Mohammadreza Hojat

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.

Mindfulness-based stress reduction lowers psychological distress in medical students

Background: Medical students confront significant academic, psychosocial, and existential stressors throughout their training. Mindfulness-based stress reduction (MBSR) is an educational intervention designed to improve coping skills and reduce emotional distress. Purpose: The purpose of this study was to examine the effectiveness of the MBSR intervention in a prospective, nonrandomized, cohort-controlled study. Methods: Second-year students (n = 140) elected to participate in a 10-week MBSR seminar. Controls (n = 162) participated in a didactic seminar on complementary medicine. Profile of Mood States (POMS) was administered preintervention and postintervention. Results: Baseline total mood disturbance (TMD) was greater in the MBSR group compared with controls (38.7 ±33.3 vs. 28.0 ±31.2; p <. 01). Despite this initial difference, the MBSR group scored significantly lower in TMD at the completion of the intervention period (31.8 ±33.8 vs. 38.6 ±32.8; p < . 05). Significant effects were also observed on Tension-Anxiety, Confusion-Bewilderment, Fatigue-Inertia, and Vigor-Activity subscales. Conclusion: MBSR may be an effective stress management intervention for medical students.

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.

Attitudes toward physician-nurse collaboration: a cross-cultural study of male and female physicians and nurses in the United States and Mexico.

BACKGROUND Inter-professional collaboration between physicians and nurses, within and between cultures, can help contain cost and insure better patient outcomes. Attitude toward such collaboration is a function of the roles prescribed in the culture that guide professional behavior. OBJECTIVES The purpose of the study was to test three research hypotheses concerning attitudes toward physician-nurse collaboration across genders, disciplines, and cultures. METHOD The Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration was administered to 639 physicians and nurses in the United States (n = 267) and Mexico (n = 372). Attitude scores were compared by gender (men, women), discipline (physicians, nurses), and culture (United States, Mexico) by using a three-way factorial analysis of variance design. RESULTS Findings confirmed the first research hypothesis by demonstrating that both physicians and nurses in the United States would express more positive attitudes toward physician-nurse collaboration than their counterparts in Mexico. The second research hypothesis, positing that nurses as compared to physicians in both countries would express more positive attitudes toward physician-nurse collaboration, was also supported. The third research hypothesis that female physicians would express more positive attitudes toward physician-nurse collaboration than their male counterparts was not confirmed. CONCLUSIONS Collaborative education for medical and nursing students, particularly in cultures with a hierarchical model of inter-professional relationship, is needed to promote positive attitudes toward complementary roles of physicians and nurses. Faculty preparation for collaboration is necessary in such cultures before implementing collaborative education.

Psychometric properties of an attitude scale measuring physician-nurse collaboration.

This study examined the psychometric properties of an assessment tool for measuring attitudes toward physician-nurse collaboration. A survey addressing areas of responsibility, expectations, shared learning, decision making, authority, and autonomy was administered to first-year medical and nursing students. Factor analysis of the survey indicated that the survey measured four underlying constructs of shared education and collaborative relationships, caring as opposed to curing, nurse’s autonomy, and physician’s authority. A scale was developed in which 15 items of the survey with large factor loadings were included. The alpha reliability estimates of the scale for medical and nursing students were .84 and .85, respectively. The mean of the scale was significantly higher for nursing than medical students. Results supported the construct validity and reliability of the scale. This scale can be used to evaluate the effectiveness of programs developed to foster physician-nurse collaboration, and to study group differences on attitudes toward interpersonal collaboration.