Joseph S. Gonnella

The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School

Purpose This longitudinal study was designed to examine changes in medical students’ empathy during medical school and to determine when the most significant changes occur. Method Four hundred fifty-six students who entered Jefferson Medical College in 2002 (n = 227) and 2004 (n = 229) completed the Jefferson Scale of Physician Empathy at five different times: at entry into medical school on orientation day and subsequently at the end of each academic year. Statistical analyses were performed for the entire cohort, as well as for the “matched” cohort (participants who identified themselves at all five test administrations) and the “unmatched” cohort (participants who did not identify themselves in all five test administrations). Results Statistical analyses showed that empathy scores did not change significantly during the first two years of medical school. However, a significant decline in empathy scores was observed at the end of the third year which persisted until graduation. Findings were similar for the matched cohort (n = 121) and for the rest of the sample (unmatched cohort, n = 335). Patterns of decline in empathy scores were similar for men and women and across specialties. Conclusions It is concluded that a significant decline in empathy occurs during the third year of medical school. It is ironic that the erosion of empathy occurs during a time when the curriculum is shifting toward patient-care activities; this is when empathy is most essential. Implications for retaining and enhancing empathy are discussed.

An empirical study of decline in empathy in medical school

Context  It has been reported that medical students become more cynical as they progress through medical school. This can lead to a decline in empathy. Empirical research to address this issue is scarce because the definition of empathy lacks clarity, and a tool to measure empathy specifically in medical students and doctors has been unavailable.

The Jefferson Scale of Physician Empathy: Development and Preliminary Psychometric Data

The present study was designed to develop a brief instrument to measure empathy in health care providers in patient care situations. Three groups participated in the study: Group 1 consisted of 55 physicians, Group 2 was 41 internal medicine residents, and Group 3 was composed of 193 third-year medical students. A 90-item preliminary version of the Empathy scale was developed based on a review of the literature and distributed to Group 1 for feedback. After pilot testing, a revised and shortened 45-item version of the instrument was distributed to Groups 2 and 3. A final version of the Jefferson Scale of Physician Empathy containing 20 items based on statistical analyses was constructed. Psychometric findings provided support for the construct validity, criterion-related validity (convergent and discriminant), and internal consistency reliability (coefficient alpha) of the scale scores.

Empathy in medical students as related to academic performance, clinical competence and gender

Context  Empathy is a major component of a satisfactory doctor–patient relationship and the cultivation of empathy is a learning objective proposed by the Association of American Medical Colleges (AAMC) for all American medical schools. Therefore, it is important to address the measurement of empathy, its development and its correlates in medical schools.

The Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item level.

