9 (11.4)
Third year	45	114.0 (12)		92.7 (10.8)
Fourth year	51	108.0 (11)		88.1 (10.7)
Gender			< 0.001 *		<0.001 *
Female	141	114.2 (10)		95.7 (9)
Male	130	109.2 (11.7)		86.9 (11.1)

^*Calculated using a two‐sample t‐test with equal variances.

^**Calculated using one‐way ANOVA.

Age and gender are significantly associated with TEQ scores. Female participants scored significantly higher on the TEQ than male participants (96 vs. 87, p < 0.001). Participants under the age of 25 scored significantly higher than those over the age of 25 (p = 0.032) (Table 2).

Age was also significantly associated with JSE‐HPS and TEQ scores respectively when stratified by gender. There was a significant association between the JSE‐HPS and age in male participants (p = 0.02). Male dental students less than 25 years old had significantly higher JSE‐HPS scores than male dental students 25 years or older (Table 3).

TABLE 3.

Associations between Jefferson Scale of Empathy and demographic variables within gender.

	In females			In males
	N	Mean (SD)	p‐value	N	Mean (SD)	p‐value
Age (years)			0.10 *			0.02 *
<25	83	115.1 (9.7)		57	111.8 (9.6)
≥25	57	112.9 (10.4)		73	107.2 (12.8)
Class year			0.16 **			0.07 **
First year	49	115.8 (8.9)		47	111.6 (10.8)
Second year	47	112.0 (11.1)		35	109.2 (11.6)
Third year	23	116.7 (10.1)		20	110.4 (13.5)
Fourth year	22	112.9 (9.4)		28	104.3 (11.1)

^*Calculated using a two‐sample t‐test with equal variances.

^**Calculated using one‐way ANOVA.

There was also a significant association between TEQ scores and age in female participants (p = 0.01). Female dental students less than 25 years old had significantly higher TEQ scores than female dental students aged 25 years or older (Table 4). In all instances, female participants scored higher than male participants on both JSE‐HPS and TEQ (Tables 3 and 4).

TABLE 4.

Associations between Toronto Empathy Scale and demographic variables within gender.

	In females			In males
	N	Mean (SD)	p‐value	N	Mean (SD)	p‐value
Age (years)			0.01 *			0.93 *
<25	83	97.3 (8.7)		57	87.0 (9.6)
≥25	57	93.3 (9.0)		73	86.8 (12.1)
Class year			0.15 **			0.44 **
First year	49	96.3 (9.4)		47	87.8 (10.8)
Second year	47	96.8 (8.9)		35	86.0 (10.4)
Third year	23	95.7 (8.5)		20	89.5 (12.6)
Fourth year	22	91.7 (8.3)		28	84.7 (11.3)

^*Calculated using a two‐sample t‐test with equal variances.

^**Calculated using one‐way ANOVA.

There is a significant positive linear correlation between the JSE‐HPS and the TEQ (Pearson r = 0.63, p < 0.001). As the TEQ score increases, JSE‐HPS increases (Figure 1).

FIGURE 1.

Pearson correlation between the Jefferson Scale of Empathy Score and the Toronto Empathy Questionnaire Score.

4. Discussion

The goal of this study was to investigate levels of cognitive and affective empathy among US dental students in a predoctoral dental education model by class year, gender, and age, as well as to assess for a potential relationship between cognitive and affective empathy via the JSE‐HPS and TEQ instruments. This study found associations between gender and empathy as well as between age and empathy. In this population of dental students, a significant change in cognitive empathy was also noted between class years. Cognitive empathy as measured by the JSE‐HPS was found to be correlated with affective empathy as measured by the TEQ.

