https://orcid.org/0000-0001-5387-6792
Figures
Abstract
This study evaluates the degree of empathy among medical students and its influencing factors at three critical moments of their degree studies (beginning of first year and end of third and sixth years) as well as establishes low-, medium-, and high-empathy cut-off points to obtain valid and reliable results that can be extrapolated to the general population. This cross-sectional study of the eight (public and private) medical schools in the province of Madrid, used an electronic questionnaire with the Jefferson Scale of Empathy (JSE), Medical Student Well-Being Index, and other independent characteristics as measuring instruments. Of the 2,264 student participants, 1,679 (74.0%) were women, with a 50.7% participation rate. No significant differences were found in empathy levels by academic year. Regarding range, percentile and cut-off point tables were established to identify students with high, medium, and low empathy levels. Women (p<0.001), volunteer workers (p<0.001), and those preferring general specialties (internal medicine, psychiatry, pediatrics, or family medicine) scored higher on the JSE (p<0.02). Moreover, 41.6% presented high level of psychological distress. Women reported a lower well-being level and a higher risk of psychological distress (p = 0.004). In sum, the empathy of medical students in Madrid did not differ among the three critical moments of their university studies. The established cut-off points could be taken into account when accessing the medical degree and identifying students with low levels of empathy to implement curricular interventions to rectify this perceived deficiency. There was a high percentage of medical students with high levels of psychological distress.
Citation: Blanco Canseco JM, Blanco Alfonso A, Caballero Martínez F, Hawkins Solís MM, Fernández Agulló T, Lledó García L, et al. (2022) Medical empathy in medical students in Madrid: A proposal for empathy level cut-off points for Spain. PLoS ONE 17(5): e0267172. https://doi.org/10.1371/journal.pone.0267172
Editor: Mohammed Saqr, University of Eastern Finland: Ita-Suomen yliopisto, FINLAND
Received: January 25, 2022; Accepted: April 3, 2022; Published: May 23, 2022
Copyright: © 2022 Blanco Canseco et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly. The database is composed of sensitive student information from 8 universities in Madrid. The information was collected for the purposes of this project. No specific permission was obtained for its transfer to third parties, as the Spanish legislation requires in terms of protection and confidentiality of the information collected for clinical-epidemiological research. The restrictions were imposed by the steering committee of the eight universities in Madrid participating in the study, following the indications of their respective university centres. However, data are available at the School of Medicine of Francisco de Vitoria University upon reasonable request (investigacion.ensalud@ufv.es) for researchers who meet the criteria for access to confidential data.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Empathy is a personal quality that involves feeling, imagining, and understanding the inner world of others [1]. Empathy is a multidimensional construct comprising cognitive, affective and behavioural dimensions [2, 3]. Medical empathy is a fundamentally cognitive ability [2, 4] which also involves knowing how to transmit this understanding to the patient with the intention of helping to prevent or alleviate their suffering [4, 5].
The communicative and empathic skills of physicians are key to their relationships with their patients and are considered a core element of professionalism [6]. Organizations such as the International College of Person Centered Medicine (http://www.personcenteredmedicine.org/) [7] and the European Society of Person Centered Healthcare (http://www.pchealthcare.org.uk/) [8] advocate the need to reinforce these skills to improve the health of both, people who are sick and their caregivers.
Greater empathy in doctors is associated with greater patient satisfaction [9], stronger adherence to treatments [10] and more favorable health outcomes [11, 12]. In professionals, it is associated with more effective clinical skills [13] and lower burnout rates [14]. More empathic medical students have greater well-being [15], less burnout [16, 17] and better clinical competence [18–20].
Empathy can be improved with correct training [21–23]. Medical schools play a key role in evaluating and monitoring the empathic skills of their students and in carrying out educational actions that maintain and maximize them [24]. Some authors [4, 24, 25] argue that admissions to universities should consider the humanistic qualities of applicants who are to be future doctors, in addition to their academic qualifications. Some countries already incorporate professional aptitude tests in access to the Degree in Medicine in order to select students with a profile of more humanistic values such as empathy, communication, compassion or social commitment [26].
The Jefferson Scale of Empathy (JSE) [27] is a valid and reliable instrument developed specifically to measure the degree of empathy among medical students and practicing physicians. It has been translated and culturally adapted into more than 56 languages/dialects and has been employed in at least 85 countries. Currently, it is the most widely used tool to measure empathy in medical education [2]. In Spain, various studies have shown the validity and reliability of the JSE [28–31].
Most of the studies in our field [28, 30–32] which analyze variables associated with higher or lower levels of empathy in medical students have been performed in a single institution or with small, unrepresentative sample sizes. Consequently, any generalization of these results could be questioned. It is therefore unclear how medical students’ empathy evolves over time, with different studies reporting conflicting results. Some studies [33–36] show a clear fall in empathy throughout the degree course, especially when students come into contact with patients in their clerkships, while this trend is not apparent in other studies [37–40]. In a recent systematic review, Ferreira-Valente et al. [39] report a significant deterioration in the level of empathy among medical students when analyzing different longitudinal studies, whereas cross-sectional studies did not corroborate this trend. Other longitudinal studies carried out in this setting observe that empathy does not deteriorate over time [31].
Different factors may affect the levels of medical students’ empathy throughout their degree studies. These include cultural differences, characteristics of the healthcare systems to which they belong, workload, burnout, emotional overload, and lack of good mentors [34, 35]. Studies have found that students in the final years of their education have a high prevalence of depression and anxiety, and that levels of psychological distress are higher than those of the general population and their age-matched peers. Taken together, the studies suggest that psychological distress may be higher among female students [41–43]. A study conducted in all 43 medical Spanish schools shows similar results [44]. Lower levels of empathy are associated with greater burnout and a lower climate of professionalism [45]. Students with signs of depression show lower empathy [44]. More empathic medical students have greater well-being [15] and less burnout [16, 17]. There is thus a growing need to analyze medical students’ empathy in large samples that represent their populations of origin, thereby making the establishment of percentile tables and cut-off points at a national level possible [46]. Having these data will allow us to detect higher and lower levels of empathy in students and thus assess the impact of different curricular activities that seek to reinforce and enhance it. Hojat and Gonella (2015) and Hojat et al. (2018) [46, 47] already achieve this with medical and osteopathy students in the United States.
