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 Table of Contents  
ORIGINAL RESEARCH ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 186-194

Strong correlations between empathy, emotional intelligence, and personality traits among podiatric medical students: A cross-sectional study


1 Department of Pre-Clinical Sciences, New York College of Podiatric Medicine, New York, NY, USA
2 Environmental Medicine and Public Health, Mount Sinai School of Medicine, New York, NY, USA
3 Department of Pre-Clinical Sciences, New York College of Podiatric Medicine, New York, NY; Environmental Medicine and Public Health, Mount Sinai School of Medicine, New York, NY, USA

Date of Web Publication11-Apr-2017

Correspondence Address:
Peter Barbosa
New York College of Podiatric Medicine, 53 East 124th Street, New York, NY 10035; Mount Sinai School of Medicine, 17, East 102 Street, Floor 2, D2-145, New York, NY 10029
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1357-6283.204224

  Abstract 

Background: The ability of health-care providers to demonstrate empathy toward their patients results in a number of positive outcomes improving the quality of care. In addition, a provider's level of emotional intelligence (EI) can further the doctor–patient relationship, stimulating a more personalized and comprehensive manner of treating patients. Furthermore, personality traits of a clinician may positively or negatively influence that relationship, as well as clinical outcomes. This study was designed to evaluate empathy levels in podiatric medical students in a 4-year doctoral program. Moreover, this study aimed to determine whether EI, personality traits, and demographic variables exhibit correlations with the observed empathy patterns. Methods: This cross-sectional study collected data using an anonymous web-based survey completed by 150 students registered at the New York College of Podiatric Medicine. There were four survey sections: (1) demographics, (2) empathy (measured by the Jefferson Scale of Physicians' Empathy), (3) EI (measured by the Assessing Emotions Scale), and (4) personality traits (measured by the NEO-Five-Factor Inventory-3). Results: Empathy levels were significantly correlated with EI scores (r = 0.62, n = 150, P< 0.0001). All the five domains of personality were also shown to correlate with empathy scores, as well as with EI scores. With respect to demographics, Asian-American students had lower mean empathy scores than students of other races (P = 0.0018), females had higher mean empathy scores compared to men (P = 0.001), and undergraduate grade point average correlated with empathy scores in a nonmonotonic fashion (P = 0.0269). Discussion: When measuring the variables, it was evident that there was a strong correlation between empathy, EI, and personality in podiatric medical students. Given the suggested importance and effect of such qualities on patient care, these findings may serve as guidance for possible amendments and warranted curriculum initiatives in medical education.

Keywords: Emotional intelligence, empathy, personality traits, podiatric medicine


How to cite this article:
Bertram K, Randazzo J, Alabi N, Levenson J, Doucette JT, Barbosa P. Strong correlations between empathy, emotional intelligence, and personality traits among podiatric medical students: A cross-sectional study. Educ Health 2016;29:186-94

How to cite this URL:
Bertram K, Randazzo J, Alabi N, Levenson J, Doucette JT, Barbosa P. Strong correlations between empathy, emotional intelligence, and personality traits among podiatric medical students: A cross-sectional study. Educ Health [serial online] 2016 [cited 2021 Oct 18];29:186-94. Available from: https://www.educationforhealth.net/text.asp?2016/29/3/186/204224


  Background Top


Empathy is defined as the ability of one person to relate and understand the situational circumstances of another human being.[1] Furthermore, medical empathy is layered, requiring the clinician to relate and understand the psychological, emotional, and physical situations gleaned from the patient during the encounter. The ability of the physician to empathize is not unsurprisingly of sole benefit to the physician or patient, rather it is mutually favorable. Studies have shown that patients' satisfaction and compliance are directly influenced by their physicians' empathy.[2],[3] Increased levels of physician empathy have also been shown to reduce the economic burden of a patient who by seeing a physician on a more consistent basis tend to experience better outcomes. Similarly, a reduction in practitioners' litigation and malpractice fees correlated to increased levels of empathy.[2],[3] It has been documented that students enter medical school with a high level of empathy. Thus suggesting an innate desire exists in the youth and future of the profession to be empathic; however, this desire seems to fade. A systematic review reported that in nine of the 11 studies being analyzed, there was a significant decline in empathy as students progressed through medical school.[4] Even studies that have questioned the decline in empathy in medical education and labeled the pattern as “greatly exaggerated” show in their analysis that an actual decline takes place in this period.[5]