4.1. Class Year Differences

There were significant differences in the JSE‐HPS by class with first and third year students demonstrating significantly higher cognitive empathy scores compared to fourth year students (p = 0.022 and 0.044). There was no significant difference in affective empathy between class years within the TEQ. The fluctuations in JSE‐HPS scores and lack of significant change in the TEQ scores between class years seen in this study do not present a clear declining trend as noted in earlier literature [14, 27]. Instead, the results align with more recent research suggesting variability in empathy throughout training [24, 32, 42]. Similar trends by class year in JSE‐HPS mean scores were also seen in a 2017 study of Chilean dental students and a 2021 study of Northern Indian dental students [24, 40]. This study's findings showed that both the JSE‐HPS and TEQ scores trended higher in first and third class years and lower in second and fourth, although to a non‐significant degree for second year JSE‐HPS comparisons and for TEQ scores.

It was initially suspected that lower scoring class years may have been affected by a varying proportion of male versus female respondents between the class years. However, the stratified analysis of class year by gender revealed that the variation in class year was not affected by gender. Although this study found that female participants and those under 25 years of age trended towards higher levels of empathy as compared to male participants and those over 25 years of age, neither gender nor age can fully explain the variability in JSE‐HPS scores between class years. It may be that the stress and rigor of the US dental school environment primarily accounts for the change in JSE‐HPS scores by class year, rather than demographic variables [24, 25, 42, 46].

Dental training is known to be particularly demanding upon one's intellectual, psychological, and interpersonal abilities, with high prevalences of stress, anxiety, and burnout noted among dental students [47, 48]. Both preclinical and clinical students have reported academic stress as the main contributor, followed closely by clinical pressures such as difficult patient interactions and learning new procedures [48]. At the dental school where the study was conducted, the second and fourth years are considered the most stressful class years, based on informal student feedback given to the study investigators. Here, the second year includes a rigorous preclinical curriculum that determines whether the student is ready to transition into the clinically based training component of the curriculum for the remaining 2 years. During the fourth year, students have individually expressed that their stress is related to factors such as completing all required clinical competencies, taking licensure exams, and beginning dental practice or residency. Such factors unique to second and fourth years may account for some of the decrease in empathy seen in the current study findings for these years.

4.2. Age Differences

In this study, dental students under the age of 25 scored higher than their classmates over the age of 25 across both instruments. The association between age and empathy level was also significant when stratified by gender. Younger male dental students scored higher than older male dental students on the JSE‐HPS (p = 0.02), and younger female dental students scored higher than older female dental students on the TEQ (p = 0.01).

Among prior studies, differences in empathy by age are subject to variability. A 2011 study of health professional students including dentistry at the University of the West Indies found that students over the age of 27 had higher levels of empathy than those younger than 21 [12]. A 2012 study of first year dental students in the United Kingdom showed no correlation between age and mean JSE score [34]. In 2016, higher empathy among dental students younger than 25 years was found in a study in India [36]. A study at a Caribbean dental school in 2022 found that empathy was higher in clinical students than preclinical, and higher in professors than students, suggesting that empathy increases with time and professional experience [15]. Note that the prior studies were conducted within non‐US undergraduate BDS models, thus, the variance in empathy among age groups may be affected by the social and cultural context of these different locations as well as the individual experiences of the participants at different life stages.

4.3. Gender Differences

Female participants scored higher than male participants on both the JSE‐HPS and TEQ (p < 0.001), which is consistent with a study of two dental institutions in India in 2016 and a study of French dental students and educators conducted in 2023 [25, 36]. While it is commonly assumed that women are, or are socialized to be, more empathetic than men, several recent studies have noted no significant difference in empathy levels between genders among dental students [4, 17, 18, 38, 42]. A systematic review by Narang et al. conducted in 2019, found that in three of the seven studies reviewed, male dental students had higher mean cognitive empathy scores than female dental students [32]. The causes of variability between genders in self‐reported empathy measures warrant further investigation.

4.4. Relationship between JSE‐HPS and TEQ

In the current study, there is a strong correlation between the JSE‐HPS and TEQ. This supports the idea that cognitive and affective empathy are related traits. As affective empathy increases, cognitive empathy increases as well. When examining scores by class year, only the JSE‐HPS showed a statistically significant change between years (p = 0.012). While the change in TEQ scores did not reach significance, the change in mean scores between years did exhibit a similar declining trend as the JSE‐HPS. Thus, the JSE‐HPS may be a more sensitive measure of dental student empathy than the TEQ.

