Having Heart: Affective and Cognitive Empathy Scores vs. Residency Specialty Match at an Osteopathic Medical School

Abstract

Background

Past studies examining the cognitive empathy of medical school graduates grouped the various residency selections vs. parsing them out. This study examines both affective and cognitive empathy scores of osteopathic medical school graduates entering eleven different residency specialties.

Methods

Participants from the Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM) classes of 2017–2019 completed the Balanced Emotional Empathy Scale (BEES; measuring affective empathy) and the Jefferson Scale of Empathy, Student version (JSE-S; measuring cognitive empathy). Empathy scores were compared to residency choice upon graduation. The specialty choices were broken into two groups: Core specialties (i.e., people-oriented) that include Family Medicine, Internal Medicine, Obstetrics and Gynecology (OB/Gyn), Pediatrics, and Psychiatry. The remaining specialties are considered Non-Core specialties (i.e., technical/procedure-oriented) and included Anesthesiology, Diagnostic Radiology, Emergency Medicine, General Surgery, Neurology, and Orthopedics. Results are compared to data from the nationwide Project in Osteopathic Medical Education and Empathy (POMEE).

Results

Women graduates tended to have larger BEES and JSE-S scores than men. Affective empathy scores were the largest for students selecting Core specialties. Four of these Core specialties were in the top four positions out of the eleven specialties selected by eight or more graduates. None of the eleven specialties was ranked higher than the 50th percentile compared to BEES score norms. Cognitive empathy scores were also the largest for students selecting Core specialties. All five of the Core specialties were in the top six positions out of the eleven specialties. None of the eleven specialties ranked greater than the 39th percentile when compared to OMS-III and OMS-IV POMEE data. Only women entering Psychiatry had a JSE-S score that was greater than the 50th percentile.

Conclusions

Osteopathic graduates selecting the five Core specialties have BEES and JSE-S scores that are, usually, larger than students entering Non-Core specialties. For either survey instrument, both Pediatrics and Family Medicine were first and second out of a possible 11 positions, respectively. Most CUSOM graduates had JSE-S scores lower than their peers in other osteopathic medical schools that participated in the POMEE study. When the CUSOM data are compared to allopathic data, there is no clear evidence that osteopathic students have substantially higher affective or cognitive empathy scores than their allopathic peers. Therefore, it appears that medical students who select osteopathy for its tenant of a more holistic approach to patient care are no more empathetic than students studying allopathic medicine. Several suggestions are made on how to potentially increase student empathy during undergraduate medical education.

Introduction

No one disagrees that the ability for a physician to form an empathic bond of trust with patients results in more compliant patients. Therefore, being able to communicate to a patient in an empathic fashion becomes an essential physician trait, and patients who feel their physicians are empathetic are viewed as better doctors [1]. As examples, in patients with type II diabetes, those who perceive their physician to be empathic have healthier outcomes [2–4]. Physicians who showed empathy to patients with cold symptoms was positively associated with shorter and less severe symptoms and a boosted patient immune response [5]. Others found a positive correlation between physicians’ empathic skills and patient adherence to treatment plans; conversely, a perceived lack of physician empathy resulted in decreased patient satisfaction and increased malpractice claims [4, 6]. Regarding medical students, those who were assessed by standardized patients as having insufficient empathy during the encounter were given lower scores that assessed their ability to take a patient history and perform a physical examination [7, 8].

There are several definitions for empathy that divide it into two broad categories: affective/vicarious and cognitive. Affective empathy is defined by Dr. Albert Mehrabian as, “An individual’s vicarious emotional response to perceived emotional experiences of others.” [9]. The Balanced Emotional Empathy Scale (BEES), developed by Mehrabian, was designed to examine this type of empathy [10]. Although the BEES was not specifically designed for the health professionals, for individuals in the health professions, this type of empathy would be the “gut reaction” they would feel in an emotionally charged situation [10]. There are several different scales that examine cognitive empathy, e.g., the Hogan Empathy Scale and the Interpersonal Reactive Index; once again, neither of these was developed with health professionals in mind [12, 13]. However, in 2001, Hojat et al. developed a widely used cognitive empathy scale (Jefferson Scale of Empathy; JSE) designed specifically for health professionals [14]. They define cognitive empathy in the context of health care professions education and patient care as, “A predominantly cognitive (rather than an affective or emotional) attribute that involves an understanding (rather than a feeling) of pain and suffering of the patient combined with a capacity to communicate this understanding and with an intention to help” [15]. The four key terms in this definition are italicized by Hojat and colleagues to underscore their significance in the construct of patient care.

There have been previous studies examining the cognitive empathy of medical residents [16–20]. Most of these studies show a decline in empathy as physician’s progress through their residencies, but one study showed a slight increase in cognitive empathy of internal medicine residents as measured by the JSE-S [19]. Whereas the above studies examined empathy among residents, affective and cognitive empathy has also been examined regarding the desired specialty choice of students as they progress through their undergraduate medical education [20–27]. In general, these studies show that medical students who select “people-oriented” specialties (considered as primary care specialties) have higher cognitive and/or affective empathy scores as compared to those students who prefer a more “technical/procedural-oriented” specialty.

Empathy and Sexual Dimorphism

The JSE-S and the BEES instruments consistently show a sex difference in their empathy scores with women having significantly higher scores than men [10, 14, 20–29]. These sex differences have been explained by various authors as having evolutionary and developmental precursors that are seen, not only in humans, but in other primates and rodents (for reviews, see refs. [11, 30, 31]). Because there are sex differences in how men and women respond to pain, this can help explain the sex differences seen in affective empathy which is closely associated with the CNS pain-axis [31–35]. It has been shown that females who detect stress or pain in others (especially their children) are more likely to have an affective empathic response to that distress than males. In theory, sex differences in affective empathy arose earlier in evolution than sex differences in cognitive empathy since the use of cognitive empathy primarily requires the development of higher cortical functions and language to effectively communicate your intentions to another. Therefore, sexual dimorphism for empathy appears to be an outcome of evolution promoting material behavior. (see refs. [30, 36–38] for thorough explanations on the development of empathy and prosocial behavior.)

