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Humanitarian approach in medicine: A study on clinical empathy among medical students and graduates using the Jefferson Scale of Empathy
Correspondence to PUJA DULLOO; pujad@charutarhealth.org
To cite: Vedi N, Dulloo P, Sharma D, Singh P. Humanitarian approach in medicine: A study on clinical empathy among medical students and graduates using the Jefferson Scale of Empathy. Natl Med J India 2022;35:100–4.
Abstract
Background
Empathy is one of the pillars of professionalism in the medical field associated with better patient satisfaction and outcome. This study aimed to assess and compare the empathy score with other institutes within and outside India using the Jefferson Scale of Empathy-Student version (JSE-S).
Methods
We did a cross-sectional study for undergraduate medical students and interns of Pramukhswami Medical College, Karamsad, for 4 months from October 2019. Voluntary participants completed the JSE-S, an internationally validated 20-item survey questionnaire.
Results
The mean empathy score of 575 voluntary participants out of 631 was 100.75, with women having higher and significant scores than men (F 102.1 [11.5]; M 98.3 [12.5]; p<0.001). The highest empathy score was observed in the first year (102 [10.8]), which increased and decreased in different years of medical education with a maximum dip in the second year (99.4 [11.5]). The choice of specialty of participants showed a lower significant difference as per the JSE-S score. A lower empathy score was identified among participants compared to medical students studying in international medical institutes.
Conclusion
There is a need to organize workshops with training modules to cater to the empathy aspect of professional care, as a continuous process, starting from the first year till the completion of internship.
INTRODUCTION
Empathy, one of the pillars of professionalism, is a complex competence that includes both affective and cognitive components.1 In healthcare professionals, empathy has been defined as an intellective quality that empowers individuals to understand the experience and perspective of the patient and develops the skill of communicating it as well.2–4 Empathy promotes patient and physician satisfaction, improves the physician’s diagnostic ability and decreases the rate of miscommunication and lawsuits and may even improve patient outcomes.5–13
Various instruments for measuring empathy used earlier were the Interpersonal Reactivity Index,14 the Empathy Scale15 and the Emotional Empathy Scale,16 which were not specific for the health professionals but the general population.17 The Jefferson Scale of Empathy (JSE), developed by Hojat et al., is a 20-item instrument with content specificity and relevance to measure empathy in the context of education of health professionals patient care of practitioners.2,3 The items are answered on a 7-point Likert-type scale (1=strongly disagree, 7=strongly agree). Ten items are positively worded and directly scored, and the other ten are negatively worded (reverse scored). Three versions of the JSE are available, which are administered to medical students (S-version), practising health professionals (HP-version) and to all health profession’s students other than medical students (HPS-version).2,18
Various studies have explored the association between clinical empathy and progressive years of medical training and gender other than the choice of specialty, outside18–27 as well as within the Indian subcontinent.21,28–32
We aimed to assess clinical empathy and the various associated factors in a cohort of medical students across four-and-a-half years of the undergraduate and internship programmes.
METHODS
Ethical approval
The study was commenced after approval from the Institutional Ethical Committee, Pramukhswami Medical College (PSMC), Bhaikaka University (BU), Karamsad, Gujarat.
Study design
We conducted a cross-sectional study to assess the empathy of undergraduate medical students and the interns at PSMC, BU, Karamsad, using the JSE-S score, after acquiring copyright permission from the Jefferson Scale of Empathy-Student version. All the interns and undergraduate medical students were included in the study. The study was conducted from October 2019 to February 2020 for 631 undergraduate medical students and interns who were enrolled for the academic year 2019–20.
The participant’s information sheet was explained and given to the undergraduate students (first, second, third, fourth and final year of medical programme) of PSMC and the interns. Volunteer undergraduates and interns were enrolled in the study. Those not willing to participate in the study after reading the participant information sheet were excluded. Incompletely filled forms were also excluded from the study. Every participant signed a written consent form before filling the questionnaire.
The principal investigator of the study acquired permission from the respective head of the department to allocate specific time to conduct the research study within the institute. Participants took 15–20 minutes to complete the JSE-S score sheet. Anonymity was maintained.
The literature was searched for other studies using the JSES score for medical students in India and globally to identify differences or similarity with our findings.