Empathy can be measured utilizing first-, second-, and third-person perspectives. These entail self-reported instruments, a patient rating of his/her provider, or a third-party observer rating of the provider, respectively.[6] The Jefferson Scale of Physician Empathy (JSPE), a first-person perspective instrument, has been shown to be a reliable test to measure empathy. The scale was created and used to measure empathy in physicians, health-care professionals, and medical students.[7],[8] The JSPE has been studied in nurses, physicians, and medical students, and shown to be valid and reliable as a tool for measuring empathy.[9] Reliability has been examined using test-retest correlation (r = 0.65 over 3–4 months in physicians and a test-retest change value of P< 0.05 over 12 months for medical students). Internal consistency total-item score between 0.30 and 0.60 and a Cronbach's alpha between 0.81 and 0.89 have been described. Validity measures show an association between empathy scores and student competence with extensive convergent and divergent validity assessments during test development.[7],[8],[10],[11]

Like empathy, emotional intelligence (EI) is an attribute that can influence patient care. EI is defined by Birks and Watt as, “a set of abilities (verbal and nonverbal) that enable a person to generate, recognize, express, understand, and evaluate their own and others' emotions in order to guide thinking and action and successfully cope with environmental demands and pressures.”[12] EI is vital in enabling the physician to utilize her/his understanding of the patient's emotional well-being to further enhance her/his therapeutic plan of action. Individuals who possess a high level of EI have been found to be more adept at decision-making.[13] This outcome supports the notion that the status of one's psychological well-being influences one's ability to perform in a high-stress work-related environment, commonly experienced in medicine. In addition, it has been demonstrated that medical students with higher EI perform better academically.[14],[15],[16] The Assessing Emotions Scale (also referred to as the Self-Report EI Test or the Schutte EI Scale) is a revised version of Salovey and Mayer's (1990) original model of EI. The three components of EI fall into the categories of appraisal and expression, regulation, and utilization of emotion. The Assessing Emotions Scale relates to these three components.[17] Strong psychometric properties for the scale have been reported, including internal consistency (measured through Cronbach's alpha) of 0.87 and 2-week test-retest reliability of 0.78 for total scale scores.[17],[18]

Personality traits yield yet another dimension of influence in the quality of the doctor–patient relationship. The field of psychology considers openness (O), consciousness (C), extraversion (E), agreeableness (A), and neuroticism (N) as the principle dimensions in measuring personality. These categories have deemed the Big Five Personality Traits quantified in the five-factor model. Researchers agree that this model best captures the variations between different personalities.[19] Personality traits have been shown to affect the stress levels and clinical competence of medical students.[20],[21] A report from three medical schools in Portugal also indicates that there is a correlation between empathy and at least two personality traits, i.e., openness and agreeableness.[22] The NEO-Five Factor Inventory (FFI) is a shorter, sixty-question questionnaire (12 items per trait), based on the longer NEO PI-R developed by Costa and McCrae. NEO-FFI scored 0.7≤ α <0.9; these numbers are considered “good” internal consistency on the Cronbach's α scale.[23],[24]

Along with the aforementioned variables, this study also aims to determine the correlation of certain demographic variables to observe empathy levels. Demographics alone have been shown to influence both doctor–patient communication and patient compliance to treatment. A 2006 study measured the quality of doctor–patient communication in patients with pulmonary nodules or lung cancer, in which measurements of communication were compared between groups of racially concordant and racially disconcordant interactions. Racially disconcordant pairs resulted in patients receiving less information and being less active in communication with their physicians as compared to racially concordant pairs.[25]