Study Purpose

This study was performed to examine both affective and cognitive empathy scores among three classes of graduating fourth-year osteopathic students (OMS-IV) just before they entered their respective residencies. It is unique in that it parses out the specialty choices made by graduates vs. grouping the choices into the broad categories of people-oriented or technical/procedural-oriented.

Materials and Methods

Study Participants and Design

The data gathered in this IRB-approved study (Campbell University IRB #30) took place at a single, mid-south US medical school: Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM). A total of 386/463 students (83.4%) in the graduating classes of 2017–2019 provided written, informed consent, and completed the BEES and JSE-Student version (JSE-S) surveys during orientation to their OMS-I year, the beginning of the OMS-II to OMS-IV years, as well as 1 week prior to the end of their OMS-IV year. Of the 386 graduates, 344 selected specialties that resulted in eight or more students entering that residency. The BEES and JSE-S scores for these 344 graduates are examined in this data set. The remaining 34 students selected specialties that had seven or fewer graduates. This small number precludes statistical analyses. In addition, the few students (n = 8) which entered a transitional or research year were not included in this study. Students also indicated their sex since empathy scores have been shown to be sexually dimorphic with women having larger BEES and JSE-S scores than their male counterparts [10, 27]. This study examines the data collected at the end of the OMS-IV year and compares it with their PGY-1 residency match. Of the 344 CUSOM graduates in this cohort, 172 were men and 172 were women.

Study Procedures

To measure affective (vicarious) empathy, the BEES (developed by Dr. Albert Mehrabian, emeritus, UCLA; BEES is currently unavailable) was used [10]. The BEES is a well-established measure of the vicarious qualities of empathy that examines the emotional level of interpersonal interactions by measuring individual differences in the tendency to feel and vicariously experience the emotional experiences of others. The BEES consists of 30 positively or negatively worded items (15 in each category) that measure responses to fictional situations and particular life events. The BEES has an alpha coefficient of 0.87 [9, 10]. The average BEES score, derived from a combined male and female undergraduate college population is 45 ± 24. However, BEES scores significantly differ among the sexes where women have higher BEES scores (60 ± 21) than men (29 ± 28) [10]. Algebraic summation of BEES scores can result in totals that range from −120 to +120. Previous studies by Newton et al., and this current study, show that scores lower than −40 or greater than 100 are rare [21, 27, 29].

Cognitive empathy scores were determined by using the widely known student version of the JSE [15]. The JSE-S consists of 20 positively or negatively worded items (10 in each category). The various iterations of the JSE were developed specifically for individuals studying or practicing in the health-related professions. The JSE-S has an alpha coefficient of 0.89 [14]. Scores can range from 20 to 140, although scores lower than 80 or higher than 135 are rare (see Tables 4 and 5 in refs. [26, 39], respectively).

Table 4.

Rank order (highest to lowest) average JSE-S scores for 2017–2019 CUSOM graduates selecting specialties with a total n ≥ 8

Specialty	n	JSE-S score	S.D	JSE-S POMEE norm percentile: OMS-III, OMS-IV
aTotal POMEE norm	4216	115–116	-	52nd
Male POMEE norm	2099	113–114	-	53rd
Female POMEE norm	2117	117–118	-	52nd
bPediatrics, total	32	112.88	15.60	39th
Male	9	106.44	21.57	29th
Female	23	115.29	12.43	44th
Family Medicine, total	86	112.43	13.42	39th
Male	33	110.15	15.43	41st
Female	53	113.85	12.17	36th
General Surgery, total	24	110.67	9.06	33rd
Male	14	107.00	8.50	35th
Female	10	115.80	7.42	44th
Ob/Gyn, total	15	110.53	17.03	33rd
cMale	5	106.40	16.92	29th
Female	10	112.60	17.60	30th
Psychiatry, total	20	110.35	14.52	33rd
Male	10	101.00	14.39	21st
Female	10	119.70	6.60	59th
Internal Medicine, total	103	110.34	15.46	33rd
Male	54	106.33	15.83	29th
Female	49	114.76	13.90	36th
Emergency Medicine, total	32	110.03	11.73	33rd
Male	16	106.88	10.11	29th
Female	16	113.19	12.70	36th
Diagnostic Radiology, total	8	108.38	11.75	27th
Male	8	108.38	11.75	35th
Neurology, total	12	106.25	13.78	22nd
cMale	4	107.00	10.86	35th
Female	8	105.88	15.73	15th
dOrthopedics	13	102.69	18.91	21st
Anesthesiology, total	14	100.07	11.61	12th
Male	12	99.00	12.05	17th
Female	2	-	-	-

^aProject in Osteopathic Medical Education and Empathy (POMEE) data from Table 4 in ref. [28]

^bCore specialties in bold print

^cNote: The n < 8, so only a trend can be established

^dMale only

Table 5.

JSE-S ranges and norms for 2017–2019 CUSOM graduates for specialties with an n ≥ 8

Specialty	Sex	n	JSE-S range	aEquivalent POMEE percentiles for OMS Years -III, -IV
Anesthesiology	M	12	124 to 80	84th to 3rd
Diagnostic Radiology	M	8	127 to 92	91st to 9th
Emergency Medicine	M	10	121 to 93	79th to 10th
	F	9	133 to 98	97th to 5th
bFamily Medicine	M	33	134 to 85	98th to 5th
	F	53	139 to 83	>99th to 1st
General Surgery	M	14	121 to 94	79th to 10th
	F	10	130 to 103	91st to 12th
Internal Medicine	M	54	137 to 69	99th to 3rd
	F	49	139 to 79	>99th to 1st
cNeurology	M	4	115 to 92	59th to 9th
	F	8	129 to 85	91st to 1st
cOb/Gyn	M	5	129 to 84	94th to 4th
	F	10	136 to 81	99th to 1st
Orthopedics	M	13	125 to 59	88th to 3rd
Pediatrics	M	9	136 to 60	99th to 3rd
	F	24	136 to 95	99th to 4th
Psychiatry	M	10	120 to 73	72nd to 3rd
	F	10	129 to 104	91st to 12th

F female, M male

^aProject in Osteopathic Medical Education and Empathy (POMEE) data from Table 4 in ref. [28]

^bCore specialties in bold print

^cn < 8, only a trend can be established

A student’s PGY-1 specialty was based upon their residency match at the time of graduation. Specialty choice was divided into two broad categories based on either people-oriented specialties that have considerable patient-physician contact and continuity of care, i.e., five primary care specialties (Internal Medicine, Family Medicine, Pediatrics, Obstetrics/Gynecology (Ob/Gyn), and Psychiatry), or 18 technical/procedure-oriented specialties (e.g., Anesthesiology, Diagnostic Radiology, Pathology, General Surgery, Emergency Medicine). In keeping with the terminology used in previous publications by Newton and colleagues, people-oriented specialties are termed “Core” and technical/procedure-oriented specialties are termed “Non-Core” [21, 27, 29].