Statistical analysis
The data were analysed via Excel and online free statistical software, using descriptive statistics for mean and standard deviation with skewness and kurtosis statistics, Spearman correlation and Kruskal–Wallis test and Mann–Whitney U test (p<0.05 was considered as significant).
RESULTS
Of 631 undergraduate medical students and interns who were approached, 602 consented to participate. The hard copy of the JES-S questionnaire was given to them. Twenty-seven partially filled questionnaires were excluded from the study (overall response rate 91.1%).
Table I shows a decrease in the JSE-S empathy scores with advancing age and a higher score in women compared to men. There was a decrease in score in the second year of the medical course but increased progressively subsequently and was maximum during the internship. Less variability was observed for the JSE-S empathy score as per the specialty chosen by the participant.
| Variable | Category (n=575) | JSE-S score | ||
|---|---|---|---|---|
| Range | Median | Mean (SD) | ||
| Age (years) | <22 (433) | 63–125 | 1 0 2 | 100.7 (12.03) |
| 22–24 (139) | 75–131 | 1 0 0 | 100.0 (12.3) | |
| 25–27 (3) | 82–96 | 9 6 | 91.3 (8.1) | |
| Gender | Men (248) | 63–131 | 9 9 | 98.3 (12.5) |
| Women (327) | 70–127 | 1 0 3 | 102.1 (11.5) | |
| Year of MBBS | First year (144) | 79–125 | 1 0 3 | 102.1 (10.8) |
| Second year (84) | 76–122 | 1 0 0 | 99.4 (11.5) | |
| Third year (107) | 63–124 | 1 0 2 | 100.4 (13.5) | |
| Final year (100) | 70–125 | 1 0 2 | 100.1 (12.4) | |
| Intern (140) | 70–131 | 1 0 0 | 99.7 (12.3) | |
| Specialty chosen | Medicine (194) | 63–131 | 101.5 | 100.5 (12.0) |
| Surgery (270) | 67–127 | 1 0 2 | 100.5 (12.0) | |
| Other (4) | 70–111 | 9 6 | 93.3 (17.1) | |
| Undecided (107) | 72–125 | 1 0 2 | 100.5 (12.4) | |
| Different percentiles in JSE-S score for the study population | 5 t h | 78.2 | ||
| 25th | 92.3 | |||
| 50th | 102.3 | |||
| 75th | 110.3 | |||
The median score was 102.25 and 5% of the students scored below 78.2. Also, 5% of the students scored above 119.35.
Spearman rho correlation for 575 participants showed a significantly high level of positive correlation for age and year of MBBS (0.71; two-tailed p<0.0001), while a low level of correlation was observed between age (0.086; two-tailed p<0.04) and gender with mean empathy score (0.157; two-tailed p<0.0001).
Cronbach alpha reliability statistics value was more than 0.70 for 20 questions of the JES-S empathy score (0.743).
Table II shows statistical significance for the JSE-S empathy score as per gender (p<0.0001). No statistical significance was observed between the JSE-S empathy score and other independent variables such as age, year of MBBS and specialty chosen, although variation was observed within the variables for mean ranks. First-year students showed more mean rank value than other groups.
| Variable | Category (n) | JSE-S mean rank | p value |
|---|---|---|---|
| Age (years) | <22 (433) | 291.70 | 0.259 |
| 22-24 (139) | 279.50 | ||
| 25-27 (3) | 148.33 | ||
| Gender | Men (248) | 258.09 | 0.001* |
| Women (327) | 310.69 | ||
| MBBS year | First year (144) | 308.51 | 0.404 |
| Second year (84) | 271.02 | ||
| Third year (107) | 293.93 | ||
| Fourth year (100) | 282.89 | ||
| Intern (140) | 276.21 | ||
| Specialty chosen | Medicine (194) | 287.32 | 0.841 |
| Surgery (270) | 288.85 | ||
| Other (4) | 213.25 | ||
| Undecided (107) | 289.87 |
Table III shows statistical significance for JSE-S empathy score as per gender for participants from third year and those who had chosen surgery as a specialty and for those who did not decide the specialty to be chosen, while no statistical significance was observed as per other chosen specialties or year of the medical course.