A 2008 study aimed to observe whether patients' perception of personal and ethnic similarity with their physician would affect the quality of care ratings and to see whether these perceptions of similarities were affected by racial and sexual concordance. Results showed that racially concordant groups reported more personal and ethnic similarities to their physicians. Perceived similarity was reported to be predictors of patients' trust, satisfaction, and intent to adhere. Perceived ethnic similarity was primarily influenced by racial concordance whereas perceived personal similarity was primarily influenced by the physicians' focus on patient-centered communication.[26] It is evident that race itself can play a role in the doctor–patient encounter; this study aims to determine how demographics such as race and ethnicity may relate to empathy of the medical students' themselves.

Gender has also been shown to influence health care. Several studies have demonstrated that females are more empathetic than males, but are more likely to exhibit indicators of burnout.[27],[28],[29],[30],[31],[32],[33],[34],[35] Gender has also been correlated with EI, where some studies (but not all)[15],[36],[37] have shown females with higher scores.[16],[38]

This study was designed to evaluate the patterns of empathy levels in podiatric medical students at the New York College of Podiatric Medicine (NYCPM) and to determine whether measured EI, personality traits, and demographics revealed statistical correlations with the observed patterns. This was designed to examine correlations between empathy and all the three variables – EI, personality traits, and demographics in a single cohort of medical students.


  Methods Top


This was a cross-sectional observational study. Participants were students enrolled at NYCPM, one of the nine institutions in the USA accredited by the Council on Podiatric Medical Education to confer the degree of Doctor of Podiatric Medicine (DPM). Each participating student was instructed to complete an anonymous web-based survey. The total responding population was 150 students registered at the college. To maintain anonymity, each participant was given a unique survey code. The survey included three instruments, measuring empathy, EI, and personality traits, as well as a fourth section collecting demographic data. Data were collected from March 17, 2014, to April 7, 2014; participants were allowed to complete segments of the survey, save, exit, and continue to finish the survey at later periods within this time frame.

Some of the demographic data collected were based on parameters established by the United States Census Bureau. Within this context, the terms “race and ethnicity” reflect the guidelines of the Bureau, adhering to the 1997 Office of Management and Budget standards. The category of “Asian” is defined as “a person having origin in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.”[39]

Empathy was measured using the Jefferson Scale of Physicians' Empathy-Medical Student version. The Jefferson Scale of Physicians' Empathy is a 20-item self-reporting questionnaire where participants respond to each item by using a 7-point Likert scale, ranging from a score of 1 representing “strongly disagree” to a score of 7 representing “strongly agree.”[7],[8] An empathy score was then determined by following the developer's instructions. In brief, respondents indicate the extent of their agreement or disagreement for each of the 20 items, making the possible range of resulting scores at 20–140, with higher scores indicating a higher degree of empathy. In the programing, it should be noted that half of the items are reverse scored (e.g., strongly agree = 1, strongly disagree = 7), and other items are directly scored based on their Likert weights (e.g., strongly agree = 7, strongly disagree = 1).

EI was measured using the Assessing Emotions Scale. In this 33-item questionnaire, participants respond to each item with a score of 1 representing “strongly disagree” to a score of 5 representing “strongly agree.”[17] An EI score was determined following developer's instructions. In brief, total scale scores are calculated by reverse coding items 5, 28, and 33, and then summing all items. Scores can range from 33 to 165, with a higher score indicating more characteristic EI.

Personality traits were measured using the NEO FFI-3. The NEO-FFI-3 is a 60-item questionnaire designed to measure the five domains of personality: neuroticism, extraversion, openness, agreeableness, and conscientiousness.[23] The NEO-FFI-3 contains 12 items per domain.[24],[40] Every fifth item assesses the individual in one particular dimension of personality. Several of the items are reverse scored.