Study Analysis

Scores for each specialty were calculated according to BEES or JSE-S instructions. The relative degree of affective empathy of a student, i.e., the percentile score in comparison to a normal population, was based on designations provided by Mehrabian (see Table 1 in ref. [10]). The mean BEES score for a combined male and female population is 45 with a s.d. of 24.

Table 1.

^aZ score and percentile equivalents of BEES scores

Z score	Percentile score	Designation of score	Abbreviation
2.5	99.4	Very extremely high	VEH
2.0	98	Extremely high	EH
1.5	93	Very high	VH
1.0	84	Moderately high	MH
0.5	69	Slightly high	SH
0.0	50	Average	Average
−0.5	31	Slightly low	SL
−1.0	16	Moderately low	ML
−1.5	7	Very low	VL
−2.0	2	Extremely low	EL
−2.5	0.6	Very extremely low	VEL

^aPercentile score equivalents and interpretations as described by Dr. Mehrabian and adapted from Table 1 in ref. [10]

Regarding z scores (see Table 1), z scores for the BEES = (total raw BEES score –45)/24. Once the z score is calculated, a statistical table can be used to find the corresponding percentile score. The percentile score can then be given a designation to interpret the z score (see Table 1 in ref. [10]).

The word “rank” in this article is used to denote which specialty has larger average BEES or JSE-S scores than the remaining specialties; e.g., in Table 2, CUSOM graduates entering Pediatrics have a higher average BEES score than do the other ten specialties and is ranked as 1 of 11. Conversely, Diagnostic Radiology has the lowest average BEES score and is ranked 11 of 11 specialties. Since this is only the second study to examine BEES scores vs. residency choice, the CUSOM rankings can only be compared to the other study concerning allopathic students [21]. The comparative ranking of CUSOM cognitive empathy JSE-S scores in this study, vs. other studies, was based on data derived from third- and fourth-year osteopathic medical students who participated in the nationwide Project in Osteopathic Medical Education and Empathy (POMEE) by Hojat et al. (see Table 4 in ref. [26]).

Table 2.

Rank order (highest to lowest) average BEES scores for specialties selected by the CUSOM graduates of 2017–2019 with a total n ≥ 8

Specialty	n	BEES score	SD	Z score	aMehrabian designation	Percentile
b,cPediatrics	32	52.30	26.31	.30	Average	50th
Male	9	43.00	20.23	.50	Slightly high	69th
Female	23	55.79	27.82	−.20	Average	50th
Population norm	-	45	24	0	Average	50th
Male	-	29	28	0	Average	50th
Female	-	60	21	0	Average	50th
Family Medicine	86	41.92	29.34	−.13	Average	50th
Male	33	26.06	24.81	−.11	Average	50th
Female	53	51.79	27.73	−.39	Average	50th
Internal Medicine	103	36.84	32.38	−.34	Average	50th
Male	54	24.04	29.26	−.18	Average	50th
Female	49	50.96	30.94	−.43	Average	50th
Ob/Gyn	15	36.27	37.77	−.36	Average	50th
dMale	5	5.60	24.30	−.84	Slightly low	31st
Female	10	51.60	34.25	−.40	Average	50th
Emergency Medicine	32	34.25	24.08	−.45	Average	50th
Male	16	17.31	18.48	−.41	Average	50th
Female	16	51.19	15.06	−.42	Average	50th
Neurology	12	31.83	33.89	−.55	Slightly low	31st
dMale	4	10.75	18.8	−.65	Slightly low	31st
Female	8	42.38	35.67	−.84	Slightly low	31st
General Surgery	24	30.79	34.15	−.59	Slightly low	31st
Male	14	12.50	29.92	−.59	Slightly low	31st
Female	10	56.40	20.93	−.17	Average	50th
eOrthopedics	13	27.23	33.58	−.05	Average	50th
Psychiatry	20	25.10	31.94	−.83	Slightly low	31st
Male	10	9.50	18.83	−.70	Slightly low	31st
Female	10	43.30	31.67	−.80	Slightly low	31st
Anesthesiology	14	19.42	22.66	−1.06	Moderately low	16th
Male	12	17.17	21.90	−.42	Average	50th
Female	2	-	-	-	-	-
fDiagnostic Radiology	8	11.88	21.23	−1.38	Moderately low	16th
eMale	8	11.88	21.23	−.61	Slightly low	31st

^aDesignations of the BEES scores by Dr. Mehrabian (see Table 1)

^bCore specialties in bold print

^cSpecialty name has combined average of the male and female scores

^dNote: n < 8, so only a trend can be established

^eScore compared to just the male population norm

^fScore compared to the total (combined men and women) population norm

Some specialties were selected by a combined seven or fewer graduates in the CUSOM classes of 2017–2019. In these instances, the lack of statistical power prevents an accurate determination of the average BEES or JSE score for those specialties. Therefore, only eleven specialties had an n ≥ 8 (Anesthesiology, Diagnostic Radiology, Emergency Medicine, Family Medicine, General Surgery, Internal Medicine, Neurology, Ob/Gyn, Orthopedics, Pediatrics, and Psychiatry). Eight specialties had an n ≤ 7 (Dermatology, Medical Pediatrics, Neurosurgery, Otolaryngology, Pathology, Physical Medicine and Rehabilitation, Preventative Medicine, and Urology). The 34 students who selected these eight Non-Core specialties are not included in this study. No CUSOM students selected four other specialties as a residency choice (Nuclear Medicine, Ophthalmology, Plastic Surgery, and Radiation Oncology).