The present study aims to evaluate the degree of empathy in a large sample of students from the eight medical schools in the province of Madrid at three critical moments in their degree studies (first, third, and sixth academic years). Given that these eight medical schools represent 20% of the 42 medical schools in the country and receives students from all over the national terrritoriy, this work has the following objectives: it aims to establish rank-percentile tables and cut-off points to identify students with high, medium, and low levels of empathy in Spain. Moreover, it seeks to deepen—with a higher level of reliability and internal and external validities than those of previous studies—the knowledge of different variables that could affect the level of empathy in medical students. These variables include their preferences for a particular specialty, current academic year, professional experience, involvement in volunteer work, or previous experience of serious illness in themselves or family members. It is of particular interest to know the degree of the well-being of medical students and its influence on their levels of empathy.
The present research is an initial study within a project that seeks to evaluate the Empathy of Medical students in Madrid over time (Project EMMA) and identify the determinants of student empathy and analyze the effect that different curricular activities may have on it.
Materials and methods
Design
This is a descriptive cross-sectional study conducted at three critical moments during the degree course in medicine: beginning of the first year and end of the third and sixth years. Data were collected in May and September 2019 prior to the COVID-19 pandemic. The work was coordinated by a research committee in which at least one professor coordinator of each medical school was represented. It had the approval and support of the deans of the eight participating medical schools.
Scope and participants
Participants included 2,264 first-third-sixth-year students (74.0% women, n = 1,679) from 8 medical schools in Madrid, Spain (out of 8), four of which were public and four were private, representing 100% of all schools of medicine. All students in each course were invited to participate by consecutive sampling.
Measuring instruments
Students responded to an electronic, anonymous, and voluntary questionnaire. The faculty of medicine managers and lecturers explained the purpose of the study to the students. Subsequently, after giving their consent to participate, the students were given time at the beginning or end of one of the classes to complete the questionnaire. As a dependent variable, self-perceived empathy by medical students was measured using the JSE. The JSE’s Spanish translated and validated version for healthcare professionals (JSE-HP) was used for medical students from Madrid [30]. This scale was specifically designed to assess empathy in the physician-patient relationship from a more cognitive point of view, and it is the most used instrument globally to evaluate the empathy of medical students [2, 27]. The JSE-HP can be used to assess the empathy of medical students who have already had contact with real or simulated patients (usually from the third year onwards) [5, 48]. First-year students who had not yet been in contact with patients were asked to make an effort to imagine the experience for themselves, rather than imagining what the situation might be like for another person. Hojat et al. [49] find no differences between the generic version for students and the physician-specific version in a before-after cross-over study with 42 internal medicine residents. The correlations between the scores of the two versions were 0.85 (p<0.01), with no differences in Cronbach’s alpha or significant changes in scale scores.
The JSE-HP consists of 20 items with a seven-point Likert scale (1 = strongly disagree to 7 = strongly agree). Ten of the 20 issues are rated negatively (with positive rectification in the subsequent analysis) to reduce the effect of the acquiescence response bias. The possible scores ranged from 20 to 140 points, with higher scores associated with a higher degree of empathy. Although there is no time limit, the questions are usually answered in less than five minutes. The scale is considered valid if at least 80% of the questions are answered. If more than four questions remained unanswered, the questionnaire is considered null and void [4, 48].
In the original version and subsequent studies, factorial analysis [5] revealed three dimensions of the scale. Dimension 1: The patient’s perspective (cognitive aspects of empathy) consisting of 10 items; Dimension 2: Attention with compassion (emotional aspects of empathy) consisting of 8 items; and Dimension 3: Putting yourself in the place of the patient, consisting of 2 items.
The cut-off points of low and high empathy were defined, as described by the authors [46] of the scale, by arbitrarily determining two points in the score distribution. To identify high levels of empathy, a cut-off point of one and a half standard deviation above the mean score was chosen. To identify low levels of empathy, one and half standard deviation below the mean score was chosen.
The following independent variable predictors of empathy were analyzed: age, gender, academic year, nationality, coexistence in the family nucleus, compatibility of studies and work, previous professional experience, experience of illness (one’s own or of a close family member), preference by type of speciality desired for future residency, and participation in volunteer work. Students were asked to choose one of the following four groups of specialties: general specialties (internal medicine, psychiatry, pediatrics, and family medicine), other medical specialties (cardiology, digestive, nephrology…), surgical and technological specialties (surgeries, radiodiagnosis, etc.), and other non-clinical specialties (clinical analysis, pathological anatomy, and preventive medicine). These types of groupings have been used in previous studies [4, 5, 50].
The level of the students’ well-being and psychological distress was analyzed using the Medical Student Well-Being Index (MSWBI) [51, 52] of the Mayo Clinic. This questionnaire has seven items [4]. In its construct, psychological distress encompasses depression, anxiety, burnout, and related mental health problems. The overall score is the sum of these seven items, and it ranges from 0 to 7 points. The higher the score, the higher the students’ degree of psychological distress and the lower their well-being. The cut-off point for detecting students with a high degree of psychological distress is four or more points [53].
Statistical analysis
Qualitative variables were described using their frequency distributions and percentages. Quantitative variables were described with their mean and standard deviation (SD) when they followed a normal distribution pattern and with median and interquartile range (P25–75) for non-parametric distributions.