4.5. Limitations and Recommendations

The overall survey response rate for this paper‐based survey was 66%, which is above the average response rate for paper‐based surveys (56%) reported previously [49]. Self‐report bias is an inherent limitation of using self‐report measures. It is noted for gender in particular that social desirability bias can affect self‐reported scores [50]. Observations of behavior by qualified examiners or patient satisfaction surveys could be used to eliminate the bias of self‐report measures. Due to the sample being limited to one dental institution, these results may not be generalizable to a wider population of students. In addition, the cross‐sectional methodology only allows for a snapshot of empathy between class year, gender, and age at a single time point.

The change in the TEQ scale from 5 to 7 Likert response options could limit the quantitative comparisons of the scale values overall and for each question with other studies using the original scoring. However, the qualitative values of the data may not be as impacted. In addition, it has been found that changing the number of response categories does not appear to substantively impact scale statistics, such as inter‐rater and test‐retest reliability, as well as validity [51]. At the time of survey development, the primary concern was that changes in scale formatting mid‐survey could affect the respondents’ interpretation and may not yield the same results if retaken using the original scale [52].

The timing of data collection and other factors related to the academic cycle could be a source of bias in this study. The survey was administered towards the end of the spring semester, so factors such as exam stress and poor class attendance, as observed in the more‐clinically focused years (third and fourth) class years, could have influenced the survey responses through confounding effects and selection bias. While it is not possible to isolate the effect of academic stress or end‐of‐semester timing within this study, placing the results in the context of each class year's didactic workload may offer insight into this potential covariate. Here, high empathy scores were recorded for the preclinical examination‐heavy year (first year), while low empathy scores were also observed in a didactically lighter, clinical year (fourth year). These results suggest a more complex relationship between student empathy and its potential modulating factors, including didactic and clinical curriculum stress.

The effects of academic and clinical pressures, burnout, and faculty role‐modeling on the development of dental student empathy should be further explored. These factors could be considered for inclusion as covariate measures in future study designs, optimally via a longitudinal design incorporating responses from multiple dental institutions. In addition, the use of a mixed‐methods design, pairing qualitative assessment of student experiences along with JSE‐HPS data, could be used to further hone in on the mechanisms influencing dental student empathy.

Enhancing dental student empathy is a challenging and multi‐faceted issue. Suggested activities include a range of self‐reflection exercises, small group discussions, faculty role‐modeling, and patient‐led interactions [4, 8, 23]. Training efforts should go beyond a single summative endpoint and instead be approached as a philosophy or an on‐going humanistic practice that strengthens the students’ ability to cope with difficult emotions, deal with uncertainty, and contend with patients’ subjective experiences of disease [8, 23]. Role‐modeling of the desired behaviors should be performed by both students and faculty mentors alike due to the strong influence of faculty on molding student perspectives and professional persona development [4, 23, 53]. Effective strategies to enhance empathy in dental students will likely be multi‐modal, experiential, and occur throughout the curricula [4, 8].

5. Conclusions

Dental students in their first and third years had significantly higher levels of cognitive empathy as compared to fourth year students, while affective empathy did not change between class years. This may be explained by the increased stress associated with the US dental curricular environment. Comparing trends and significance findings between the JSE‐HPS and TEQ, the JSE‐HPS appears to be a more sensitive measure in this study population. Female and younger participants were found to have higher levels of cognitive and affective empathy than male or older participants. As the JSE‐HPS and TEQ scores relate to overall empathy expression, the results of this study suggest that higher cognitive empathy is linked to higher affective empathy. Dental educators should be aware of the variation in empathy level by class year, gender, and age. Understanding when and why students struggle to develop or maintain empathy during dental training is important to facilitate the development of empathetic dental professionals. Thus, empathy training should be tailored to meet the needs of various dental student demographics and educational models.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting File 1: jdd70131‐sup‐0001‐SuppMat.pdf