The hypothesis is that students with higher BEES or JSE-S scores will enter Core specialties (i.e., Family Medicine, Internal Medicine, Ob/Gyn, Pediatrics, and Psychiatry) and that these specialties will be preferentially chosen from the eleven residencies with an n ≥ 8. The data should also reconfirm that affective and cognitive empathy is sexually dimorphic with most women having higher BEES and JSE-S scores than men.

Results

Note, when only 1–3 graduates selected a particular specialty, the BEES or JSE-S averages are not reported since the remote possibility exists the empathy scores could be paired with an individual.

Distribution of BEES Scores (Measuring Affective Empathy) of CUSOM Classes of 2017–2019

Table 2 shows that out of the 11 specialties with an n ≥ 8, four of the five Core specialties had the highest total (i.e., male and female scores combined) BEES scores, with Pediatrics having the highest score, followed in turn by Family Medicine, Internal Medicine, and Ob/Gyn. All these Core specialties have a total BEES score that falls within the average range (50th percentile) of the population norm (see Table 1). However, men entering Pediatrics have a BEES score that is slightly higher (+0.5 s.d.; 69th percentile) than the male population norm; whereas women entering into Pediatrics had average BEES scores when compared to the female population norm. Men who entered Ob/Gyn had an average BEES score that was slightly lower than the male norm; with the caveat that only five men selected Ob/Gyn as a residency choice, so only a trend can be established. The other Core specialty, Psychiatry, is ranked ninth out of the eleven specialties with an n ≥ 8; with a total BEES score, as well as both male and female BEES scores, slightly lower (−0.5 s.d.; 31st percentile) than the population norms.

Table 2 also shows the only total BEES score for a Non-Core specialty with an average designation was Emergency Medicine. (see Table 1 for designations.) Neurology, General Surgery, and Orthopedics had total BEES scores designated as slightly low (−0.5 s.d.; 31st percentile), while Anesthesiology and Diagnostic Radiology had a moderately low designation (−1.0 s.d.; 16th percentile). Since only men entered a Diagnostic Radiology residency, if their average BEES score is compared to just the male population norm (29 ± 28), vs. a combined male and female norm (45 ± 24), then the average male Diagnostic Radiology BEES score is described as slightly low because of the sexual dimorphism revealed by the BEES.

The BEES score for the 13 men entering an Orthopedic residency has a designation of average when compared to just the male population norm. For Anesthesiology, two female BEES scores lowered the total BEES score of the 14 graduates from a designation of average to moderately low.

Total high and low BEES scores ranged from 52.30 ± 26.31 to 11.88 ± 21.33 for Pediatrics and Diagnostic Radiology, respectively. Male residency choice, in descending order of BEES scores, are Pediatrics (43.00 ± 20.23; slightly high designation), Ob/Gyn, Orthopedics, Family Medicine, Internal Medicine, Diagnostic Radiology, Emergency Medicine, Anesthesiology, General Surgery, Neurology, and Psychiatry (9.50 ± 18.83; slightly low designation). Female residency choice, in descending order of BEES scores, are General Surgery (56.40 ± 20.93; average designation), Pediatrics, Family Medicine, Ob/Gyn, Emergency Medicine, Internal Medicine, Psychiatry, and Neurology (42.38 ± 35.67; slightly low designation).

Regarding the z scores, only the men entering Pediatrics had a z score that was positive (0.50). All other male or female z scores had a negative value. Male z scores ranged from −0.05 (Orthopedics) to −1.38 (Diagnostic Radiology); women z scores ranged from −0.17 (General Surgery) to −0.84 (Neurology).

Table 3 shows the distribution of the various BEES score designations using the Mehrabian descriptors (see Table 1). As expected, the largest percentage of BEES scores (29.6%; 102/344) were in the average range when compared to the population norm, with men and women accounting for 35.5% (61/344) and 23.7% (41/344) of the average BEES scores, respectively. Since z scores are based on 0.5 s.d. increments, it is logical to assume the largest percentage of student BEES scores are within +0.50 to −0.50 s.d. of the population norm. This is true when combining the students with an average BEES designation (29.6% of 344) along with the slightly low (11.3% of 344) and the slightly high (18.6% of 344) designations. Those students who had BEES scores designated as moderately high, very high, or extremely high accounted for 13.0% (45/344) of the combined men and women scores. Of these 45 students, almost two-times the number of women vs. men (29 vs. 16) had the BEES scores that were 1.0–2.0 s.d. above the population norm. Only one woman had a very extremely high BEES score. Unfortunately, 79 students had BEES scores that were either moderately low, very low, or extremely low. This accounted for 22.9% of the student population. Similar to those students 1.0–2.0 s.d. above the population norm, women accounted for almost twice as many of these lower BEES scores than men (52 vs. 27). Unlike the very extremely high designation that contained one student, 15 students (4.3% of 344) had very extremely low BEES scores (≥ 2.5 s.d. lower than the population norm) with women accounting for 11 of the scores; this accounts for 6.4% of the 172 women. Six of the very extremely low scores came from women entering Internal Medicine. The four male very extremely low BEES scores were divided equally among Internal Medicine and General Surgery. Therefore, graduates entering an Internal Medicine residency accounted for over half (8/15) of the very extremely low BEES scores, which is −2.5 s.d. (i.e., 0.6% of a normal population) below the norm.

Table 3.