| Independent variable and category | Gender | n | JSE-S mean rank | Sum of ranks | JSE-S score by Mann-Whitney U | Z (two-tailed significance) |
|---|---|---|---|---|---|---|
| Year of medical programme (n) | ||||||
| First year (n=144) | Men | 69 | 65.83 | 4542.00 | 2127.0 | -1.842 (0.065) |
| Women | 75 | 78.64 | 5898.00 | |||
| Second year (n=84) | Men | 36 | 4 0.17 | 1446.00 | 780.0 | -0.759 (0.448) |
| Women | 48 | 44.25 | 2124.00 | |||
| Third year (n=107) | Men | 45 | 41.87 | 1884.00 | 849.0 | -3.446 (0.001*) |
| Women | 62 | 62.81 | 3894.00 | |||
| Fourth year (n=100) | Men | 44 | 4 6.00 | 2024.00 | 1034.0 | -1.375 (0.169) |
| Women | 56 | 54.04 | 3026.00 | |||
| Intern (n=140) | Men | 54 | 6 6.50 | 3591.00 | 2106.0 | -0.925 (0.355) |
| Women | 86 | 73.01 | 6279.00 | |||
| Specialty chosen (n) | ||||||
| Medicine and allied branch (n=194) | Men | 77 | 9 0.05 | 6933.50 | 3930.5 | -1.50 (0.134) |
| Women | 117 | 102.41 | 11981.50 | |||
| Surgery and allied branch (n=270) | Men | 129 | 123.53 | 15935.00 | 7550.0 | -2.41 (0.016*) |
| Women | 141 | 146.45 | 20650.00 | |||
| Other (n=4) | Men | 3 | 2.00 | 6.00 | 0.000 | -1.34 (0.18) |
| Women | 1 | 4.00 | 4.00 | |||
| Undecided (n=107) | Men | 39 | 45.13 | 1760.00 | 980.0 | -2.24 (0.025*) |
| Women | 68 | 59.09 | 4018.00 |
DISCUSSION
We aimed to assess clinical empathy using the JSE-S score in medical students and interns and to identify the relation between the scores acquired as per age, gender, year of medical course and specialty to be chosen by the participants in the near future.
Empathy
The mean empathy score of the undergraduate medical students and interns was 100.75, the values were close to Nair et al. from Udupi, Karnataka (101.04),27 although it was much lower than that reported by Chen et al. from the USA (114.3),20 Mostafa et al. from Bangladesh (110.41)17 and Kataoka et al. from Japan (104.30).21 The score was lower than those from other states of India, as reported by Shashikumar et al. from Pune (102.91),28 and Murthy et al. from Vijayawada (103.29),25 although it was higher than Kulkarni et al. from Nagpur (99.25)24 and Chatterjee et al. from New Delhi (96.01).26 Our institute, being a nodal centre for medical education and technology (MET), found it necessary to identify the basal empathy score of the undergraduate students and attempt to raise it for better patient care.
The empathy score at the entry level of medical school in our study was lower (102.1; Table I) than that reported from the USA by Chen et al. (115.5)20 and Hojat et al. (114.5)3 and even from different states of India––Shashikumar et al. from Pune (107.85)28 and Nair et al. from Karnataka (105).27 Similar results were reported from Vijayawada by Murthy et al. (102.52),25 while a lower value was reported by Kulkarni et al. from Nagpur (96.05).24
Clinical empathy and gender
In our study, the clinical empathy score was higher in women (102.1 [11.5]) compared to men (98.3 [12.5], p<0.0001, Table II). The results are similar to those observed by Chen et al.20 from the USA where women medical students had higher empathy than men medical students (116.5 v. 112.1, p<0.001). Similarly, Kataoka et al.21 from Japan showed that women had higher scores than men (mean scores were 107 and 103.7, respectively). Indian studies such as those by Shashikumar et al.28 showed similar results with significantly higher empathy levels in women compared to men (p<0.01). Chatterjee et al.26 from New Delhi also found a significantly higher level of empathy scores in women (p<0.001). Similar results were observed by Kulkarni et al.24 from Nagpur with women showing a significantly higher empathy score (p<0.05).