The association between qualitative variables was carried out using the chi-square test. The relationship between continuous variables and qualitative variables was determined by the t Student for independent samples or analysis of variance when the variables presented a normal distribution. The non-parametric Mann-Whitney U test or the Kruskal-Wallis test was employed when the variable was proven to be asymmetric. The association between continuous quantitative variables was determined using Pearson or Spearman correlations. In cases wherein it proved necessary, the effect’s magnitude was estimated when the association was statistically significant, using the Cohen’s d test, to determine the practical (clinical) importance of statistically significant results. Effect magnitudes smaller than 0.2 were not considered to be of importance [54]. A multiple linear regression model (with JSE as a dependent variable) was used to assess the independent effect of each of the other variables that could influence levels of empathy. We used gender (women vs. men), volunteer work, serious illness, work placements started, Spanish nationality, living with your family as binary variables, and preference by specialty as a categorical variable. Total MSWBI, age, and the academic year were continuous variables.
For statistical analysis, the IBM-SPSS Stadistics_21 program for Windows was used, with a priori significance level of alpha<0.05, in all analyses.
Ethical aspects
To respect international data protection standards as well as the Spanish legislation in force—Organic Law 3/2018 of December 5 on the Protection of Personal Data and Digital Rights Guarantees, Official State Bulletin (BOE) 294, dated 6/12/2018—all questionnaires were anonymous. The Ethics Committee of the Universidad Francisco de Vitoria approved the study. Students’ participation was voluntary, the informed consent was written and their (non-)participation did not affect their academic results.
Results
A total of 2,301 students completed the questionnaire. Of these, 37 questionnaires were discarded because students failed to answer more than four JSE items. All told, 2,264 of the 4,469 students enrolled in the first, third, and sixth years of the eight medical schools in Madrid participated in the study. The overall participation rate was 50.7%. Participation rates among the first-, third-, and sixth-year students were 59.7% (n = 893), 46.3% (n = 714), and 45.9% (n = 657), respectively. Their mean ages were 18.9 (SD = 2.8) years, 22.2 (SD = 2.0) years, and 25.1 (SD = 1.8) years, respectively. Further, the number of women participants from each year was 681 (76.3%), 536 (75.1%), and 460 (70.1%), respectively. Gender distribution in the study sample did not differ from that in the source population.
Of the students, 95.1% (n = 2,157) were Spanish nationals. A total of 62.9% (n = 1,426) reported living with their family, and 10.7% (n = 243) shared their studies with some form of work activity. Further, 34.2% (n = 775) had previous professional experience. In 15.8% of cases (n = 122), this professional experience was in the health field.
Of the sample studied, 33.1% (n = 750) reported having participated in volunteer work. This percentage was significantly higher in women (35.7%) than in men (25.3%; p<0.001). Moreover, 68.2% (n = 1,547) reported having had a previous experience of serious illness, be it their own or that of a close family member. This percentage was higher in men (38.3%) than in women (32.8%; p = 0.017).
Further, 31.7% of the students (n = 718) opted for a general specialty (internal medicine, psychiatry, pediatrics, or family medicine), 27.6% (n = 625) chose other medical specialities (cardiology, digestive, nephrology, etc.), 32.1% (n = 727) preferred surgical or technological specialities (surgeries, radiodiagnosis, etc.), and 8.7% (n = 198) chose non-clinical specialities (clinical analysis, pathological anatomy, or preventive medicine). By analyzing this preference by academic year, students in their sixth year, compared to those in their first, chose more general specialities (37% in the sixth vs. 27% in the first) and medical specialities (33.5% vs. 23.7%) compared with surgical or technological (25.7% vs. 33.3%) and non-clinical (3.8% vs. 16%; p<0.001) specialities.
Internal consistency of JSE-HP is shown in Table 1. No item is dispensable as the Cronbach’s alpha obtained of 0.80 would not significantly improve. Pearson correlation coefficients were calculated to examine correlations between each item score and the total score of the JSE. There is positive and significant correlation between each of the items and the overall result of the scale, the median being 0.39 (p< 0.01).
The overall mean JSE score was 115.22 points (SD = 14.24) for men and 121.17 points (SD = 11.18) for women. Table 2 reflects the sample empathy levels with ranges and percentile ranges disaggregated by gender. Table 3 reflects the JSE scores (total and by dimensions) of the sample by academic year.
In the analysis of variables that could influence student empathy, women scored a mean of 6.05 (95% confidence interval [CI] 4.73–7.36) points higher than men in overall JSE scores (p<0.001; Cohen’s d: 0.46). Fig 1 shows the overall total JSE scores disaggregated by gender across academic years.
There were no differences in levels of empathy among the first-, third-, and sixth-year students, except the third- and sixth-year male students. Sixth-year male students scored an average of 5.09 points more than those in their third year (95% CI 1.50–8.68 points; Cohen’s d = 0.35).
The overall mean well-being (MSWBI) score was 2.76 points (SD = 2.19) for men and women had 3.05 points (SD = 2.13); the mean difference was 0.29 points (95% CI 0.09–0.50; p = 0.004; Cohen’s d = 0.13). In addition, 41.6% of the students (n = 944) scored 4 or higher (psychological distress). This percentage was significantly higher in women than in men (43.4% vs. 36.7%; p = 0.007; see Fig 2).
Students who preferred general specialities (internal medicine, psychiatry, pediatrics, or family medicine) scored a mean JSE score of 121.85 points (SD = 11.62). Those who chose other medical specialities (cardiology, digestive, nephrology, etc.) had 119.80 points (DE = 12.33) points, and those who chose surgical-technological (surgeries, radiodiagnosis, etc.) and non-clinical (clinical analysis, pathological anatomy, or preventive medicine) specialities scored 118.46 (SD = 12.11) and 114.86 (SD = 13.91) points, respectively. In the post-hoc tests of multiple Bonferroni comparisons, these differences were statistically significant for all subgroups, except when the scores of those who chose other medical specialities versus surgical-technological specialities were compared. These differences remained significant after controlling for age and gender (Tables 4 and 5).
