R. Brent Stansfield

The neural substrates of cognitive empathy

Abstract Neuroscientific research has consistently found that the perception of an affective state in another activates the observers own neural substrates for the corresponding state, which is likely the neural mechanism for “true empathy.” However, to date there has not been a brain-imaging investigation of so-called “cognitive empathy”, whereby one “actively projects oneself into the shoes of another person,” imagining someones personal, emotional experience as if it were ones own. In order to investigate this process, we conducted a combined psychophysiology and PET and study in which participants imagined: (1) a personal experience of fear or anger from their own past; (2) an equivalent experience from another person as if it were happening to them; and (3) a nonemotional experience from their own past. When participants could relate to the scenario of the other, they produced patterns of psychophysiological and neuroimaging activation equivalent to those of personal emotional imagery, but when they could not relate to the others story, differences emerged on all measures, e.g., decreased psychophysiological responses and recruitment of a region between the inferior temporal and fusiform gyri. The substrates of cognitive empathy overlap with those of personal feeling states to the extent that one can relate to the state and situation of the other.

The empathic, physiological resonance of stress

Physiological resonance between individuals is considered fundamental to the biological capacity for empathy. Observers of pain and distress commonly exhibit increases in reported distress, autonomic arousal, facial mimicry, and overlapping neural activity. An important, unstudied question is whether physiological stress can also resonate. Physiological stress is operationalized as activation of the hypothalamic pituitary adrenocortical (HPA) and sympatho-adrenomedullary (SAM) axes. People often report an aversive state resulting from the stress of another, but this could be conveyed through resonating arousal or distress, without activating the physiological stress response. Physiological stress is particularly important to examine since it commonly occurs chronically, with known negative effects on health. Salivary cortisol and salivary alpha-amylase (sAA) were measured in both speakers and observers during a modified Trier Social Stress Test (TSST) to assess activation of the HPA and SAM axes (respectively). Cortisol (but not sAA) responses resonated between speakers and observers. The cortisol response of observers increased with trait empathy and was not related to the speakers subjective fear or distress. This study provides a novel method for examining physiological resonance, and indicates that we can indeed catch anothers physiological stress, suggesting a specific health risk for those in the social network of stressed individuals.

I know how you feel: Task-irrelevant facial expressions are spontaneously processed at a semantic level

Previous studies have demonstrated that emotions are automatically processed. Even with subliminal presentations, subjects involuntarily mimic specific facial expressions, are influenced by the valence of a preceding emotion during judgments, and exhibit slowed responses to personally meaningful emotions; these effects are due to reflexive mimicry, unconscious carryover of valence, and attentional capture, respectively. However, perception-action effects indicate that rapid processing should involve deep, semantic-level representations of emotion (e.g., “fear”), even in the absence of a clinical emotion disorder. To test this hypothesis, we developed an emotional Stroop task (Emostroop) in which subjects responded nonverbally to emotion words superimposed over task-irrelevant images of faces displaying congruent or incongruent emotional expressions. Subjects reliably responded more slowly to incongruent than to congruent stimuli, and this interference was related to trait measures of emotionality. Rapid processing of facial emotions spontaneously activates semantic, content-rich representations at the level of the specific emotion.

The Multiple Mini-Interview for Emergency Medicine Resident Selection

BACKGROUND The Multiple Mini-Interview (MMI) uses multiple, short-structured contacts to evaluate communication and professionalism. It predicts medical school success better than the traditional interview and application. Its acceptability and utility in emergency medicine (EM) residency selection are unknown. OBJECTIVE We theorized that participants would judge the MMI equal to a traditional unstructured interview and it would provide new information for candidate assessment. METHODS Seventy-one interns from 3 programs in the first month of training completed an eight-station MMI focused on EM topics. Pre- and post-surveys assessed reactions. MMI scores were compared with application data. RESULTS EM grades correlated with MMI performance (F[1, 66] = 4.18; p < 0.05) with honors students having higher scores. Higher third-year clerkship grades were associated with higher MMI performance, although this was not statistically significant. MMI performance did not correlate with match desirability and did not predict most other components of an application. There was a correlation between lower MMI scores and lower global ranking on the Standardized Letter of Recommendation. Participants preferred a traditional interview (mean difference = 1.36; p < 0.01). A mixed format (traditional interview and MMI) was preferred over a MMI alone (mean difference = 1.1; p < 0.01). MMI performance did not significantly correlate with preference for the MMI. CONCLUSIONS Although the MMI alone was viewed less favorably than a traditional interview, participants were receptive to a mixed-methods interview. The MMI does correlate with performance on the EM clerkship and therefore can measure important abilities for EM success. Future work will determine whether MMI performance predicts residency performance.

Conditional reliability of admissions interview ratings: extreme ratings are the most informative

Context  Admissions interviews are unreliable and have poor predictive validity, yet are the sole measures of non‐cognitive skills used by most medical school admissions departments. The low reliability may be due in part to variation in conditional reliability across the rating scale.

Use of simulated electronic mail (e-mail) to assess medical student knowledge, professionalism, and communication skills.

Background Physicians communicate with patients using electronic mail (e-mail) with increasing frequency. Communication skills specific to e-mail do not appear to be taught explicitly in medical school. Therefore, the effect of an instructive session on effective e-mail communication was examined. Method Four simulated e-mails from a parent were developed. Students responded to an initial e-mail and then participated in a session on effective e-mail communication. Responses to a final e-mail were assessed using a rubric with subscores for medical knowledge, communication, and professionalism. Results Performance improved from the first to final e-mail response in the overall score and in each subscore. Improvement was sustained over the course of the academic year. Interrater reliability revealed good agreement. Conclusions Communicating effectively with patients via e-mail is not intuitive but can be taught. It is feasible to introduce responses to a simulated e-mail case in a clinical clerkship as an assessment tool.