BEES norm designations and ^aranges for specialties selected by CUSOM 2017–2019 graduates with n ≥ 8

Specialty	Sex	n	bVEH	EH	VH	MH	SH	AVE	SL	ML	VL	EL	VEL	Range
Anesthesiology	M	12	-	-	-	1	-	5	4	1	1	-	-	69 to −13
Diagnostic Radiology	M	8	-	-	-	-	-	4	1	3	-	-	-	38 to −21
Emergency Medicine	M	10	-	-	-	-	-	4	4	-	2	-	-	42 to −21
	F	9	-	-	-	-	-	3	5	-	-	1	-	72 to −17
Family Medicine	M	33	-	1	1	1	7	8	10	4	1	-	-	86 to −16
	F	53	1	-	5	4	5	12	5	9	6	5	1	114 to 5
General Surgery	M	14	-	-	-	1	-	5	6	-	-	-	2	64 to −48
	F	10	-	-	-	1	2	3	-	4	-	-	-	82 to 29
Internal Medicine	M	54	-	1	1	3	7	21	13	3	2	1	2	92 to −72
	F	49	-	-	3	6	5	12	6	5	6	-	6	99 to −26
cNeurology	M	4	-	-	-	-	-	2	1	1	-	-	-	36 to −9
	F	8	-	-	-	-	3	1	-	1	1	-	2	79 to −13
cOb/Gyn	M	5	-	-	-	-	-	2	1	-	2	-	-	38 to −21
	F	10	-	-	1	1	2	2	-	1	-	2	1	98 to −2
Orthopedics	M	13	-	-	1	3	5	2	-	-	-	2	-	73 to −32
Pediatrics	M	9	-	-	1	1	2	4	1	-	-	-	-	72 to −8
	F	24	-	1	2	4	1	5	3	2	5	1	-	108 to −11
Psychiatry	M	10	-	-	-	-	-	4	2	3	-	1	-	34 to −29
	F	10	-	1	-	-	-	3	2	2	1	-	1	104 to −17
Total		345	1	4	15	26	39	102	64	39	27	13	15
Total %			0.3	1.2	4.3	7.5	11.3	29.6	18.6	11.3	7.8	3.8	4.3
Male total		172	-	2	4	10	21	61	43	15	8	4	4
Male %			-	1.2	2.3	5.8	12.2	35.5	25.0	8.7	4.7	2.3	2.3
Female total		173	1	2	11	16	18	41	21	24	19	9	11
Female %			0.6	1.2	6.4	9.2	10.4	23.7	12.1	13.9	11.0	5.2	6.4

M male, F female

^aBEES scores can range from −120 to 120

^bSee Table 1 for definitions of Mehrabian descriptors

^cn < 8, only a trend can be established

In a normal population, a combined 9.6% of people should have BEES scores described as either very extremely high, (0.6%) extremely high (2%), or very high (7%); and the same percentages apply to individuals who have very extremely low, extremely low, or very low BEES scores. If the very extremely high, extremely high, and very high scores are combined (i.e., ≥ 1.5 s.d. off the population norm), this equals 5.8% (n = 20) of the total graduate population, which is lower than expected for the population norm of 9.6%. Conversely, if the very extremely low, extremely low, and very low BEES scores are combined (i.e., ≤  −1.5 s.d. off the population norm), this equals 15.9% (n = 55) of the cohort, which is much larger than the expected population distribution. Women graduates who had combined very extremely low, extremely low, and very low BEES scores (i.e., ≤ 7% of a normal population) accounted for over twice the number compared to men: 39 vs. 16, respectively. However, the same discrepancy did not occur when combining very extremely high, extremely high, and very high BEES scores. In this instance, men and women had comparable numbers, 16 vs. 14, respectively.

Distribution of JSE-S Scores (Measuring Cognitive Empathy) of CUSOM Classes of 2017–2019

Because of the nation-wide POMEE study by Hojat and colleagues, CUSOM JSE-S scores can now be compared to thousands (n = 4216) of students in their third and fourth years of osteopathic medical school (see Table 4 in ref. [26]). The first three rows of data in Table 4 of the current study shows the POMEE range of JSE-S scores of third- and fourth-year osteopathic students that are clustered around the 50th percentile. The remaining rows show the CUSOM data for the graduates of the classes of 2017–2019. The five core specialties are in the first six positions out of the eleven residencies with a total n ≥ 8. For graduating CUSOM students, all eleven specialties had combined male and female JSE-S scores lower than the combined POMEE JSE-S normal range; the same was true for the average JSE-S score for men. Only women entering Psychiatry had an average JSE-S score (59th percentile) that was greater than all the POMEE norms for the OMS-III and OMS-IV students.

Residency choice, in descending order of male JSE-S scores, are Family Medicine (110.15 ± 15.43; 41st percentile), Radiology, General Surgery, Neurology, Emergency Medicine, Pediatrics, Ob/Gyn, Internal Medicine, Orthopedics, Psychiatry, and Anesthesiology (99.00 ± 12.05; 17th percentile). Four of the specialties selected by men (Emergency Medicine, Pediatrics, Ob/Gyn, and Internal Medicine) clustered around scores of 106.88–106.33; this places them at the 29th percentile when compared to the POMEE norm. Residency choice, in descending order of female JSE-S scores, are Psychiatry (119.60 ± 6.60; 59th percentile), General Surgery, Pediatrics, Internal Medicine, Family Medicine, Emergency Medicine, Ob/Gyn, and Neurology (105.88 ± 15.73; 15th percentile). Unlike the men, there was no obvious clustering of women JSE-S scores.

Table 5 shows the ranges of the JSE-S scores of CUSOM graduates as compared to the OMS-III and OMS-IV students who participated in the POMEE study. For men, the highest JSE-S scores were found in Internal Medicine and Pediatrics, both at the 99th percentile. Other specialty choices that scored > 90th percentile were in descending order Family Medicine, Ob/Gyn, and Radiology. Thus, four of the five Core specialties had some JSE-S scores > 90th percentile. The lowest JSE-S scores for men was a five-way tie for the 3rd percentile for those entering Anesthesiology, Internal Medicine, Orthopedics, Pediatrics, and Psychiatry. For Core specialties, all the lowest male JSE-S scores were < the 6th percentile. Table 5 also shows the highest JSE-S score for women graduates was a four-way tie for the 99th percentile in Family Medicine, Internal Medicine, Ob/Gyn, and Psychiatry. All high JSE-S scores for women were > 90th percentile compared to the POMEE norm. There was a five-way tie for the lowest JSE-S score for women at the 1st percentile: Family Medicine, Internal Medicine, Ob/Gyn, Pediatrics, and Neurology. Except for Psychiatry (12th percentile), the remaining Core specialties selected by women had low JSE-S scores at < 5th percentile.