Students engaged in volunteer work obtained mean scores in the total JSE of 121.8 points (SD = 11.50) versus 118.5 points (SD = 12.59) for those who did not. Mean averages difference: 3.31 (95% CI 2.24–4.38) points (p = 0.001; d Cohen 0.13). 0.27). This difference remained significant after controlling for age and gender (Table 5).
The mean overall empathy score for students who had had a previous experience of serious illness, be it personally of that of a family member, was 118.85 points (SD = 12.92) compared with 119.95 points (SD = 12.04) for those who had no such experience (p = 0.056).
To analyze the independent effect of each variable on empathy, we performed a linear regression model (Table 5), controlled for age and gender. The characteristics associated with higher empathy were as follows: being a woman (β = -0.201, p<0.001), having performed some form of voluntary work (β = 0.103, p<0.001), reporting a higher level of well-being (β = -0.071, p<0.005) and reporting a preference for a general medical speciality (β = -0.124, p<0.001).
As in the present study and a large number of previous studies [4, 18, 46, 47], there are differences in empathy according to gender (higher values in women), and so we set different cut-off points for men and women. As no differences in empathy were found between academic years, the calculations were made with the total sample of students from the three years studied [50]. Table 6 shows the proposed empathy level cut-off points for Spanish medical students. Thus, the frequency distribution table and the cut-off points proposed for low, medium, and high empathy can be used in other Spanish universities, provided the students’ demographic characteristics and JSE scores do not differ substantially from those presented in Table 2.
Discussion
The sample size of the study is much larger than that in previous research [28, 29, 31] analyzing empathy in this field. All of Madrid’s medical schools, both public and private, participated in the study. The province of Madrid has a population of 6,745,591 inhabitants, 14.2% of the Spanish population. 20% of the country’s medical schools are concentrated in this community, receiving students from all over the country. Consequently, the conclusions presented here may be considered highly reliable (consistency and repeatability) as well as sound regarding internal validity (true relationship between variables) and external validity (generalization).
The response rate to the questionnaire (50.7%) was higher than the usual rate in previous research employing online questionnaires. Cho et al. [55] report an average online questionnaire response rate of 35% in a review study. Hojat et al. [47] find no differences in JSE results from students who answered online compared with those who answered in person. Further, 37.1% of the students in the sample declared that they did not live with their family, meaning that they most likely came from other provinces of the country. As described in other studies in Spain [28, 29] a greater number of women than men were found among the medical students. Considering the aforementioned observations, we believe that the sample of medical students from this research offers a fair representation of the medical degree student population at the national level.
There are no precise data in our setting that can explain the evolution of medical students’ empathy throughout the academic years. In this study, the academic year doesn´t decrease empathy. Indeed, it improved for men in their final academic year compared to their third year. Andersen et al. [56] conduct a systematic review of 30 studies carried out in 20 different countries over five continents (24 cross-sectional and 6 longitudinal studies) on the evolution of empathy in medical students over time; they report a deterioration of empathy in 14 studies. In the remaining 16, empathy improved or did not change, or the studies presented conflicting results. Cultural differences could be the cause of this heterogeneity of results, as evidenced by the systematic review [56] in which medical students from Asian countries scored lower in empathy than those from Western countries. A recent review by Ponnamperuma et al. [57] supports this idea, observing that while most US studies show a deterioration in empathy over time, other countries show a stabilization or even a modest increase. Other possible explanations for these differences could be the different designs (longitudinal or cross-sectional) or instruments used to measure empathy. A cohort study [31] conducted at one of the universities participating in this study centered on 102 medical students over a five-year period, showed that empathy did not decline during this time. In fact, it improved slightly in women, especially in terms of cognitive empathy.
To date, no studies have been published in Europe with a sufficiently broad and representative sample that would allow for a proposal of cut-points and tables with percentile ranks representing the population of a European country, which in turn would help in differentiating between students with high, medium, and low levels of empathy. This study offers, as do other authors in USA [46, 47], some cut-off points that can help us better analyze the levels of empathy of any first-year student enrolled in medical colleges in Europe at the beginning of the academic year, observe their evolution over time, and determine the impact of curricular activities that seek to improve them. As a result, we can prepare and train future physicians to have better clinical and human skills, as well as be more satisfied with their professional lives. Some authors argue that the teaching of all components of empathy, not only cognitive and behavioral aspects but also emotional and moral aspects, must be included in the curriculum of a degree in medicine. Different systematic reviews [58] support this thesis. For example, a man who begins his medical studies at a school of medicine and obtains a JSE score of 95 will find himself in the 11th percentile, and his level of empathy may be considered moderate. However, the same score in a woman would place her in the 3rd percentile, which corresponds with a low level of empathy. A medical school in another Spanish locality with sociodemographic data and JSE scores comparable to those presented in Table 2 could make use of the same cut-off points.
If we compare the cut-off points established by Hojat et al. in 2,637 medical students at Sidney Kimmel Medical College with those proposed in this study, we find that, except at the lower limit of empathy in men, other points that define empathy as high and low are higher in our study. We believe that this is a reflection of the higher average levels of global empathy found in Spanish medical students [30, 31], compared with those in US students [39, 46]. The empathy scores of medical students in this study showed moderate negative asymmetry (-0.95 in men and -0.94 in women). This means that the score curve moves to the right toward higher scores [59]. On another note, the curve is slightly leptokurtic [59] as the kurtosis values are positive (0.21 in men and 1.08 in women). These results are similar to those reported in other studies [46].
Our study confirms, as in previous studies [18, 46, 47, 50, 56], that women obtain higher empathy scores than men, although the magnitude of this difference is moderate. Different factors, such as social learning or genetic predisposition, could justify this finding [4].