Researchers agree that empathy has a positive role in clinical outcomes and in improving interpersonal relationships, but they are divided on its definition and components. In the context of health care, we define empathy as ‘‘a cognitive (as opposed to affective) attribute that involves an understanding of the inner experiences and perspectives of the patient, combined with a capability to communicate this understanding to the patient.’’ With the exception of the affective domain, this definition is similar to the conceptualization of empathy by Feighny and colleagues. The key feature of empathy, according to our definition, is understanding, rather than affective involvement with patients’ experiences. The affective domain is a key component of sympathy, rather than empathy. The Association of American Medical College’s Medical School Objectives Project (MSOP) lists empathy among the educational objectives by emphasizing that medical schools should strive to educate altruistic physicians who are ‘‘compassionate and empathetic in caring for patients’’ and who can understand a patient’s perspective by demonstration of empathy. Medical educators concede that empathy is a significant factor in patient care that must be cultivated during medical education and can be assessed at admission to medical school. Likewise, empathy is an important component of ‘‘professionalism’’ in medical practice. Yet, empirical research on empathy among medical students and physicians is scarce. One reason for this dearth of empirical research is the absence of a psychometrically sound and specific research instrument. A few empathy scales for the general population exist that we previously described but to the best of our knowledge there is no psychometrically sound tool available for measuring empathy among medical students and physicians. There is a need for an operational measure of empathy for medical students and physicians. Such a measure can be used to evaluate the effectiveness of educational interventions aimed at promoting empathy. In response to this need, we developed the Jefferson Scale of Physician Empathy. In our previous studies with students, we found that total empathy scores were significantly associated with clinical competence ratings in medical school, but not with licensing examination scores. A significant overlap between empathy and clinical competence constitutes key validity evidence for the empathy scale. In another study, we noticed a significant decline in mean empathy scores during the third year of medical school. Such a decline was also observed among internal medicine residents, but it did not reach the conventional level of statistical significance. Overall, we found that female students and physicians scored higher in empathy than males. In our studies with physicians, we noted that physicians in ‘‘patient-oriented’’ specialties obtained a significantly higher average empathy score than those in ‘‘technology-oriented’’ specialties. Psychiatrists obtained the highest mean empathy score and anesthesiologists, orthopedists, neurosurgeons, and radiologists received the lowest. Although we found no significant difference in the total empathy scores between physicians and nurses, the two groups differed significantly on some items. Some of these findings that were consistent with our expectations can be considered as evidence in support of the validity of the empathy scale. This study was designed to further examine the psychometric properties of the Jefferson Scale of Physician Empathy, and to investigate differences on individual items between men and women and between physicians in specialty areas defined as ‘‘people-oriented’’ and ‘‘technology-oriented.’’

The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy

Purpose To test the hypothesis that scores of a validated measure of physician empathy are associated with clinical outcomes for patients with diabetes mellitus. Method This retrospective correlational study included 20,961 patients with type 1 or type 2 diabetes mellitus from a population of 284,298 adult patients in the Local Health Authority, Parma, Italy, enrolled with one of 242 primary care physicians for the entire year of 2009. Participating physicians’ Jefferson Scale of Empathy scores were compared with occurrence of acute metabolic complications (hyperosmolar state, diabetic ketoacidosis, coma) in diabetes patients hospitalized in 2009. Results Patients of physicians with high empathy scores, compared with patients of physicians with moderate and low empathy scores, had a significantly lower rate of acute metabolic complications (4.0, 7.1, and 6.5 per 1,000 patients, respectively, P < .05). Logistic regression analysis showed physicians’ empathy scores were associated with acute metabolic complications: odds ratio (OR) = 0.59 (95% confidence interval [CI], 0.37–0.95, contrasting physicians with high and low empathy scores). Patients’ age (≥69 years) also contributed to the prediction of acute metabolic complications: OR = 1.7 (95% CI, 1.2–1.4). Physicians’ gender and age, patients’ gender, type of practice (solo, association), geographical location of practice (mountain, hills, plain), and length of time the patient had been enrolled with the physician were not associated with acute metabolic complications. Conclusions These results suggest that physician empathy is significantly associated with clinical outcome for patients with diabetes mellitus and should be considered an important component of clinical competence.

Measurement of empathy among Japanese medical students: psychometrics and score differences by gender and level of medical education.

Purpose To examine psychometric properties of a Japanese translation of the Jefferson Scale of Physician Empathy (JSPE), and to study differences in empathy scores between men and women, and students in different years of medical school. Method The student version of the JSPE was translated into Japanese using back-translation procedures and administered to 400 Japanese students from all six years at the Okayama University Medical School. Item-total score correlations were calculated. Factor analysis was used to examine the underlying components of the Japanese version of the JSPE. Cronbach coefficient alpha was calculated to assess the internal consistency aspect of reliability of the instrument. Finally, empathy scores for men and women were compared using t test, and score differences by year of medical school were examined using analysis of variance. Results Factor analysis confirmed the three components of “perspective taking,” “compassionate care,” and “ability to stand in patient’s shoes,” which had emerged in American and Mexican medical students. Item-total score correlations were all positive and statistically significant. Cronbach coefficient alpha was .80. Women outscored men, and empathy scores increased as students progressed through medical school in this cross-sectional study. Conclusions Findings provide support for the construct validity and reliability of the Japanese translated version of the JSPE for medical students. Cultural characteristics and educational differences in Japanese medical schools that influence empathic behaviors are described, and implications for cross-cultural study of empathy are discussed.