Categorical variables were presented using frequencies and percentages. Continuous variables were described using mean, standard deviation (SDs), and 95% confidence intervals. Analysis of variance and two-sample t-tests were used as appropriate to test for differences in mean scores among groups. The relationship between EI, each of the five personality scores, and empathy scores was assessed using Pearson's Correlation Coefficient. Statistical analyses were performed using SAS version 9.4. (SAS Institute Inc., Cary, NC, USA).

The Institutional Review Board approved the study prior to any data collection.


  Results Top


Participant demographics

A total of 150 out of 368 registered students responded to and completed the survey, resulting in a response rate of 40.8%. This response was representative of the student population at large in all demographics. There was a preponderance of women (53.3%) and students of Caucasian ethnicity (47.3%). A detailed description of participant demographics is shown in [Table 1]. For comparison purposes, college-wide data are shown for the entire enrolled student population in the areas of gender and race; other demographic data were not collected at the institution level. Respondents to the survey are representative of the overall student enrollment as a whole; responses in gender and race fall within a 7% range as the matriculated population.
Table 1: Participant demographics

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Correlation between empathy and emotional intelligence

As shown in [Figure 1], there was a strong correlation between empathy scores and EI scores (r = 0.62, P< 0.0001).
Figure 1: Correlation between empathy and emotional intelligence. Pearson correlation coefficient between empathy and emotional intelligence scores from participating students (n = 150, r = 0.62, P< 0.0001). X-axis = Assessing Emotions Scale emotional intelligence scores; Y-axis = Jefferson Scale of Physician Empathy scores

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Correlation between empathy, emotional intelligence, and personality traits

As shown in [Table 2], there was a significant correlation between empathy, EI, and each of the five domains of personality. Note that for neuroticism, the correlation was inverse, while for the other four domains, the correlation was positive.
Table 2: Correlations between the Jefferson Scale of Physician Empathy scores, Assessing Emotions Scale emotional intelligence scores, and NEO Five Factor Inventory-3 personality domains

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Correlation between empathy and demographics

[Table 3] shows a nonsignificant decrease in empathy observed among students by year of enrollment from 1st year to 4th year (P = 0.68).
Table 3: Empathy scores by year of enrollment

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As shown in [Table 4], females were found to be significantly more empathetic than males (mean ± SD = 112.3 ± 11.2 vs. 104.8 ± 15.7; P = 0.001).
Table 4: Correlations between empathy, emotional intelligence, and gender

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Empathy scores for Asian-American students were significantly lower than for other racial groups (F = 6.63, P = 0.0018), as shown in [Figure 2].
Figure 2: Boxplot of empathy score by race. A one-way, between-subjects shows that empathy scores for Asian-American students were significantly lower than for other racial groups (F = 6.63, P = 0.0018)

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There was a significant association of undergraduate grade point average (GPA) with empathy for the four GPA categories (F = 3.15, P = 0.0269), but this was not monotone. The distribution of empathy scores among the four GPA categories is shown in [Figure 3]. No significant correlation was observed between empathy and graduate GPA, while at NYCPM, no significant differences in empathy scores were observed with respect to religion, ideological group, or self-reported stress levels.
Figure 3: Boxplot of empathy score by undergraduate grade point average. A one-way, between-subjects analysis of variance shows that there was a significant effect of grade point average on empathy for the four-grade point average categories (F = 3.15, P = 0.0269)

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Correlation between emotional intelligence and demographics

Females showed a nonsignificant elevation in mean EI score [Table 4]; P = 0.07].


