Evaluation of empathy between First and Final year medical students of

Rehman Medical College: a cross-sectional study

Abstract

Introduction: Empathy is an important component of physician professionalism.

Thus, proper assessment and education of empathy in medical students is
important for medical education. Empathy is generally regarded as comprising an
affective capacity: the ability to be sensitive to and concerned for, another and a
cognitive capacity: the ability to understand and appreciate the other person’s
perspective.
Objectives: To quantify empathy level in First and Final year medical students
and compare mean empathy scores between male and female medical students.
Design: Cross-sectional study
Setting: First and Final-year medical students of Rehman Medical College,
Peshawar.
Measurement: Empathy level was assessed in 190 First and Final-year medical
students using the Jefferson’s Scale of Empathy- Medical Student version.
Results: The mean empathy score was 100.22 (standard deviation (SD) 15.43).
First-year medical students mean empathy was higher compared to final-year,
105.16 (standard deviation (SD) 12.75) and 95.27 (standard deviation (SD)
16.33) respectively. Empathy score was higher in females than males. Cronbach’s
coefficient alpha was 0.79.
Limitations: There is a possibility that self-reports may be subjected to unwitting
biases and discrepancies between self-reflection and actual behavior may exist.
Conclusion: This cross-sectional study showed that the empathy measures of
First year students were higher than the scores of Final Year. JSE-S is a
psychometrically sound instrument to measure empathy.
Keywords: Empathy, gender, medical student, Jefferson Scale of Physician
Empathy- Student version
 Introduction

Empathy is the capacity to understand or feel what another person is experiencing

from within the other person's frame of reference, i.e., the capacity to place
oneself in another's position 1. Empathic communication in the context of patient
care is associated with improved health care outcomes and is a buttress of
physician professionalism. Empathy is a cognitive attribute that mainly involves
comprehension of anxiety. Patients visiting hospitals are usually worried and
nervous and doctors should have a certain degree of empathy to put these patients
at ease 2. Patient’s confidence is increased when their problems are carefully
listened and understood, and the patients who trust their physician definitely show
better compliance to the treatment. Empathy is the essence of a meaningful
patient doctor relationship, it is considered as “cognitive quality”. Sir William
Osler one of the founding professors of Johns Hopkins Hospital said that it is as
important to know what kind of a man has the disease, as it is to know what kind
of disease has the man 3.

There is consensus that empathy is important for the physician-patient

relationship and thus an important issue in medical education. Empathy
represents the “touch” in today’s medicine, at present ill-reputed as “high tech,
low touch” 4. As the theoretical theories of empathy are complex, physicians’
appropriate empathy is still under discussion. Jodi Halpern suggested an answer
to the question “What is clinical empathy?” in view of the attention to the patient
as the focus of the physicians’ task, not seeing any necessity of experiencing
vicariously their patients’ emotions 5. Depending upon developmental,
experiential, social, educational, and other factors, one group may possess more
or less empathy than another group 6.

Empathy improves the quality of data obtained from the patient, improves the
physician’s diagnostic ability, and decreases the rate of miscommunication 7,8,9,10.
While there may not be a characteristic struggle between technology and
humanism, it does seem that the human dimension of medicine has been reduced
11
. Social changes have led to new needs that require changes to develop an
‘effective’ physician with appropriate skills including empathic capacity 12.
Study conducted in Ziauddin Medical University show no significant difference
in empathy score among first year and final year students 13. Researches show a
decline in empathy levels during medical training 14. Another research conducted
in University of Minho, Portugal interestingly show that level of empathy in final
year was more compared with first year 15. Iman Hegasi et al. found that highest
mean scored by year five students who have completed personal and professional
development courses and further there is a gender difference in the levels of
empathy favoring female medical students 16. According to another research
conducted at China medical university shows that early exposure to clinical
training and curriculum for professional competencies help to enhance the
empathy of medical students 17.

Regardless of a general awareness of the status of physician empathy in patient

care, some studies in the North-American context have found a decrease in self-
reported measures of empathy of undergraduate students throughout medical
school 18, 19. In those studies, it is suggested that "erosions" in empathy can be
associated with the learning context, the "hidden curriculum", student difficulties
in dealing with stressors in medical education, and poor role modelling in the
academic and clinical workplaces 20, 21.

A widely expressed view is that medical student empathy declines during

undergraduate education and that there is a need for initiatives to prevent this 22–
27
. However, recently this view has been subject to debate, with some studies
reporting a decline, but others showing no change 28–37.