Physician empathy in medical education and practice: experience with the Jefferson scale of physician empathy

Abstract Despite the importance of physician empathy in patient care, empirical investigation on the topic is scarce because of conceptual ambiguity and a lack of a psychometrically sound tool for measuring physician empathy. In this article we describe different conceptual views of empathy, draw a distinction between empathy and sympathy, and define physician empathy. We also describe the development and psychometric properties (ie, validity and reliability) of the Jefferson Scale of Physician Empathy (JSPE), a brief research tool (20 Likert-type items) that we developed as a response to a need for an operational measure of physician empathy. We outline an agenda for future research on physician empathy. We conclude that research regarding physician empathy is crucial considering the rapid developments in biotechnology and the current trend toward market-driven, corporate medicine, which strains the physician-patient relationships.

Relationships between scores of the Jefferson Scale of Physician Empathy (JSPE) and the Interpersonal Reactivity Index (IRI)

This study was designed to examine the relationships between scores of two measures of empathy. One was specifically developed for measuring empathy in patient care situations; the other was developed for the general population. It was hypothesized that the overlap between scores of the two measures would be greater for their constructs that are more relevant to patient care. Study participants were 93 first-year internal medicine residents at Thomas Jefferson University Hospital in Philadelphia. The Jefferson Scale of Physician Empathy (JSPE, specifically developed for administration to health professionals), and the Interpersonal Reactivity Index (IRI, developed for the general population) were administered. A statistically significant correlation of a moderate magnitude between the total scores of the JSPE and IRI (r = 0.45, p < 0.01) was found. The research hypothesis was confirmed by observing higher correlations between those scales of the IRI that were relevant to patient care (e.g. empathic concern, perspective taking) and related factors of the JSPE (compassionate care, perspective taking) than other scales of the IRI that seemed less relevant to patient care (e.g. personal distress and fantasy). These findings provide further support for the validity of the JSPE. It is concluded that physician empathy as measured by the JSPE and its underlying factors are distinct personal attributes that have a limited overlap with fantasy and no overlap with personal distress defined as dimensions of an empathy measure that was developed for the general population.

Prescription drug use during pregnancy: a population-based study in Regione Emilia-Romagna, Italy

PurposeDrug utilization studies in pregnant women are crucial to inform pharmacovigilance efforts in human teratogenicity. The purpose of this study was to estimate the prevalence of prescription drug use among pregnant women in Regione Emilia-Romagna (RER), Italy.MethodsWe conducted a retrospective prevalence study using data from the RER health care database. Outpatient prescription drug data were reconciled for RER residents who delivered a baby in a hospital between January 1, 2004 and December 31, 2004. Drug data were stratified by trimester of use, pregnancy risk categorization, and anatomical classification.ResultsAmong the 33,343 deliveries identified in 2004, 70% of women were exposed to at least one prescription medication during pregnancy and 48% were exposed to at least one prescription medication after excluding vitamin and mineral products. Many of the most commonly used medications were anti-infectives, such as amoxicillin, fosfomycin, and ampicillin. Nearly 1% of women were exposed to drugs contraindicated (i.e., category X) in pregnancy, including 189 women (0.6%) who received these drugs during the first trimester. Several statin medications were among the most common contraindicated drug exposures.ConclusionA large proportion of women who gave birth in RER in 2004 were exposed to prescription medications. Approximately 1 in 100 women were exposed to contraindicated drugs. The most commonly identified drug exposures can help focus pharmacoepidemiologic efforts in drug-induced birth defects.