Multiple cross-sectional assessments of empathy in medical undergraduate students

Abstract

Introduction:

Empathy a cognitive phenomenon, with affective and behavioral components; helps improve clinical competence. It varies depending on physicians' gender and specialty. While some western studies reported significant fall in empathy levels when they progressed from non-clinical to clinical training years, Asian studies including Indian had varied results. We hypothesize that empathy will decrease among medical undergraduates over four years while they progress from non- clinical to clinical rotations and that female medical students and those opting for clinical specialties will have higher empathy than male medical students and those opting for non clinical specialty.

Methodology:

This study was carried out in a medical college from the year 2012 to 2015. Each year at the beginning of academic session all students were asked to complete Jefferson's -Scale for Physician's Empathy (JSPE student) student version. Over next three years similar assessments were repeated for all batches. The results were tabulated and analyzed using EpiInfo7 software.

Results:

Over four years 481, 416, 412 and 354 medical students in 1^st, 2^nd, 3^rd and 4^th year respectively from seven different batches were evaluated. Choice of specialty differed significantly in each year different batches. The empathy score had no relation to gender or choice of specialty. Empathy declines from first year onwards till third year but is not statistically significant.

Conclusion:

In this large multiple sample cross sectional study, it is evident empathy drops from 1^st to 3^rd year therefore there is an urgent need to evaluate why empathy falls.

The word empathy is derived from Greek word “empatheia” meaning affection or passion with a quality of suffering.[1] Empathy is essentially a cognitive phenomenon, but also involves affective sensitivity to patients' needs and a behavioral ability to communicate the same to him/her.[2] William Osler very aptly summed up empathy when he had said “It is as important to know what kind of a man has the disease as to know what kind of a disease has the man.”[3] Empathy among physicians is known to vary depending on their personality[4] and choice of specialty.[5]

Change in empathy occurs among medical students as they progress from nonclinical to clinical training. While some Western studies found a significant fall,[6,7,8] others from Iran and Korea did not find a similar change; on the contrary among Japanese medical students, empathy improved.[9,10,11] Studies have shown that medical students who plan to pursue people-oriented specializations such as internal medicine, family medicine, psychiatry, and pediatrics, showed higher empathetic scores and across all years of study; than those who choose to pursue technology-oriented specialties such as radiology, surgery, and anesthesiology.[7,12] These changes may also be influenced by gender, where women tend to have more empathy than men across various years of medical education.[6,7,11,13,12,13,14,[15] However, one study from Iran did not find any significant difference, though women did score more than men.[9] Similarly, changes have been noted in a study from India in a cross-sectional study.[16]

All these studies have been of single cohorts. There have been very few longitudinal studies. Thus, there is a need to study multiple batches of medical students serially, to assess if these changes are persistent over the years. A 4-year longitudinal study was undertaken and data of four different batches in each year of medical training were also collected. The latter is being presented and discussed in this article while the longitudinal study will be presented separately.

METHODS

This study was carried out in a medical college from 2012 to 2015. Each year at the beginning of the academic session all students present in class on a particular day (same for all batches in all years) were asked to fill up Jefferson's Scale for Physician's Empathy-Student Version (JSPE student). Institutional and individual consents were obtained beforehand. Over the next three years, similar assessments were repeated for all batches.

Participants were assured of confidentiality. Forms were coded to avoid identification of the student by assessors, by a person not associated with the study (the course of medical education is divided into nine terms of 6 months duration each. This college has 105 men and 25 women in each term. All first-year students were present at evaluation, but some from other years were absent on the day of evaluation.) The first-year students had completed a month of medical education following admission and second-year medical students had finished a month of clinical rotations. The final-year students were 3 months away from final examinations.

JSPE-Student Version was administered at their respective classrooms. Demographic parameters such as age and gender, together with the choice of specialty were recorded. Permission of the principal author of JSPE was obtained for utilizing it. The scale was completed in about 30 min and returned to the researcher.