  Discussion Top


Empathy has been shown to contribute to better outcomes in medical care.[2],[3],[41],[42] The Association of American Medical Colleges has stated that one task of medical education is to train selfless physicians who “must be compassionate and empathetic in caring for patients.”[43] Paradoxically, empathy has been shown to decline as students progress through their medical education.[4],[5],[27],[35],[44],[45],[46]

While most curriculums in medical education cover clearly delineated objectives in basic sciences and clinical courses, instruction and training on empathy and compassionate care are often sporadic and nonstandardized.[44],[47],[48],[49],[50],[51],[52],[53],[54] One of the challenges in teaching empathy lies in the limited understanding about the variety of factors and elements related to the concept. This study was designed to determine whether factors such as EI, personality traits, and demographic variables correlate with measured empathy among podiatric medical students. The understanding of empathy and its connection with areas such as EI, personality, and demographics in medical students has been a topic of interest in recent scientific literature. However, to the best of the authors' knowledge, this is the very first study to combine the analysis of correlations of all of these variables into a research design examining a single cohort of medical students. Such insight could be valuable in the elucidation of proper curriculum initiatives, such as the recently developed USA-wide project curriculum guide, in which objectives for all courses in podiatric medical education are listed and ranked.[55]

The DPM program in the USA is similar to that of allopathic (MD) and osteopathic (DO) medical students. Students enter the program with comparable undergraduate science course requirements, and scores in the Medical College Admissions Test are used as criteria for admission. The first 2 years consist primarily of basic science courses, followed by 2 years of clinical training. The American Podiatric Medicine Association House of Delegates “in order to ensure that podiatrists are universally accepted and recognized as physicians consistent with their education, training, and experience” developed Vision 2015-The Path to Parity. Vision 2015 has served as guidance for many positive changes to the profession over the last decade.[56] This study examines the parameters of empathy, EI, personality traits, and demographic variables in podiatric medical students.

A portion of the models and definitions of EI implicitly or explicitly includes empathy as one of its key components.[57],[58],[59],[60] As such, the study design included EI as one of the primary variables to examine in terms of its potential correlation with empathy scores. As stated above, EI did correlate with empathy (r = 0.62). EI in medicine, and specifically in medical students, has been an area of great research interest. In recent years, there has been a wide variety of publications in the field [14],[15],[16],[36],[37],[38],[61],[62],[63],[64],[65],[66],[67],[68] that others have not reported a strong correlation between empathy and EI as it was observed in this study.

Similarly, the study was designed under the expectation that at least some of the five domains of personality would demonstrate a correlation to empathy scores. This hypothesis proved accurate, and the data went further with each of the five personality domains exhibiting correlations. Openness to experience, conscientiousness (or the desire to complete a task well), extroversion, and agreeableness, all positively correlated with empathy. Neuroticism negatively correlated with empathy with higher values in this domain associated with lower empathy scores. Two other studies have explored associations between empathy and personality traits. Their findings only partially matched with ours in the sense that certain personality traits (but not all) correlated with empathy.[22],[66] Similar correlations were observed between all the five domains of personality and EI [Table 2]. While all the five domains of personality correlated with both empathy and EI, extraversion and conscientiousness correlated more strongly with EI than empathy, whereas openness correlates more strongly with empathy. These correlations appear aligned with the constructs' definitions of each term.

When comparing empathy and year of matriculation in the podiatric medical program at NYCPM, there was no significant decline in empathy scores. While at first glance this may seem to contradict the prior reports of decline of empathy during the course of medical education,[4] it should be noted that this study was of cross-sectional design and no longitudinal data were collected. The lack of statistical significance in the observed decline over the 4 years–from a mean empathy score of 110.6 (1st year) to 107.5 (4th year)–could be explained by a cohort effect representing intrinsic differences between each of the classes. Longitudinal data would need to be collected to determine whether the same pattern previously reported of empathy decline in medical students is also true in podiatric medical education. Interestingly, while these findings are similar to a reported cross-sectional study from the United Kingdom medical students,[31] it was not the case for cross-sectional studies in Japan and China.[33],[34] Such results continue to pose questions pertaining to the cultural and programatic differences between medical education in different countries.