Medical Student Perceptions of the Learning Environment at the End of the First Year: A 28-medical School Collaborative

Purpose Accreditation and professional organizations have recognized the importance of measuring medical students’ perceptions of the learning environment, which influences well-being and professional competency development, to optimize professional development. This study was conducted to explore interactions between students’ perceptions of the medical school learning environment, student demographic variables, and students’ professional attributes of empathy, coping, tolerance of ambiguity, and patient-centeredness to provide ideas for improving the learning environment. Method Twenty-eight medical schools at 38 campuses recruited 4,664 entering medical students to participate in the two-cohort longitudinal study (2010–2014 or 2011–2015). The authors employed chi-square tests and analysis of variance to examine the relationship between Medical School Learning Environment Survey (MSLES) scores and student characteristics. The authors used mixed-effects models with random school and campus effects to test the overall variances accounted for in MSLES scores at the end of the first year of medical school. Results Student attributes and demographic characteristics differed significantly across schools but accounted for only 2.2% of the total variance in MSLES scores. Medical school campus explained 15.6% of the variance in MSLES scores. Conclusions At year’s end, students’ perceptions toward the learning environment, as reported on the MSLES, differed significantly according to the medical school campus where they trained. Further studies are needed to identify specific factors, such as grading policies, administrative support, and existence of learning communities, which may influence perceptions of the learning environment at various schools. Identifying such variables would assist schools in developing a positive learning environment.

Altruism in the Wild: When Affiliative Motives to Help Positive People Overtake Empathic Motives to Help the Distressed

Psychological theories of human altruism suggest that helping results from an evolved tendency in caregiving mammals to respond to distress or need with empathy and sympathy. However, theories from biology, economics, and social psychology demonstrate that social animals also evolved to affiliate with and help desirable social partners. These models make different predictions about the affect of those we should prefer to help. Empathic models predict a preference to help sad, distressed targets in need, while social affiliative models predict a preference for happy, positive, successful targets. We compared these predictions in 3 field studies that measured the tendency to help sad, happy, and neutral confederates in a real-world, daily context: holding the door for a stranger in public. People consistently held the door more for happy over sad or neutral targets. To allow empathic motivations to compete more strongly against social affiliative ones, a 4th study examined a more consequential form of aid for hypothetical hospital patients in clear need. These conditions enhanced the preference to help a sad over a happy patient, because sadness made the patient appear sicker and in greater need. However, people still preferred the happy patient when the aid required a direct social interaction, attesting to the strength of social affiliation motives, even for sick patients. Theories of prosocial behavior should place greater emphasis on the role of social affiliation in motivating aid, particularly in everyday interpersonal contexts. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Development of a metacognitive effort construct of empathy during clinical training: a longitudinal study of the factor structure of the Jefferson Scale of Empathy

Empathy is crucial for effective clinical care but appears to decline during undergraduate medical training. Understanding the nature of this decline is necessary for addressing it. The Jefferson Scale of Empathy (JSE) is used to measure medical students’ clinical empathy attitudes. One recent study described a 3-factor model of the JSE. This model was found in responses from matriculating medical students, but little is known about how the factor structure of the scale changes during clinical training. The Learning Environment Study is a longitudinal prospective study of two cohorts from 28 medical schools. At matriculation and at the end of each subsequent year, students self-reported clinical empathy attitudes using the JSE. Data from 4,797 students were randomly partitioned for exploratory (EFA) and confirmatory factor analyses using responses from preclinical and clinical years of medical school. Five models were compared for confirmatory factor analysis: two null models for control, the recent 3-factor model, and the two models resulting from the EFAs of preclinical and clinical year responses. Preclinical year responses yielded a 3-factor model similar to the recent 3-factor model. Clinical year responses yielded a 4-factor model (“feelings,” “importance,” “ease,” and “metacognitive effort”) suggesting changes in the structure of clinical empathy attitudes over time. Metacognitive effort showed the largest decline over time. The model is a better fit for both preclinical and clinical responses and may provide more insight into medical students’ clinical empathy attitudes than other models. The emergence of metacognitive effort in the clinical years suggests empathy may become more nuanced for students after clinical exposure and may account for much of the observed decline in clinical empathy attitudes.

Validation of the Revised Brief Diabetes Knowledge Test (DKT2)

Purpose The purpose of this study is to examine the reliability and validity of the revised Diabetes Knowledge Test (DKT2). The original test was updated to reflect current diabetes care and education guidelines. The test has 2 components: a 14-item general test and a 9-item insulin use subscale. Methods Two samples were used to evaluate the DKT2. The first came from an online survey company (Qualtrics, LCC) (n = 101) and the second from University of Michigan’s (UofM) Diabetes Registry (n = 89). Cronbach’s coefficient alpha was used to calculate reliability. To examine validity, comparisons by type of diabetes, insulin use and oral medication use, and educational level were completed. Correlations between diabetes duration and both the general test and insulin subscale were calculated for the UofM sample. Results The two samples differed demographically. While the reliabilities between the samples were disparate, when combined, the coefficient alphas demonstrated reliability for both the general test (.77) and the insulin use subscale (.84). The validation comparisons proved to be similar; different results occurred between samples but when combined demonstrated validity. Conclusions The reliability and validity tests were inconsistent by sample. The different results can, in part, be attributed to the demographic differences between the 2 samples. With the exception of age, the samples differed in every other measured variable. However, when the samples were combined, the analyses supported the reliability and validity of the Diabetes Knowledge Test 2. The DKT2 is a quick and low-cost method of assessing general knowledge of diabetes and diabetes self-care.