The effect of choice of specialization on empathy was assessed by grouping the choice of subjects of students into technologically oriented (pathology, surgery and surgical subspecialties, radiology, radiation oncology, and anesthesiology) and people-oriented (internal medicine, family medicine, pediatrics, neurology, rehabilitation medicine, psychiatry, emergency medicine, obstetrics and gynecology, ophthalmology, and dermatology) as done by Hojat et al.[12] Those who chose any other participants or were undecided were classified as others.

Scales for measuring empathy have been as varied as the definitions of it have been. Interpersonal reactive index (IRI) is a 28 item scale with four subcategories measuring different dimensions of empathy such as “perspective taking” “empathetic concern” and “personal distress.” IRI taps both emotional and cognitive empathy.[17] The Balanced Emotional Empathy Scale is a well-established 30 item scale for measuring empathy, especially vicarious empathy, however, due to it being gender-sensitive, men tend to score lower than women.[6] Emotional empathy scale includes 33 items.[18] However, none of these have been developed in a specific patientdoctor context, and more specifically among medical students.

JSPE student is specially designed to study empathy among medical students. It is a psychometrically validated instrument, consisting of twenty statements for which the respondent can indicate their level of agreement on a seven-point Likert scale. Thus, possible score ranges from 20 to 140. The level of empathy is directly proportional to the score. Ten of the items are negative statements and are marked in reverse order.[12] The validity and reliability of this scale have been well demonstrated. The Cronbach's alpha internal consistency estimate for the 20 items on the JSPE was 0.76.[15] This scale had been used across the world to measure empathy among resident and practicing doctors, paramedics, as well as medical students. In India so far, no such study has been done on medical students. The students undergo medical training in English; hence the English version of the scale was used.

The data collected were tabulated in MS Excel and analyzed using Epi Info is statistical software for epidemiology developed by Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia (USA), under the guidance of a statistician.

RESULTS

A total of 481 students in first year, 461 in second year, 412 in third year, and 354 in fourth year completed the JSPE (student). Gender distribution is described in Table 1. The number of females to male ratio was not significantly different among different batches in each year of study. Batch 1 was followed up for all 4 years, the results of this follow-up and its analysis shall be discussed in another article under preparation. The batches two and five were followed up for 3 years, while batch three and six were followed up for 2 years. Batches four and seven were assessed only once. Analysis revealed a decline in empathy from first to second and then the third year with a small raise in the fourth year [Figure 1]. However, the differences were not statistically significant (P > 0.05).

Table 1.

Empathy scores: Gender wise, in different years of medical education

Empathy
Year	Gender	n	Mean	SD	Minimum-maximum	Mean rank	Mann-Whitney test asymptotic significance (two-tailed)
First	Male	392	92.17	13.905	35-139	242.30	0.66
	Female	89	89.64	14.193	46-136	235.27
Second	Male	333	87.98	12.783	44-134	202.51	0.04
	Female	83	92.51	14.538	70-135	232.55
Third	Male	323	89.53	13.612	33-137	204.47	0.51
	Female	89	90.87	14.910	50-133	213.85
Fourth	Male	274	89.59	11.811	48-137	177.21	0.92
	Female	80	89.53	11.730	62-121	178.49

There is increase in empathy among females in the second year, while in males there is a fall, causing a significant difference. In later years, the difference becomes insignificant, as in the first 1^st year. SD – Standard deviation

Figure 1.

Change in mean empathy from the first year to the fourth year of medical education

DISCUSSION

This study is the first one from India that has recorded empathy of seven different batches of medical students over 4 years. It was conducted in a single medical college.

An interesting finding of this study was that irrespective of which training year the first assessment was done, the mean empathy score was always higher than at the next assessment [Table 2]. This raises a pertinent point that students are likely to overestimate their empathy when assessed the first time. These participants were unaware of either their individual scores or the group mean scores until the whole study was completed. One explanation could be that this instrument has not been validated for Indian medical students. However, could it be that even among other nations' medical students, similar results would be found? There have been no studies where for four consecutive years all batches had been assessed, as in this study.

Table 2.

