|ORIGINAL RESEARCH ARTICLE
|Year : 2018 | Volume
| Issue : 3 | Page : 142-147
Does medical students' empathy change during their 5-year MBBS degree?
Alexia Papageorgiou1, Susan Miles2, Michelle Fromage3
1 Centre for Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
2 Norwich Medical School, University of East Anglia, Norwich, England
3 Norwich Medical School and the School of Psychology, University of East Anglia, Norwich, England
|Date of Web Publication||23-May-2019|
Centre for Primary Care and Population Health, University of Nicosia Medical School, 21 Ilia Papakyriakou, Engomi, P.O. Box 24005, 1700 Nicosia
Source of Support: None, Conflict of Interest: None
Background: Research evidence over the past 20 years has established that doctors' ability to empathize with their patients is a crucial component of effective health care. Consequently, teaching and reinforcing empathy has entered undergraduate medical education curricula; however, there have been mixed results in terms of its effectiveness. While there is evidence that empathy fluctuates during undergraduate medical training, there has been very little longitudinal research looking at medical students' empathy levels over their full course of study. The aim of the current study was to investigate whether medical students' empathy changed during their 5-year MBBS degree. Methods: Students completed the medical student version of the Jefferson Scale of Physician Empathy (JSPE) at the start of Year 1 and then near the end of Years 2, 3, 4, and 5 during 2009–2015. Total empathy score for students who had completed the JSPE in all 5 years of medical training was compared over time using nonparametrical statistical analysis. Results: Results indicated that medical students' empathy varies with empathy being highest at the start of the medical course in Year 1, declining to a low in Year 3 and then rising again in Years 4 and 5. There was a tendency for female students to have higher empathy scores compared to male students in each of the 5 years, with scores significantly different in Years 2, 3, and 4. However, there were no differences in empathy scores according to the students' age. Discussion: The decline in empathy in the early years of undergraduate medical training is a concern. Medical educators should teach and reinforce empathy during early years of undergraduate medical training in a sustainable way to guard against declining empathy levels. Specific interventions targeted at increasing empathy in male students might be warranted in the future.
Keywords: Empathy, Jefferson Scale of Physician Empathy, medical students, undergraduate medical education
|How to cite this article:|
Papageorgiou A, Miles S, Fromage M. Does medical students' empathy change during their 5-year MBBS degree?. Educ Health 2018;31:142-7
| Background|| |
Defining empathy in the context of clinical care has been a challenging task for academics who undertake research in this area.,, For our teaching at Norwich Medical School and the study reported in this article, we adopted the cognitive definition of empathy. According to this definition, an empathic doctor and/or medical student is able to understand the patients' experience of their illness and its biopsychosocial effects on their lives and has the ability to communicate this understanding back to the patient with an intention to help.,,
Research evidence over the past 20 years has established that doctors' ability to empathize with their patients is a crucial component of effective health care.,, Empathy improves patients' satisfaction and concordance with treatment, reduces malpractice litigation, and improves doctors' competence in consulting with patients and their ability to make accurate diagnoses and efficiently utilize resources.,,, Based on the growing body of research evidence that supports the importance of empathy medical schools, at least in the UK, attempt to choose prospective medical students with empathic attitudes in addition to good grades.
At Norwich Medical School, once medical students start their undergraduate medical education, students practice with simulated and real patients how to recognize patients' emotions and what affective reactions these emotions trigger in them as medical students and as human beings under clinical communication teaching. They are also encouraged to acknowledge and legitimize patients' emotions during role plays with simulated and real patients. In addition, they practice active listening, eliciting patients' ideas, concerns and expectations, expressing support, and sharing their thinking with patients; all of which are geared toward equipping students with skills that will enable them to understand the patients' experience and provide care in a humane and compassionate manner., Empathy is also reinforced and promoted through a reflective writing assessment, interprofessional learning (IPL) opportunities, and problem-based learning (PBL) and is heavily assessed during the Objective Structured Clinical Examinations (OSCEs). These methods of teaching and reinforcing empathy require substantial academic input and expense.
Given the cost on the one hand and the importance of empathy in clinical care on the other hand, early research evidence of declining empathy in undergraduate medical students as they progressed from preclinical to clinical years was disappointing for all involved in clinical communication teaching. A recent systematic review by Batt-Rawden et al. suggested several reasons behind this finding such as gender, age, specialty choice, “psychological factors, the “hidden curriculum,” unsuitable learning environments, cynicism/loss of idealism, and the perceived need for detachment.” (p. 1172).
More evidence as to how and why empathy fluctuates during undergraduate and postgraduate medical education has come from qualitative studies., Aomatsu et al.'s study showed that medical students' understanding of empathy focused on sharing emotions with patients (sympathy), while residents' expression and perception of empathy was that of a cognitive process that was shaped by patients' physical and mental health status. Tavakol et al.'s study corroborated the above finding and additionally showed that students were aware of the importance of maintaining cognitive and intellectual control over their feelings and they considered skill training and role models important in achieving this.
Recent research indicates a more optimistic picture in relation to empathy changes during medical school. Cross-sectional studies using the Jefferson Scale of Physician Empathy (JSPE) have shown that senior-year medical students scored either higher than junior students ,, or there were no differences between students starting and approaching the end of their course., These findings were corroborated by a longitudinal study that used the JSPE scale  and another one that used the Interpersonal Reactivity Index.