Hojat et al.14,29 in a longitudinal study found that the mean empathy scores in men and women changed equally over the years, women showed consistently higher scores than men, even when the mean scores dipped in general, and that the difference remained significant. Hasan et al.18 studied medical students in Kuwait and found a statistically significant difference in empathy scores of men and women (p<0.003). Other researchers globally have found similar findings.23,30
The majority of Indian studies have shown better empathy scores in women medical students compared to men medical students probably due to the traditional cultural role of the woman as a caregiver. Although Baez et al.31 found that a tool based on self-reporting to identify empathy scores may induce biases leading the participating individual to assume traditional gender-based stereotypes. In contrast, a review by Christov-Moore et al. found that higher empathy in women has not only social but also phylogenetic and ontogenetic roots.32
The study by Rahimi-Madiseh et al. in Iranian students showed higher empathy scores in women than men, but the difference was not significant (105.6 v. 103.7).22 Mestre et al. found that women adolescents have a more empathic disposition, i.e. the main driver of pro-social behaviour, than men adolescents.33
Clinical empathy and number of years of study
In our study, the mean empathy scores were highest in the first year (102.1 [10.8]), which decreased in the second year (99.4 [11.5]), and increased in the third and fourth year (100.4 and 100.5) of medical education. However, the score decreased again at the time of the internship (99.7 [11.5]). Similar results were observed by a few researchers in India,24,27 and researchers from other countries.17,22
The National Medical Commission introduced competency-based medical curriculum (CBME) from the year 2019, for first-year students. As per this curriculum, few sessions related to empathy and ethics had been introduced during the foundation course. This might be one of the reasons behind the high score among first-year students.
Although other researchers in India26,28 and other countries showed a sequential increase in empathy as the students progressed in their course,18,20,21 a study by Murthy et al. did not show any significant change.25
Our study showed a statistical significance only in the third year as per gender (p<0.001, Table III). This probably indicates the positive effects of the teaching of community medicine along with the rotational community posting.
Researchers have found that the doctors of family medicine (loosely an off-shoot of community medicine) are more empathetic than others.34 The decline in empathy score, in our study, as the course progressed could be attributed to the traditional curriculum with less scope for the development of skills related to the affective domain.35,36 Moreover, there is limited scope of students being assessed in terms of the affective domain either at the level of an undergraduate course or postgraduate selection test in India.37
With the present revised curriculum based on CBME, competency-based approach might lead to better empathy with students having a specific focus on early clinical exposure and attitude, ethics and communication skill being part of the first year of medical course.38 Some researchers have attempted to explain the variability in empathy levels by a curriculum that relies on a problem-based approach to addressing a patient’s complaint than by more humanistic interaction.39
Clinical empathy across different settings
Our study shows an almost similar score for empathy as per the specialty they would plan/like to choose in the near future compared to those who had not decided the specialty. Although lesser empathy was observed for those who chose a specialty other than surgery or medicine (Table II), statistical significance was observed only for those who chose a surgical specialty and those undecided as per gender (p<0.05, Table III).
Some Indian studies did not show a difference concerning the preference for desired specialty, highlighting that ‘Indian medical schools come under the vigilance of a regulatory body, there is no scope for offering electives, humanities or otherwise, and we were, therefore, unable to study this effect’.27 With the revised competency-based curriculum, it would be interesting to see if any difference occurs.
This was a cross-sectional study; thus, we could not capture the actual progression of empathy among undergraduate medical students. Moreover, this represents the response from a single private medical institute of India. The social environment may have led students to under- or over-report empathy.
Limitations
All the students from each year of undergraduate medical programme were included in the study irrespective of their category of admission selection, socioeconomic or cultural background. Variability in admission to the course could be one of the factors affecting the score range. It would be good to know the progress of the students, for estimating the empathy level during their journey within the medical institute.
Conclusion
William Osler said: ‘The good physician treats the disease; the great physician treats the patient who has the disease.’
As per our study, there is a wide disparity in the JSE-S score among both genders between states, and globally. This indicates a strong need to reflect on our curriculum and evaluate its progression. As a caregiver, it should be a mandate that medical students from their entry be taught professional values for being a good physician, specifically focusing on communication skills with the patient, other healthcare professionals and colleagues. Only a longitudinal study can determine the empathy-inducing effectiveness of CBME curriculum for undergraduate medical students.
ACKNOWLEDGEMENTS
We thank the undergraduate medical students and interns of PSMC for participating and providing transparent feedback for the study. Our sincere thanks to all the departmental heads of the institute to provide us the time to interact with the students and interns.
Conflicts of interest
None declared
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