Table 6 shows the number of men and women CUSOM graduates who scored at the high and low ends of the POMEE percentiles. The combined men and women scores reveal more graduates had lower JSE-S scores (46; 13.4% of cohort) vs. higher scores (40; 11.6% of cohort). Lower JSE-S scores of men and women comprised 15.1% and 11.5% for each sex, respectively, with men having more than twice the number of JSE-S scores ≤ 5th percentile than women. Higher JSE-S scores of men and women comprised 6.4% and 16.8% for each sex, respectively, with women having twice the number of men at ≥ 94th percentile. Thus, overall, men had a greater number lower JSE-S scores than women, and vice versa for the higher JSE-S scores. By far, the specialty that had the greatest number of low JSE-S scores was Internal Medicine: comprised of nine men and nine women. However, men accounted for seven of ten JSE-S scores at ≤ 5th percentile, whereas women had six of eight individuals who were in the 9th to 7th percentiles. Similarly, 13 men and women had high JSE-S scores in Internal Medicine, with women comprising 11 of the 13 individuals. Graduates entering Anesthesiology did not have any of the higher JSE-S scores, and those eight men entering Diagnostic Radiology had no JSE-S scores on either end of the POMEE percentile spectrum.

Table 6.

JSE-S score percentile rankings^a for 2017–2019 CUSOM graduates entering specialties with an n ≥ 8

Specialty	Sex	n	Men and women ≥ 94th percentile	bMale 91st to 88th percentile; female 91st to 85th percentile	bMale 6th to 10th percentile; female 9th to 7th percentile	Men and women ≤ 5th percentile
Anesthesiology	M	12	-	-	3	1
Diagnostic Radiology	M	8	-	-	-	-
Emergency Medicine	M	10	-	1	1	1
	F	9	2	-	1	-
cFamily Medicine	M	33	2	3	1	3
	F	53	1	6	3	2
General Surgery	M	14	-	-	-	-
	F	10	-	1	-	-
Internal Medicine	M	54	2	-	2	7
	F	49	6	5	6	3
dNeurology	M	4	-	-	1	-
	F	8	-	1	1	-
dOb/Gyn	M	5	1	-	-	1
	F	10	2	-	-	2
Orthopedics	M	13	-	-	1	-
Pediatrics	M	9	1	-	1	1
	F	24	3	1	2	-
Psychiatry	M	10	1	-	1	1
	F	10	-	1	-	-
Total		345	21	19	24	22
Total %			6.1	5.5	7.0	6.4
Male total		172	7	4	11	15
Male %			4.1	2.3	6.4	8.7
Female total		173	14	15	13	7
Female %		6.1	8.1	8.7	7.5	4.0

^aPercentiles based on OMS-III and OMS-IV DO students from the POMEE study (see Table 4, ref. [28])

^bJSE-S percentiles differ between men and women

^cCore specialties in bold print

^dn < 8, only a trend can be established

Discussion

Most studies that have examined residency choice by graduates divide the various specialties into two broad groups. Those that have considerable physician–patient contact and continuity of care are called “Core” specialties in studies by Newton et al., or “people-oriented” specialties by Hojat et al. [10, 21, 22, 26–29, 39]. Conversely, the remaining specialties have little or no patient contact or continuity of care and are termed in this study as “Non-Core” specialties or “technology/procedure-oriented” specialties by others. Various studies by Hojat et al. categorize Family Medicine, Internal Medicine, Obstetrics/Gynecology (Ob/Gyn), and Pediatrics as “people-oriented,” but places Psychiatry into a category of its own as opposed to being placed into a “people-oriented” specialty [26, 29]. It should be noted that since Psychiatry normally has extensive physician–patient interactions and continuity of care, this study places it into the Core (“people-oriented”) specialties along with Family Medicine, Internal Medicine, Obstetrics/Gynecology, and Pediatrics. Many consider these Core specialties as primary care.

There is a considerable difference in what the POMEE study indicates as a “technical/procedure-oriented” specialty vs. what this study indicates as a Non-Core specialty [26, 29]. The POMEE technical/procedure-oriented and Non-Core specialties overlap with Anesthesiology, Dermatology, General Surgery, Neurosurgery, Ophthalmology, Orthopedic Surgery, Otolaryngology, Pathology, Plastic Surgery, and Diagnostic Radiology. However, this current study also includes Emergency Medicine, Medical Pediatrics, Neurology, Physical Medicine/Rehabilitation, Preventative Medicine, and Urology under the Non-Core category (since there is less continuity of care as compared to the Core specialties), whereas the POMEE study lists them under the “Other” category. (The placement of residencies into Core and Non-Core categories was maintained in this study to compare these current data with previous studies by the author and colleagues [10, 21, 27, 29].)

As anticipated, the data in this current study reveals the specialties selected by CUSOM graduates with the largest averaged cognitive (JSE-S) empathy scores are in five of the top six positions, with Pediatrics and Family Medicine at the 39th percentile when compared to national norms, and Ob/Gyn, Psychiatry, and Internal Medicine at the 33rd percentile. Only women who entered Psychiatry scored above the POMEE 50th percentile. Anesthesiology had the lowest average JSE-S score and was in the 12th percentile nationally. What is concerning about the CUSOM JSE-S scores is that all specialties were below the 52nd–53rd percentiles for the OMS-III and OMS-IV student national norm. This suggests some of the CUSOM graduates, especially those with the lowest JSE-S scores, may have a lesser ability to form a cognitive empathic bond of trust with patients as compared to their graduating peers from other US osteopathic medical schools (vide infra).

The top four averaged affective (BEES) empathy scores were from Core specialties, with Psychiatry dropping to 9th place out of 11 specialties with an n ≥ 8. The top four Core specialties were all at the 50th percentile when compared to the general population norm, with Psychiatry lowest at the 32nd percentile. Both Anesthesiology and Diagnostic Radiology were at the 16th percentile. Only men who entered Pediatrics had an average BEES score that was above the 50th percentile and is termed “slightly high” at the 69th percentile.