Empathy scores: Year wise in different years of medical education

Assessment year	n	Mean	SD	Minimum-maximum	Mean rank	Kruskal-Wallis Test
1st year
Batch 1 (2011)	88	106.19	20.911	35-139	381.35	χ2=110.107
Batch 2 (2012)	130	85.90	8.214	50-114	213.46	df=3
Batch 3 (2013)	133	85.86	8.012	65-111	208.87	Asymptotic significance=0.000
Batch 4 (2014)	130	85.67	7.987	56-107	206.41
Mean of all batches		90.905
2nd year
Batch 1 (2012)	88	89.08	8.412	76-135	223.05	χ2=78.071
Batch 2 (2013)	128	83.84	7.774	60-106	158.42	df=3
Batch 3 (2014)	112	85.36	8.412	62-105	183.38	Asymptotic significance=0.000
Batch 5 (2011)	88	100.52	19.966	44-134	298.76
Mean of all batches		89.7
3rd year
Batch 1 (2013)	87	85.80	8.377	49-106	180.16	χ2=116.530
Batch 2 (2014)	124	85.08	7.383	64-111	163.23	df=3
Batch 5 (2012)	87	83.85	10.318	50-105	161.23	Asymptotic significance=0.000
Batch 6 (2011)	114	102.60	16.711	33-137	308.21
Mean of all batches		89.3325
4th year
Batch 1 (2014)	88	87.42	9.973	62-137	158.77	χ2=35.569
Batch 5 (2013)	88	87.38	9.265	48-109	164.70	df=3
Batch 6 (2012)	100	87.04	8.020	64-109	157.84	Asymptotic significance=0.000
Batch 7 (2011)	78	97.73	16.034	53-130	238.28
Mean of all batches		89.8925

It is interesting to note that empathy measured in 2011 was significantly higher than other samples in all years of medical training. SD – Standard deviation; Df – Degree of freedom

Female participants scored higher on empathy than males, in all years of study. However, this reached significant levels only in the second year (P = 0.04) [Table 1]. This is in consonance with studies from the USA, Portugal, and Japan.[7,11,19] However, the study from Iran did not find a significant difference, though women did have higher mean scores (105.6 vs. 103.7).[20] The difference in this study from the Iranian one could be due to the different proportion of women to men in both studies (26.19% vs. 70.16%). Women are probably less affected by factors that tend to diminish empathy. It could also be that they can handle pressures of medical life much more easily. However, these aspects have not been explored in this study and merit further research.

Empathy scores are uniformly higher among those choosing technology-oriented specialties, compared to other specialties, except in the first year [Table 3]. In all years of study, there are significantly larger number of students preferring technology-oriented specialties over either of the other two categories, with the undecided being the lowest [Table 4]. This difference in empathy scores is significantly higher among those preferring technology-oriented specialties, only in the second year. The undecided has the lowest empathy score in all years of study. In an earlier cross-sectional study, no significant difference in empathy scores was noted among those choosing different groups of specialty (P = 0.2468).[16] However, Chen et al. found students preferring people-oriented specialties having significantly (P = 0.002) more empathy, than those preferring technology-oriented specialties.[7] Hojat et al. on the contrary found a decline in empathy scores among those choosing technology-oriented specialization, in the third year.[12] The curriculum in this college is in many respects different from medical schools in the US, Japan, Iran. The students are exposed to clinical rotation from the second year onwards.

Table 3.

Empathy scores: Specialty wise, in different years of medical education

Empathy
Year	Specialty choice	n	Mean	SD	Minimum-maximum	Mean rank	Kruskal–Wallis Test
First	Person oriented	182	91.38	15.066	35-136	253.80	χ2=4.857
	Technology oriented	193	89.60	14.514	44-139	242.38	df=2
	Undecided/others	106	86.25	9.776	40-116	216.51	Asymptotic significance=0.088
Second	Patient oriented	162	89.13	13.038	44-135	210.48	χ2=7.239
	Technology oriented	176	90.22	14.794	46-134	220.67	df=2
	Undecided/others	78	85.37	8.816	63-115	176.92	Asymptotic significance=0.027
Third	Patient oriented	171	88.32	11.260	64-122	197.19	χ2=2.172
	Technology oriented	177	91.15	15.493	33-137	215.96	df=2
	Undecided/others	64	90.14	15.351	50-133	205.21	Asymptotic significance=0.338
Fourth	Patient oriented	143	90.85	11.893	64-137	186.08	χ2=1.903
	Technology oriented	167	88.90	10.754	48-122	173.35	df=2
	Undecided/others	44	87.95	14.664	53-125	165.35	Asymptotic significance=0.386