The finding that females scored significantly higher in the empathy scale was aligned with previous reports.[27],[28] However, it was intriguing that given such a strong correlation between empathy and EI, there was no significant difference in gender for EI. While there is a possibility that this reflects a type II error in the analysis, a more plausible explanation could be inferred by examining the work of Imran et al. in Pakistani medical students. Their findings showed a lack of significance between the overall score of EI and gender, as was seen in this study. However, when they analyzed EI by subscales, two of these (Appraisal and Regulation of Emotions) were significantly higher in female students.[37] If their findings hold in our population, they might explain our lack of a gender difference when examining only the total score. It should be noted that several other studies have reported female medical students as scoring higher in empathy and/or EI.[16],[30],[31],[32],[33],[34],[35],[38],[69],[67]

Undergraduate GPA, as opposed to medical college GPA, was found to significantly correlate with empathy scores [Figure 3]. Interestingly enough, the pattern was not monotone, and students in the highest undergraduate GPA category (3.75–4.0) had recorded lower levels of empathy than the second highest GPA group (3.5–3.74). These results provide the opportunity for further research. Should these data be reproducible in other cohorts of medical students, it would be noteworthy to investigate the causes. Does a student's rigorous attention to academic performance neglect the acquiescence of empathetic skills or hinder skills already obtained? Perhaps, the feverish dedication and the perception of academics' prime importance accelerate burnout, thus decreasing empathy levels. These ideas warrant further exploration.

The analysis of correlation of empathy by race also resulted in intriguing findings. Asian-American students scored significantly lower in empathy than all other races [Figure 2]. While these findings are similar to others reported,[70],[71] their significance is not clear. For instance, cultural biases may be present in the methods for measuring empathy. Perhaps, cultural differences in the Asian-American community are perceived as lower levels of empathy from a Western perspective. Additional studies and further exploration are needed to quench these concerns. Of interest is a report from Australian medical students, in which Asian students scored higher in EI than white counterparts.[36] This again poses the aforementioned question regarding cultural perspectives when measuring empathy or EI in different countries and settings.

No additional correlations were observed between empathy and any other of the demographic variables.

The study limitations included those that are common for anonymous surveys and cross-sectional designs. Since the surveys were completed anonymously, there was no way to verify accuracy of the data. As a cross-sectional study, these findings represent data from a single time point, and future studies should include longitudinal data collection for a more compressive analysis. The response rate of 40.8% was lower than anticipated and future studies should implement strategies for increasing this rate. The study is also limited in the sense that students from a single podiatric medical school were assessed; future studies should include other medical schools (allopathic, osteopathic, and/or podiatric) as well as other geographical locations.


  Conclusion Top


The correlations observed in this study facilitate additional venues and language to study empathy in medicine. In some settings, it may be easier to assess EI and/or personality traits than empathy. Given the strong correlations presented in this study between these fields, each parameter could serve as a surrogate for one another.

The interconnection of empathy, EI, personality traits, and other demographics could critically impact the aspects of health-care delivery. Understanding such correlations could provide a framework for possible curriculum developments in medical education and could possibly inform the admission process. The work presented in this study, in particular, the strong correlations demonstrated between empathy, EI, and personality traits, signifies an additional piece of knowledge in the development of a structure in which the biopsychosocial model of health-care delivery is advanced.

Acknowledgments

The authors of this work would like to thank Dr. Michael Trepal and Dr. Eileen Chusid for their guidance and support during this research. The team is in deep gratitude to COO Joel Sturm, who approved and facilitated fund-raising strategies for the completion of the work and to Ms. Erica Benoit whose time, commitment, and dedication were critical in survey design, administration, and data collection. Ms. Caroline Fruge provided critical input in the area of personality traits. Finally, the authors acknowledge Dr. Michael Huchital's contributions in the editing of this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

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