When comparing JSE-S scores to BEES scores, both Pediatrics and Family Medicine were ranked as first and second out of the 11 specialties, and Ob/Gyn took the fourth place. However, the most divergent scores were in General Surgery and Psychiatry, with General Surgery and Psychiatry ranked third and fifth for JSE-S scores, but ranked seventh and ninth, respectively, for BEES scores.

What is concerning are comparisons of the JSE-S and BEES scores for Internal Medicine, which was the most popular residency choice for all the CUSOM graduates (103/463, 22.2%). Eight of the 103 graduates had very extremely low BEES scores (−2.5 s.d. off the population norm), and ten of the graduates had JSE-S scores ranked at < 5th percentile. This was not seen for the second most popular residency choice, Family Medicine, where there was only one very extremely low BEES score, and five JSE-S scores < 5th percentile. These numbers far exceeded similar scores for the other nine residencies. These data also reveal graduates entering the 11 different residencies had almost twice as many BEES scores described as slightly low to very extremely low (158/344; 45.8%) as compared to scores ranging from slightly high to very extremely high (85/344; 24.6%).

For JSE-S scores, only 21 graduates (6.1%) had JSE-S scores ≥ 94th percentile and 22 (6.4%) had scores ≤ 5th percentile. If the JSE-S scores for men ≥ 88th percentile and women ≥ 85th percentile are examined, both Internal Medicine and Family Medicine have the preponderance of those scores with women representing 18 of the total 25 scores (72%). Overall, these highest scores comprise 11.6% of the total cohort. In contrast, JSE-S scores ≤ 10th percentile for men and ≤ 9th percentile for women were split almost evenly among the 27 graduates. Overall, these lowest scores comprise 13.3% of the total cohort. Once again, Internal Medicine had the greatest number of JSE-S scores at the extremes, with ten men and women scoring ≤ 5th percentile and eight with scores ≥ 94th percentile.

Osteopathic vs. Allopathic BEES Scores

This current study used survey instruments that examined both affective and cognitive empathy. A former longitudinal study, by the author and colleagues, examined just the affective empathy of allopathic graduates in the 2001–2004 classes at a medical school in Arkansas [21, 27]. In this regard, the five Core specialties were in the top six rankings with an OB/Gyn BEES score of 49.19 ± 28.28, followed by Pediatrics, Psychiatry, Family Medicine, and Internal Medicine in sixth place (33.81 ± 26.61). All the aforementioned scores had a designation at the 50th percentile and were considered as “average” for the general population norm. The BEES scores for the CUSOM osteopathic graduates ranged from 52.30 ± 26.31 for Pediatrics, followed by Family Medicine, Internal Medicine, and Ob/Gyn in fourth place. Psychiatry was in ninth place (of 11 specialties) with a BEES score of 25.10 ± 31.94, which places it in the 39th vs. the 50th percentile for the other four Core specialties. Thus, other than Psychiatry, the other four Core specialties did not have allopathic or osteopathic BEES scores that significantly differed. The only other difference was that osteopathically trained men entering Pediatrics had BEES scores that were slightly higher than the normal population, whereas all allopathically trained men and women had average BEES score for the Core specialties.

For Non-Core specialties, the highest average BEES score in the allopathic school was for Anesthesiology (35.68 ± 26.03; at the 50th percentile and designated as average), and the lowest was for Orthopedics (15.06 ± 18.46; at the 16th percentile and moderately low). For the osteopathic students, the highest Non-Core BEES score was for Emergency Medicine (34.25 ± 24.08; at the 50th percentile and average), and the lowest was for Diagnostic Radiology where only men entered that specialty (11.88 ± 21.3; at the 16th percentile which is moderately low for the general population, but at the 31st percentile with a slightly low male designation). Of note, Anesthesiology has the largest Non-Core BEES score for allopathic graduates and was ranked fifth of 14 listed specialties but was ranked tenth of 11 listed specialties for osteopathic students.

CUSOM JSE-S Scores vs. Other Studies

There are a number of studies that examined residency choice of OMS-IV students vs. cognitive empathy as measured by the JSE-S. Data from the recent POMEE study, by Hojat et al. [28], reveals the OMS-IV students (n = 1,936) selecting people-oriented specialties (i.e., Core specialties in this study minus Psychiatry) had an average JSE-S score of 114.17 ± 12.29 (41st percentile) vs. the CUSOM score of 111.55 ± 15.38 (35th percentile). The POMEE score for Psychiatry was 116.21 ± 11.11 (47th percentile) vs. the CUSOM score of 110.35 ± 14.52 (29th percentile). Thus, for the five-abovementioned specialties, CUSOM graduates had significantly lower JSE-S scores as compared to the POMEE norms. It is more difficult to compare the POMEE technical/procedure-oriented JSE-S average scores vs. the CUSOM scores, since the POMEE study includes many specialties that were not selected by the CUSOM students. Nevertheless, the average POMEE JSE-S score for the technical/procedure-oriented specialties was 110.53 ± 15.40 (29th percentile) vs. the significantly lower 106.44 ± 12.70 (19th percentile) for CUSOM graduates.

Empathy Scores vs. Physician–Patient Communication

As noted by Dr. Hojat (p. 190 ref. [40]), there is a theoretical link between clinician-patient engagement and positive outcomes. The assumption being when an empathic relationship is formed between a physician and a patient, this leads to the development of trust, promoting a more truthful medical history provided by the patient, which leads to a more accurate assessment of the diagnosis and better patient adherence. As mentioned in the “Introduction” [2–4, 7], there are studies using the JSE showing those students or physicians that have higher cognitive empathy scores are rated as being more empathetic by standardized patients and actual patients, and vice versa [8, 41]. A review by Stewart, and studies by other authors show that an empathic engagement with patients equates to more effective physician–patient communication skills that leads to better health outcomes [1, 2, 4, 5]. Many studies reveal (see chapter 11 in ref. [40]) that students and physicians in people-oriented specialties have higher cognitive empathy scores than their counterparts in technically oriented specialties [28]. Although some students buck the trend, this current study supports these observations by showing graduates who have higher JSE-S scores preferentially select those specialties that have increased patient contact and continuity of care, i.e., the five primary care (Core) specialties. Conversely, those students with lower JSE scores tend to select technically oriented specialties that have little or no patient contact or continuity of care, i.e., the Non-Core specialties.