Only in second year, empathy significantly varied, according to choice of specialty. SD – Standard deviation; Df – Degree of freedom

Table 4.

Choice of specialty

	Patient oriented	Technology oriented	Undecided/others	Total	Value	df	Asymptotic significance (two-sided)
Year 1
Batch 1	47	34	7	88	25.424a	6	0.000
Batch 2	52	41	37	130
Batch 3	36	63	34	133
Batch 4	47	55	28	130
Total	182	193	106	481
Year 2
Batch 1	47	34	7	88	38.068a	6	0.000
Batch 2	52	39	37	128
Batch 3	29	56	27	112
Batch 5	34	47	7	88
Total	162	176	78	416
Year 3
Batch 1	46	34	7	87	37.441a	6	0.000
Batch 2	52	36	36	124
Batch 5	34	47	6	87
Batch 6	39	60	15	114
Total	171	177	64	412
Year 4
Batch 1	47	34	7	88	14.371	6	0.026
Batch 5	34	47	7	88
Batch 6	33	52	15	100
Batch 7	29	34	15	78
Total	143	167	44	354

^aIn all years, there is a significant difference in the number of students choosing different specialty groups. Df – Degree of freedom

There is a decline of score in the second year, but it is statistically not significant [Figure 1]. The decline continues into the third year, though only marginal. An earlier study by the same author had found a sharp decline in the empathy scores at beginning of the third year, similar to those found in studies of third-year students in the US.[7,12,16] Interestingly, there was now an increase in empathy scores in the fourth year, possibly explained by the course on communication skills that the students took in the preceding year.

The medical curriculum in this college and in India differs from both western and other Asian countries. First, students here have no exposure to humanities such as economy, literature, philosophy, and other sciences, as found in the Japanese medical curriculum and undergraduate curriculum in the USA.[11] Second, students in this college are exposed to clinical rotation right from the beginning of the second year, in contrast to the beginning of the third year in the USA and Iran and the fifth year in Japan.[7,11,12] The clinical rotations are daily from the second year onwards. Probably early clinical exposure without adequate preparation on means to handle the human dilemmas of patients contributes to decline in empathy.

In a systemic review of studies of medical students, Neumann et al. had put forth issues that might explain the decline in empathy. They reasoned that students were probably overwhelmed by the mortality and morbidity they encountered in clinical rotations and most often did not have anybody to help them to deal with such issues. Furthermore, such issues are not routinely discussed by their trainers.[10] This is very much applicable to our students as the curriculum or clinical training hardly contains methods to help medical students to deal with such issues.

Some of the limitations of this study have been as follows. First, the number of respondents was smaller in the fourth year which might have probably affected the outcome of the study, especially the findings in relation to the specialty chosen. Second, the fewer number of women may have affected the overall mean empathy scores. Third, the findings from a single medical college that is unique in some respects may not be representative of empathy levels among medical students across the country. This uniqueness is because as an academy with compulsory residential stay away from family, medical students must adhere to discipline more assiduously than in other medical colleges.

CONCLUSIONS

The trend of progressive decline in empathy levels of medical students in medical college is as from studies in Western countries, but the decline is not statistically significant. Women are marginally more empathetic than men. The relation of mean empathy scores and choice of specialty is inconclusive and at variance from other studies. A longitudinal follow-up study including a larger sample from more colleges would help find if the decline in senior years is true. It would also help understand the effect of gender and choice of specialty, on empathy score.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.