Regarding MSWBI, 43.4% of women and 36.7% of men scored ≥4 points. Of concern is the high percentage of medical students with a high degree of psychological distress in the present study, although this percentage is less than the 52.9% recently reported by Rajapuram et al. [60] for medical students in the United States. Both studies were conducted prior to the start of the COVID-19 pandemic. Compared with men, women showed higher levels of empathy and were more involved in volunteer work. However, they also reported higher levels of psychological distress. A systematic review in the United States and Canada by Dyrbye et al. [41] finds higher levels of anxiety, depression, and stress in medical students in North America, compared with those reported by peers of the same age in the general population. In addition, the study found an association between psychological distress and a deterioration in academic performance, professionalism, and empathy toward patients.
In a systematic review, Wilkinson et al. [61] observed an inverse relationship between burnout and empathy. There have been many explanations for the cause of empathy deterioration suffered by medical students, although there is no clear and objective causal relationship. Such causal factors include stress [62], work overload, burnout [15, 63], contact with patients, lack of adequate mentors, hidden curricula, highly biologicist teaching, climate of cynicism, and distancing from the suffering of others [4, 64]. Identifying students with a high degree of psychological distress could prevent some of the fatal consequences described previously. Some medical schools [65] already offer programs to their students to improve their level of well-being, although such initiatives are still underdeveloped and their effectiveness has been poorly evaluated [66].
In line with what has already been purported by previous authors [50, 67–69], the present study finds that students who participate in volunteer work and choose people-centered specialities (general and medical) obtain better empathy scores than those who lean more toward technology, surgical procedures, and non-medical specialities. Guilera et al. [70], in a study of a single faculty of medicine in Spain, find an association between empathy and a preference for person-centered specialties in 110 students. This fact has also been observed [67] in medical students at the beginning of their first year of studies before the formal teaching commenced. Students with more empathy tended to choose specialties that require more frequent and intense contact with patients, such as internal medicine, pediatrics, family medicine, and psychiatry [50, 67–69, 71, 72]. The magnitude of this effect became clearer as the students chose specialities without direct treatment. This paper provides some relevant findings regarding this phenomenon, as in the previous systematic reviews that analysed it [56], only one-third find a clear association between empathy and medical specialties.
Awareness of the level of empathy in medical students and its determinants may enable us to identify students who most need concrete interventions to help reinforce the quality of empathy [4, 73]. Furthermore, it may help medical schools strengthen their curricula and offer better guidance to students in choosing a future specialty. Evaluating the degree of empathy in applicants of a medical degree may be a factor to consider during candidate selection, given the vital importance of this quality in medical practice [4]. In this way, we can train future doctors to maintain quality, humane, and meaningful relationships with their patients, which are mutually beneficial to both parties.
Limitations
This research consists of a cross-sectional study with empathy analysis at three points in the medical students’ studies (their first, third, and sixth years). Therefore, we analyze different student samples, and not the same group, over time.
The present study evaluates empathy using a questionnaire that is self-administered and is not from the perspective of third parties (real or simulated patients or expert evaluations); nevertheless, some previous studies [19, 74–76] have demonstrated the correlation between these two methods of measurement.
The bias of social desirability may also have affected the results. Even so, Hojat et al. [47], in a study with students of osteopathic medicine, find that only 2.5% of the students were likely to give false “good impressions,” as detected by the Scale of the Zuckerman-Kuhlman Personality Questionnaire [77]. A recently published cohort study [31] finds no significant differences between the empathy levels of students who identified themselves compared with those who preferred to remain anonymous when answering the JSE. The large sample size of our research and the anonymous and voluntary nature of the questionnaire minimized the possible bias of social desirability.
Future research
More studies with students from other medical schools in Spain are needed to confirm that the medical student populations all over the country are similar to those in Madrid. If this proves to be the case, the use of the same percentile tables and cut-off points proposed here may be justified throughout the country. The empathy of the students in this study should continue to be monitored longitudinally at least at three critical moments during their degree studies (first, third, and sixth years). It would also be interesting to measure students’ empathy from the perspective of patients (real or simulated) or communication experts and to analyze whether there is a relationship between their scores and the levels of empathy attained in this study. It is also desirable to relate the proposed levels of empathy to other variables [18–20] which are known to influence student empathy, such as their clinical performance or their best scores on the Objective Structured Clinical Examination. In this way, we can confirm the predictive validity of the cut-off points presented here.
This study found a relationship between the personal well-being of medical students and their levels of empathy. A systematic review of residents found that the higher the students’ well-being, the better their empathic ability [78]. Future studies are needed to analyze the determinants of students’ well-being throughout their degree studies, as well as their influence on their level of empathy.
It is necessary to evaluate the evolution of student empathy over time through longitudinal studies and to study the factors that determine students’ levels of empathy. This knowledge will help us implement curricular activities that encourage empathy among medical students. The EMMA project will present soon the influence of different academic study programs of all the medical schools in Madrid on the empathy levels of their students.
Conclusions
The empathy of medical students in Madrid did not differ among the three critical moments of their university studies. The established cut-off points will allow identifying students with lower levels of empathy in populations similar to the one described here. This identification is essential for the subsequent implementation of curricular activities that aim to reinforce and enhance this quality to help promote a more person-centered and meaningful physician-patient relationship. Further, we observed a high percentage of medical students with considerable psychological distress. Therefore, an analysis of the causes is important to implement activities or structural changes that prevent the severe risks associated with such distress, such as anxiety, depression, suicidal ideation, and abandonment of medical studies.
Acknowledgments
The authors are grateful for the cooperation of the students and professors of Universidad Autónoma de Madrid, Universidad de Alcalá de Henares, Universidad Alfonso X el Sabio, Universidad CEU San Pablo, Universidad Complutense de Madrid, Universidad Europea de Madrid, Universidad Francisco de Vitoria, Universidad Rey Juan Carlos, without whom this work would never have seen the light of day. They are also grateful to the Deanship of all these universities for their humanistic outlook on teaching.