Somewhat less is known about an inferred link between affective empathy, physician performance, and patient satisfaction. One hypothesis is that increased affective empathy scores may result in students or physicians not being able to effectively focus on patient care if they allow their vicarious response to an emotionally charged situation distract them from their proper care of the patient, since the physician is reflecting on their own emotional state vs. attending to the patient [10, 42, 43]. Nevertheless, a certain degree of vicarious/affective empathy is needed for the health care professional to “feel into” the patient, before using cognitive empathy to respond to the patient [10, 43]. Previous studies by the author and colleagues show a dramatic decrease in BEES scores during undergraduate medial education among allopathic and osteopathic students [27, 29], indicating the possibility that some students, especially those in Non-Core specialties, are blunting their affective empathy presumably to better focus their attention on the patient. However, the caveat is that many osteopathic and allopathic students with higher BEES scores also enter the Core, primary care, specialties. This may infer that they are at a greater risk of burnout due to their empathic connection with their patients which causes an emotional toll to cognitively control their vicarious empathic responses [10, 43]. This is especially true for women graduates/physicians who have greater levels of burnout compared to men [44, 45].

Limitations

There are several limitations to this study. First, it took place at one osteopathic medical school, so these data may be reflective of just our own student population. Secondly, the survey instruments were completed on a voluntary basis. Since the amount of empathic concern is correlated with prosocial behavior and moral development [10, 36–38, 42], students who were compliant in filling out the BEES and JSE-S surveys for all five time points may exhibit more prosocial behavior and may, presumably, be more “empathic” than those who did not participate. This would also be true, and a limitation, for any study using survey instruments. Therefore, it is possible that those students who did not participate in the survey may have lower empathy scores than their compliant peers. If it is assumed the non-participating students did participate, and their scores were included, then the average BEES and JSE-S empathy scores for the CUSOM classes of 2017–2019 maybe lower than what is published here.

A final limitation to consider is that osteopathic students are more likely to enter a Core, people-oriented, specialty than a Non-Core, technically oriented, specialty. This may be reflective of the CUSOM mission statement attracting applicants desiring to enter primary residencies and to practice in community-based, rural, and underserved areas. In this regard, whereas only 53.4% of UAMS allopathic graduates entered Core specialties, 67.2% of CUSOM graduates entered the five Core specialties. This equates to a 1 in 5 chance (21.1%) that an osteopathic graduate will enter a Core specialty vs. an allopathic graduate. This predominance of primary care specialty choice may skew the results toward higher JSE and BEES scores for the osteopathic graduates who entered Core specialties vs. allopathic graduates. However, when comparing affective empathy scores for primary care residency choices between allopathic and osteopathic schools, only allopathic graduates entering Psychiatry had significantly higher BEES scores than osteopathic graduates (average vs. slightly low designation, respectively). Although the remaining Core specialties selected by osteopathic graduates had higher BEES scores than allopathic graduates, all allopathic and osteopathic scores were designated as “average” when compared to a normal population [10, 21]. Therefore, the osteopathic graduates who participated in this study did not appear to skew the results toward significantly higher BEES scores than the allopathic students. (Note: The JSE-S was not developed at the time the study was done at UAMS.)

Conclusions

These data show that graduates from an osteopathic medical school who enter residencies that are considered as primary care/people-oriented (i.e., Family Medicine, Internal Medicine, Ob/Gyn, Pediatrics, and Psychiatry), have, in general, larger affective and cognitive empathy scores then those graduates who enter technical/procedure-oriented specialties (e.g., Anesthesiology, Emergency Medicine, Radiology). The average CUSOM cognitive empathy scores for the specialties selected by eight or more students are lower than the norms established by the thousands of OMS-III and OMS-IV graduates who took part in the POMEE study [26]. One concern is that women had many more BEES scores that were − 1.0 to − 2.5 s.d. of the population norm than men; and that many of these lower BEES scores were from in women who entered primary care (Core) specialties vs. technically oriented (Non-Core) specialties. Mainly men entered the Non-Core specialties listed in this study, and many of their BEES scores (other than Orthopedics) were also −1.0 to −2.5 s.d. of the population norm.

Since these osteopathic data do not significantly differ from the earlier allopathic data collected by Newton et al. [21], this may indicate the “holistic” approach to osteopathic medical education, that takes into account the “mind, body and spirit” of the patient, does not significantly improve the affective and cognitive empathy scores of CUSOM students. Therefore, a more concerted effort needs to be made in the didactic and clinical aspects of the curriculum to help enhance the ability of CUSOM students to form a more effective empathic bond of trust with their future patients. Several ways to initiate this process is to better incorporate the use of the E.M.P.A.T.H.Y. tool developed by Riess and Kraft-Todd [46], as well as emphasizing various measures suggested by Hojat [47] to increase awareness for using cognitive empathy when dealing with patients. Better training on how to break bad news would also be efficacious [48]. Another potential solution to ameliorate the lower empathy scores for current and future CUSOM students is to determine their attitude toward the osteopathic principles during the interview process for matriculation. Although determining this may be labor intensive, this would help in selecting matriculants who may, naturally, have increased clinical empathy and a greater disposition to enter primary care. In this regard, using POMEE data [26], Hojat and colleagues have just developed the “ATOM” (Attitudes Toward Osteopathic Medicine) scale to determine an applicant’s orientation to applying to an osteopathic medical school [49].

Author Contribution

The author designed the study, collected the data, and wrote the manuscript.

Declarations

Ethics Approval

N/A. Informed consent was obtained from all participants in this study via Campbell University IRB #030.

Consent for Publication

N/A.

Conflict of Interest

The author has no conflicts of interest to declare that are relevant to the content of this article.