Problems in measurement of the empathy may be partially accountable for the

mixed picture. Systematic reviews of research on empathy in medicine have
highlighted problems relating to the variety and number of measures used, the
failure to present evidence supporting their reliability and validity and the failure
to indicate whether the affective or cognitive aspects of empathy are being
addressed 38, 39. Most studies of medical students involve self-report
questionnaires which reflect personal perceptions rather than actual behavior in
clinical encounters, the latter being recorded only rarely 40, 41. Although self-
reported measures of empathy have potential biases, the psychometric properties
of the Jefferson Scale of Empathy–student version (JSE-S) have been found to be
very robust.

In spite of the importance placed on the empathic doctor patient association for
refining health care outcomes, little is formally known about the medical
students’ empathy orientation or attitudes toward empathetic relationships in the
context of patient care in our province, Khyber Pakhtunkhwa. This is so because
less consideration has been given for the development of empathy and
interpersonal relationships in the undergraduate medical education course. So, we
felt that it is essential to discover the empathy level among undergraduate medical
students to give an evidence-based lessons for educational legislators to advance
the quality of the empathic course in undergraduate medical education, effective
doctor-patient communication and health outcomes. No research is previously
conducted in Khyber Pakhtunkhwa to evaluate the empathy level in medical
students. Therefore, the purpose of this study is to measure empathy amongst
medical students.
 Objectives

The objectives of this study are:

1. To quantify empathy level in First and Final year medical students.

2. To compare mean empathy scores between male and female medical

students.
 Methodology

1. Study design: Cross- sectional study

2. Setting: Cross sectional study was conducted on students of First Year
and Final Year of Rehman Medical College, Peshawar. Duration of this
study was six months i.e. from January 2018 to June 2018.
3. Participants: We selected all students of First Year and Final Year and
convenient sampling technique was used.
4. Measurement: The JSE-S created by the researchers at Jefferson
Medical College in the United States was developed as a measure of
empathy applicable specifically to patient care. It measures both
cognitive and affective empathy. The 20 items in this scale form three
underlying factors: (1) Perspective Taking or JSE-PT (10 positively
worded items), (2) Compassionate Care or JSE-CC (8 negatively
worded items), and (3) Standing in the Patient’s Shoes or JSE-SPS (2
negatively worded items). Most studies of medical student empathy
report only the total JSE-S score. Respondents rate their level of
agreement with each statement on an ascending seven-point Likert-type
scale from 1 = “Strongly disagree” to 7 = “Strongly agree.”
5. Statistical Method: SPSS version 25 was used for data entry and
analysis. Cronbach's Alpha was used to check the reliability. T test was
used to compare the empathy mean score in male and female students.
 Results

Reliability Statistics
Cronbach's N of Cronbach’s Internal
Alpha Items Alpha Consistency
0.792 20 α ≥ 0.9 Excellent
0.9 > α ≥ 0.8 Good
0.8 > α ≥ 0.7 Acceptable
0.7 > α ≥ 0.6 Questionable
0.6 > α ≥ 0.5 Poor
0.5 > α Unacceptable

Likert scale Range of responses Mean score per SD of responses on

responses to selected on Likert statement Likert scale
statements (R is scale
negatively worded)
1R 1-7 4.89* 2.01
2 1-7 5.98 1.64
3R 1-7 4.42* 1.54
4 1-7 5.52 1.53
5 1-7 5.23 1.71
6R 1-7 3.50* 1.57
7R 1-7 5.32* 1.92
8R 1-7 5.03* 1.78
9 1-7 4.74 1.91
10 2-7 5.35 1.33
11R 1-7 5.13* 1.83
12R 1-7 5.24* 1.83
13 1-7 5.25 1.49
14R 1-7 5.38* 2.06
15 1-7 5.17 1.70
16 1-7 5.17 1.60
17 1-7 4.88 1.61
18R 1-7 3.27* 1.69
19R 1-7 5.11* 1.84
20 1-7 5.64 1.55
*: Reverse Score
 T Test for comparing means of Male and Female students of First and
Final Year

Gender of N Mean Std. Error

Respondent Mean
Score of Female 71 103.4 1.6
Respondent Male 119 98.3 1.5

t- test for the equality of means

T p- value Mean 95% Confidence
Difference Interval of the
Difference
Lower Upper
Score of Equal variances not 2.3 0.021 5.1 0.8 9.4
Respondent assumed

First and Final Year Mean Empathy Score

106 105.2
104
102
100
98
95.3
96
94
92
90
First Year Final Year
 First Year Male and Female Mean
Empathy Score

Female 109

Male 102.8

99 100 101 102 103 104 105 106 107 108 109 110

Final Year Male and Female Mean Emapthy

Score

Female 97.7

Male 93.9

92 93 94 95 96 97 98
 Total Empathy Score
115
109
110

105 102.8

100 97.7

95 93.9

90

85
Mean

First Year Male Final Year Male First Year Female Final Year Female
 Discussion

Key results: Our findings provide evidence in support of reliability and construct
validity of student version of Jefferson’s Scale of Empathy for assessing empathy
among first and final professional medical students’ empathy, and statistically
significant differences were observed between male and female among both
years.