References
- 1. Huddleston A. Coplan , Amy and Peter , Goldie . Empathy: Philosophical and Psychological Perspectives. Oxford University Press, 2011, xlvii + 382 pp., $99.00 cloth. J Aesthet Art Crit. 2013;71: 294–296.
- 2. Sulzer S, Feinstein N, Wendland C. Assessing empathy development in medical education: a systematic review. Med Educ. 2016 [cited 23 Aug 2017]. Available: http://onlinelibrary.wiley.com/doi/10.1111/medu.12806/full pmid:26896015
- 3. Irving P, Dickson D. Empathy: towards a conceptual framework for health professionals. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2004;17: 212–220. pmid:15481687
- 4.
Hojat M. Empathy in Health Professions Education and Patient Care. Cham: Springer International Publishing; 2016. https://doi.org/10.1007/978-3-319-27625-0
- 5. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry. 2002;159: 1563–9. pmid:12202278
- 6.
Stern DT. Measuring medical professionalism. Oxford University Press; 2006. Available: https://books.google.es/books?hl=es&lr=&id=lIwRDAAAQBAJ&oi=fnd&pg=PA117&dq=64.%09+Veloski,+J.,+%26+Hojat,+M.+(2006).+Measuring+specifi+c+elements+of+professionalism:+Empathy,+teamwork,+and+lifelong+learning.+In+D.+T.+Stern+(Ed.),+Measuring+Medical+Professionalism+(pp.+117–145).+Oxford:+Oxford+University+Press&ots=l7JO49E4D0&sig=xSre83O7QTAiBBuGMv4BEsIAUwc#v=onepage&q&f=false
- 7.
ICPCM. [cited 9 Jun 2017]. Available: http://www.personcenteredmedicine.org/
- 8.
European Society For Person Centered Healthcare |. [cited 28 Jul 2017]. Available: http://www.pchealthcare.org.uk/
- 9. Pollak K, Alexander S, Tulsky J. Physician empathy and listening: associations with patient satisfaction and autonomy. J. 2011 [cited 23 Aug 2017]. Available: http://www.jabfm.org/content/24/6/665.short pmid:22086809
- 10. Zolnierek K, DiMatteo M. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009 [cited 22 Aug 2017]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728700/ pmid:19584762
- 11. Del Canale S, Louis DZ, Maio V, Wang X, Rossi G, Hojat M, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med. 2012;87: 1243–9. pmid:22836852
- 12. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86: 359–64. pmid:21248604
- 13. Ogle J, Bushnell J, Caputi P. Empathy is related to clinical competence in medical care. Med Educ. 2013 [cited 22 Aug 2017]. Available: http://onlinelibrary.wiley.com/doi/10.1111/medu.12232/full pmid:23837429
- 14. Lamothe M, Boujut E, Zenasni F. To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. BMC Fam. 2014 [cited 23 Aug 2017]. Available: https://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-15-15 pmid:24456299
- 15. Thomas M, Dyrbye L, Huntington J. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen. 2007 [cited 23 Aug 2017]. Available: http://link.springer.com/article/10.1007/s11606-006-0039-6 pmid:17356983
- 16. Paro H, Silveira P, Perotta B, Gannam S. Empathy among medical students: is there a relation with quality of life and burnout? PLoS One. 2014 [cited 23 Aug 2017]. Available: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0094133
- 17. Hojat M, Vergare M, Isenberg G, Cohen M, Spandorfer J. Underlying construct of empathy, optimism, and burnout in medical students. Int J Med Educ. 2015;6: 12–6. pmid:25633650
- 18. Hojat M, Gonnella J, Mangione S, Nasca T. Empathy in medical students as related to academic performance, clinical competence and gender. Medical. 2002 [cited 9 Jun 2017]. Available: http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2923.2002.01234.x/full pmid:12047665
- 19. Berg K, Majdan J, Berg D, Veloski J, Hojat M. A comparison of medical students’ self-reported empathy with simulated patients’ assessments of the students’ empathy. Med Teach. 2011 [cited 13 Sep 2017]. Available: http://www.tandfonline.com/doi/abs/10.3109/0142159X.2010.530319 pmid:21517687
- 20. Berg K, Blatt B, Lopreiato J, Jung J, Schaeffer A, Heil D, et al. Standardized Patient Assessment of Medical Student Empathy: Ethnicity and Gender Effects in a Multi-Institutional Study. Acad Med. 2015;90: 105–111. pmid:25558813
- 21. Stepien K, Baernstein A. Educating for empathy. Gen Intern Med. 2006 [cited 9 Jun 2017]. Available: http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2006.00443.x/full pmid:16704404
- 22. Batt-Rawden SA, Chisolm MS, Anton B, Flickinger TE. Teaching Empathy to Medical Students. Acad Med. 2013;88: 1171–1177. pmid:23807099
- 23. Kelm Z, Womer J, Walter J. Interventions to cultivate physician empathy: a systematic review. BMC Med. 2014 [cited 10 Sep 2017]. Available: https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-14-219 pmid:25315848
- 24. Cohen J. Our compact with tomorrow’s doctors. Acad Med. 2002 [cited 28 Jul 2017]. Available: http://journals.lww.com/academicmedicine/Abstract/2002/06000/Our_Compact_with_Tomorrow_s_Doctors.2.aspx pmid:12063190
- 25. Miles A. Person-centered medicine-at the intersection of science, ethics and humanism. Int J Pers Cent Med. 2012 [cited 28 Jul 2017]. Available: http://www.ijpcm.org/index.php/ijpcm/article/view/281
- 26. Stegers-Jager KM, Stegers-Jager M. Lessons learned from 15 years of non-grades-based selection for medical school. Med Educ. 2018;52: 86–95. pmid:28984374
- 27.