Enrollment numbers of students for both years were same. The effective response
was of First year students as compare to Final year. The Cronbach’s alpha
coefficient in this study (0.792) was slightly less than those reported for Chinese
medical students(r=0.83). We found that the mean score for Rehman medical
students (mean= 100.22, SD=15.43).

Limitations: This study has some limitations. First, the possibility of using cohort
study cannot be dismissed. Given that the results are dependent upon a single
cross-sectional design in which baseline differences could not be controlled, in
future longitudinal cohort study should be used to check whether such differences
exist and to confirm the validity of the results. Second, although the JSPE was
reported to be well correlated with observer ratings, there is a possibility that self-
reports may be subjected to unwitting biases and discrepancies between self-
reflection and actual behavior may exist.

Interpretation: We obtained a significant difference in empathy scores between

different genders, which was in favor of female (p<0.05 t=5.57) over male. Our
study compared the mean empathy scores for medical students in both years.
There were statistically significant differences in empathy scores among medical
students of both years, the First-year students have more empathy
score(mean=105) and the final year medical students have less empathy score
(mean=96.6). Final year students are less empathetic than first year students
because at this stage they take patient as a routine they are more interested in
treating patient instead of maintaining a healthy doctor patient relationship while
first year students are more passionate in learning & understanding patient
emotions.

Contrary to our result, the study conducted at Minho, Portugal show the empathy
scores of students in the final year were higher as compared to first year students
42
and similar study in New Zealand shows that both male and female of medical
school have no significant difference in empathy scores when starting and
approaching end of their course and gender was found to significantly predict
empathy scores with females scores higher than males that is similar to our results
43
. Cross sectional study in Korea show that significant differences in empathy
scores were observed among years in medical schools but not between genders44.
A research study on United Kingdom found that female students score
significantly (t=-6.63: 95% CI=-0.30, -0.16) higher than male students, no
significant differences were observed between empathy mean scores and medical
year 45. According to the study conducted in Iran psychometric analysis consist
of three factors Compassionate care, perspective-taking and the ability to walk in
the patient’s shoes. There was no statistically significant differences in the
empathy means scores were found by gender and the different years of medical
school 34. This may be attributed to cross-cultural differences in social, norms,
ethnicity, religious beliefs, pedagogical methods and sex stereotyping, which can
influence empathic engagement. The empathy score in first year is more than final
year.

Medical Curriculum reforms that introduce early exposure to clinical training

gave students opportunities to have more interaction between theoretical and
practical disciplines through observing real medical practice and empathizing
with patient needs. By seeing more patients with faculties, medical students were
able to have more opportunities to be exposed to role models, which almost all
research participants stated as the most effective approach to teach empathy. In
addition to exposure to role models, students will develop patient doctor
relationships over a longer period, which is more conducive for enhancing
empathy 46-47.
 Conclusion

Our results provide fundamental support for the reliability and construct validity
of Jefferson’s Scale of Empathy for medical students. Students of different
genders of First and Final Professional have significant difference in empathy.
Results show that First professional students display higher scores of empathy
than Final professional students. Our study also suggests that compared to
females, males recorded lower levels of affective empathy. To find out that why
females are more empathetic than males and to gain richer description of medical
students’ experiences, perceptions and meaning of empathy, qualitative methods
are required as a complement to the Jefferson scale of students empathy.

We suggest that curriculum include systematic training of humanistic qualities,

more teaching on empathy through proper counseling by arranging different sorts
of workshops, seminars and interesting programs to improve empathy levels
among new graduates. Further research can be done to identify factors that
contribute to changes of empathy and for the growth and evaluation of targeted
educational curricula designed to retain, nurture and enhance empathy among
medical students. In Khyber Pakhtunkhwa, with strictly defined gender roles and
where women are more comfortable approaching women than they are
approaching men, students may show different responses to empathy with the
same gender patient. Qualitative and quantitative research studies from large
representative samples are therefore recommended.
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