Jefferson Scale of Empathy—Philadelphia University + Thomas Jefferson University. [cited 22 May 2019]. Available: https://www.jefferson.edu/university/skmc/research/research-medical-education/jefferson-scale-of-empathy.html
- 28. Ferreira-Valente A, Costa P, Elorduy M, Virumbrales M, Costa MJ, Palés J. Psychometric properties of the Spanish version of the Jefferson Scale of Empathy: making sense of the total score through a second order confirmatory factor analysis. BMC Med Educ. 2016;16: 242. pmid:27647296
- 29. Alcorta-Garza A, San-Martín M, Delgado-Bolton R, Soler-González J, Roig H, Vivanco L. Cross-Validation of the Spanish HP-Version of the Jefferson Scale of Empathy Confirmed with Some Cross-Cultural Differences. Front Psychol. 2016;7: 1002. pmid:27462282
- 30. Blanco JM, Caballero F, García FJ, Lorenzo F, Monge D. Validation of the Jefferson Scale of Physician Empathy in Spanish medical students who participated in an Early Clerkship Immersion programme. BMC Med Educ. 2018;18. pmid:30208887
- 31. Blanco JM, Caballero F, Álvarez S, Plans M, Monge D. Searching for the erosion of empathy in medical undergraduate students : a longitudinal study. 2020; 1–9. pmid:33384394
- 32. Alcorta-Garza A, González-Guerrero JF T-HS, Rodríguez-Lara FJ MH. Validacion de la escala de empatia medica de Jefferson en estudiantes de medicina mexicanos. Salud Ment. 2005;28: 57–63.
- 33. Hojat M, Mangione S, Nasca T, Rattner S. An empirical study of decline in empathy in medical school. Medical. 2004 [cited 24 Aug 2017]. Available: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2929.2004.01911.x/full pmid:15327674
- 34. Hojat M, Vergare M, Maxwell K, Brainard G. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic. 2009 [cited 28 Jul 2017]. Available: http://journals.lww.com/academicmedicine/Abstract/2009/09000/The_Devil_is_in_the_Third_Year__A_Longitudinal.12.aspx pmid:19707055
- 35. Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86: 996–1009. pmid:21670661
- 36. Hojat M, Shannon SC, DeSantis J, Speicher MR, Bragan L, Calabrese LH. Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-Institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools. Acad Med. 2020; 1. pmid:31977341
- 37. Roff S. Reconsidering the “decline” of medical student empathy as reported in studies using the Jefferson Scale of Physician Empathy-Student version (JSPE-S). Med Teach. 2015;37: 783–786. pmid:25665629
- 38. Colliver J, Conlee M, Verhulst S. Reports of the decline of empathy during medical education are greatly exaggerated: a reexamination of the research. Academic. 2010 [cited 24 Aug 2017]. Available: http://journals.lww.com/academicmedicine/Abstract/2010/04000/Reports_of_the_Decline_of_Empathy_During_Medical.16.aspx
- 39. Ferreira-Valente A, Monteiro JS, Barbosa RM, Salgueira A, Costa P, Costa MJ. Clarifying changes in student empathy throughout medical school: a scoping review. Adv Heal Sci Educ. 2017;22: 1293–1313. pmid:27465064
- 40. Papageorgiou A, Miles S, Fromage M. Does medical students’ empathy change during their 5-year MBBS degree? Educ Heal Chang Learn Pract. 2018;31: 142–147. pmid:31134944
- 41. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine. Lippincott Williams and Wilkins; 2006. pp. 354–373. pmid:16565188
- 42. Erschens R, Keifenheim KE, Herrmann-Werner A, Loda T, Schwille-Kiuntke J, Bugaj TJ, et al. Professional burnout among medical students: Systematic literature review and meta-analysis. Med Teach. 2019;41: 172–183. pmid:29656675
- 43. Rotenstein LS, Ramos MA, Torre M, Bradley Segal J, Peluso MJ, Guille C, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students a systematic review and meta-analysis. JAMA—J Am Med Assoc. 2016;316: 2214–2236. pmid:27923088
- 44. Capdevila-Gaudens P, Miguel García-Abajo J, Flores-Funes D, García-Barbero M, García-Estañ J. Depression, anxiety, burnout and empathy among Spanish medical students. PLoS One. 2021;16: 1–16. pmid:34855803
- 45. Brazeau CMLR, Schroeder R, Rovi S, Boyd L. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010;85: 33–36. pmid:20881699
- 46. Hojat M, Gonnella JS. Eleven Years of Data on the Jefferson Scale of Empathy-Medical Student Version (JSE-S): Proxy Norm Data and Tentative Cutoff Scores. Med Princ Pract. 2015;24: 344–50. pmid:25924560
- 47. Hojat M, DeSantis J, Shannon SC, Mortensen LH, Speicher MR, Bragan L, et al. The Jefferson Scale of Empathy: a nationwide study of measurement properties, underlying components, latent variable structure, and national norms in medical students. Adv Heal Sci Educ. 2018;23: 899–920. pmid:29968006
- 48. Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonnella JS, Erdmann JB, et al. The Jefferson Scale of Physician Empathy: Development and Preliminary Psychometric Data. Educ Psychol Meas. 2001;61: 349–365.
- 49. Hojat M, Gonnella JS, Mangione S, Nasca TJ, Magee M. Physician empathy in medical education and practice: experience with the Jefferson scale of physician empathy. Semin Integr Med. 2003;1: 25–41.
- 50. Hojat M, Gonnella J, Nasca T, Mangione S. The Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item level. Academic. 2002 [cited 9 Jun 2017]. Available: http://journals.lww.com/academicmedicine/Fulltext/2002/10001/The_Jefferson_Scale_of_Physician_Empathy__Further.19.aspx pmid:12377706
- 51. Dyrbye LN, Szydlo DW, Downing SM, Sloan JA, Shanafelt TD. Development and preliminary psychometric properties of a well-being index for medical students. BMC Med Educ. 2010;10. pmid:20105312
- 52.
Physician Well-Being Index | Invented By Mayo Clinic Well-Being Index. [cited 2 Feb 2020]. Available: https://www.mededwebs.com/well-being-index/physician-well-being-index
- 53. Dyrbye LN, Schwartz A, Downing SM, Szydlo DW, Sloan JA, Shanafelt TD. Efficacy of a brief screening tool to identify medical students in distress. Acad Med. 2011;86: 907–914. pmid:21642810
- 54. Hojat M, Xu G. A Visitor’s Guide to Effect Sizes—read already. Adv Heal Sci Educ. 2004;9: 241–249.
- 55. Cho YI, Johnson TP, VanGeest JB. Enhancing Surveys of Health Care Professionals: A Meta-Analysis of Techniques to Improve Response. Eval Heal Prof. 2013;36: 382–407. pmid:23975761
- 56. Andersen FA, Johansen ASB, Søndergaard J, Andersen CM, Assing Hvidt E. Revisiting the trajectory of medical students’ empathy, and impact of gender, specialty preferences and nationality: A systematic review. BMC Med Educ. 2020;20. pmid:32066430
- 57. Ponnamperuma G, Yeo SP, Samarasekera DD. Is empathy change in medical school geo-socioculturally influenced? Med Educ. 2019;53: 655–665. pmid:30891799
- 58. Ave O. Empathy–can it be taught? 1 1. 2016; 107–112.
- 59. Blanca MJ, Arnau J, López-Montiel D, Bono R, Bendayan R. Skewness and kurtosis in real data samples. Methodology. 2013;9: 78–84.
- 60. Rajapuramid N, Langness S, Marshall MR, Sammann A. Medical students in distress: The impact of gender, race, debt, and disability. 2020 [cited 14 Feb 2021]. pmid:33270759
- 61. Wilkinson H, Whittington R, Perry L, Eames C. Examining the relationship between burnout and empathy in healthcare professionals: A systematic review. Burn Res. 2017;6: 18–29. pmid:28868237
- 62. Ludwig AB, Burton W, Weingarten J, Milan F, Myers DC, Kligler B. Depression and stress amongst undergraduate medical students. BMC Med Educ. 2015;15: 1–5. pmid:25592199
- 63. Brazeau C, Schroeder R, Rovi S. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010 [cited 9 Jun 2017]. Available: http://journals.lww.com/academicmedicine/Abstract/2010/10001/Relationships_Between_Medical_Student_Burnout,.12.aspx
- 64. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84: 1182–91. pmid:19707055
- 65. Drolet BC, Rodgers S. A comprehensive medical student wellness program-design and implementation at vanderbilt school of medicine. Academic Medicine. Lippincott Williams and Wilkins; 2010. pp. 103–110. pmid:20042835
- 66. Wasson LT, Cusmano A, Meli L, Ed M, Louh I, Falzon L, et al. Association Between Learning Environment Interventions and Medical Student Well-being: A Systematic Review HHS Public Access. pmid:27923091
- 67. Hojat M, Zuckerman M, Magee M, Mangione S, Nasca T, Vergare M, et al. Empathy in medical students as related to specialty interest, personality, and perceptions of mother and father. Pers Individ Dif. 2005;39: 1205–1215.
- 68. Chen D, Lew R, Hershman W, Orlander J. A cross-sectional measurement of medical student empathy. J Gen Intern Med. 2007;22: 1434–8. pmid:17653807
- 69. Chen DCR, Kirshenbaum DS, Yan J, Kirshenbaum E, Aseltine RH. Characterizing changes in student empathy throughout medical school. Med Teach. 2012;34: 305–11. pmid:22455699
- 70. Guilera T, Batalla I, Forné C, Soler-González J. Empathy and big five personality model in medical students and its relationship to gender and specialty preference: A cross-sectional study. BMC Med Educ. 2019;19: 1–8. pmid:30606170
- 71. Chopik WJ , O’Brien E, Konrath SH. Differences in Empathic Concern and Perspective Taking Across 63 Countries. J Cross Cult Psychol. 2017;48.
- 72. Hojat M, DeSantis J, Shannon SC, Speicher MR, Bragan L, Calabrese LH. Empathy as related to gender, age, race and ethnicity, academic background and career interest: A nationwide study of osteopathic medical students in the United States. Med Educ. 2020;54: 571–581. pmid:32083747
- 73. Hojat M, Axelrod D, Spandorfer J, Mangione S. Enhancing and sustaining empathy in medical students. Med Teach. 2013;35: 996–1001. pmid:23758178
- 74. Glaser K, Markham F, Adler H. Relationships between scores on the Jefferson Scale of physician empathy, patient perceptions of physician empathy, and humanistic approaches to patient care: a. Med Sci. 2007 [cited 13 Sep 2017]. Available: http://www.medscimonit.com/abstract/index/idArt/487348/act/3
- 75. Blanco Canseco JM, Valcárcel Sierra C, Guerra Jiménez MDC, Ortigosa Rodríguez E, García López F, Caballero Martínez F, et al. Clinical empathy among family and community medicine residents and tutors. The view of physicians and patients. Aten Primaria. 2018. pmid:30522783
- 76. LaNoue MD, Roter DL. Exploring patient-centeredness: The relationship between self-reported empathy and patient-centered communication in medical trainees. Patient Educ Couns. 2018;101: 1143–1146. pmid:29395476
- 77. Zuckerman M. Zuckerman-Kuhlman Personality Questionnaire (ZKPQ): an alternative five-factorial model. Big five Assess. 2002 [cited 9 Jun 2017]. Available: http://grupsderecerca.uab.cat/zkpq/sites/grupsderecerca.uab.cat.zkpq/files/zkpq7.pdf
- 78. Raj KS. Well-Being in Residency: A Systematic Review. J Grad Med Educ. 2016;8: 674–684. pmid:28018531