Gender has been one of the most studied variables in empathy research, and several studies showed that female students enter medical school with higher empathy scores than males and continue to maintain higher scores toward the end of their studies.,,,,,,,,,
Our knowledge regarding whether empathy changes during medical school has certainly improved over the past 20 years. We are also better informed about the interventions that help medical students maintain and even increase their empathy. However, we still need more multicenter, randomized controlled trials, reporting long-term data to evaluate this important aspect of clinical care.
The aim of the current study was to measure changes in medical students' empathy during a 5-year undergraduate medical program which included a PBL approach, an IPL course, and a longitudinal clinical communication course with OSCE assessments. The longitudinal clinical communication course used the Calgary–Cambridge model which adopts the cognitive definition of empathy and a skill-based approach.
| Methods|| |
For this longitudinal study investigating empathy in medical students, we used the student version of the JSPE,, which we purchased from the Center for Research in Medical Education and Health Care, Jefferson Medical College in 2009, for the purposes of this study. According to Batt-Rawden et al.'s recent systematic review, this is a valid and reliable measure of empathy in the context of medical education. The JSPE is a 20 item, self-assessment questionnaire which defines empathy as a predominantly cognitive attribute “that involves an understanding of experiences, concerns, and perspectives of the patient, combined with a capacity to communicate this understanding and an intention to help.” (p. 997). It is scored on a seven-point scale anchored by 1 = strongly disagree and 7 = strongly agree. Ten of the items are reverse scored. The total empathy score is the sum of all the item scores up to a maximum possible score of 140; a higher score represents a more empathetic orientation. Example JSPE items:
3. It is difficult for a doctor to view things from patients' perspectives. (reversed)
20. I believe that empathy is an important therapeutic factor in medical treatment.
As per the student version of the JSPE, students were asked to provide their name and registration number, indicate their year of study, gender and age (from a list of provided age ranges), and select which specialty they intended to pursue (the specialty data were subsequently not analyzed because most students selected the “not decided” response or multiple specialties). These demographic questions on the standard JSPE were altered slightly to accurately capture the data of our population. Students were informed that their name and registration number would only be used to match their responses for this year's JSPE with responses to the JSPE they had given previously or would give in future years.
We developed a student information sheet which provided details about the study and requested the students' voluntary participation and an information sheet for our clinical communication tutors who would recruit the students into the study.
We piloted the material with a small number of students and tutors, and following their feedback, we finalized the study material to ensure optimum clarity and ease of completion.
The study was carried out between 2009 and 2015 with two cohorts of undergraduate medical students (n = 333) from Norwich Medical School studying a 5-year MBBS degree. All medical students in these two cohorts were invited to complete the JSPE at the start of Year 1 and then near the end of each of Years 2, 3, 4, and 5.
To maximize data collection and avoid data attrition, which is an inherent issue in longitudinal studies, we decided to collect our data in person at the start of clinical communication skills sessions. Clinical communication skills sessions were determined to be the most appropriate teaching session for this research study as empathy is explicitly taught and promoted during these sessions.
The first set of data collection was immediately before the first clinical communication skills session in Year 1, which takes place at the start of the academic year. The information sheet for the clinical communication tutors outlining the purpose of the study and what would be expected of them in collecting the data was e-mailed to the tutors after they confirmed their teaching availability for that semester. Folders with hard copies of the JSPE questionnaire and the study information sheet for each student were handed to the clinical communication tutors before the start of the teaching. The tutors were instructed to hand out the study material to their students and collect it before the start of the session; sufficient time was allowed for the students to read the information sheet and discuss the study among themselves. Participation was completely voluntary; all students in attendance were handed the information sheet and JSPE questionnaire by their tutor, and they were then free to complete the questionnaire or not. Students gave their consent if they completed the questionnaire. If they did not wish to participate, they were able to return the uncompleted questionnaire when the tutor collected in the questionnaires. At the end of the teaching session, the tutors were instructed to place the completed forms in a designated box held securely at the medical school reception. The same procedure was followed in Years 2, 3, 4, and 5 with one exception. The data collection happened at the last clinical communication skills session of the corresponding year which was closest to the end of the academic year.
The study protocol, including the proposed procedure and all study materials, was reviewed and approved by the Head of School before the study commenced, and ethical committee approval was judged not to be needed.
The data we collected were entered in Microsoft Excel 2013 spreadsheets, and analysis was conducted in both Excel and IBM ® SPSS Statistics (v22) (Armonk NY, US).
As per JSPE scoring guidance provided to us by the JSPE developers, participants were required to have completed a minimum of 16 of the 20 questions to be included in the analysis; missing values from 4 or fewer unanswered questions were replaced with the mean score across all the questions the participant had answered. Total empathy score (out of 140) for students who had completed the JSPE in all 5 years of medical training was compared over time (Year 1, Year 2, Year 3, Year 4, and Year 5) using the nonparametric Friedman test for multiple-related conditions. Post hoc paired comparisons were then conducted using the Wilcoxon test with a corrected significance level of 0.005 for multiple tests (Bonferroni correction: 0.05/10 = 0.005). Mann–Whitney U-tests were used to compare the empathy scores of males and females, and younger (≤20 years) and older (>21 years) students with a correct significance level of 0.01 for multiple tests (Bonferroni correction: 0.05/5 = 0.01). Nonparametric tests were used throughout as the data were ordinal.
| Results|| |
Students from two cohorts (n = 333) were invited to complete the JSPE at the start of Year 1 and then near the end of each of Years 2, 3, 4, and 5. The number of students who completed the JSPE during each year of study was as follows: Year 1 = 210 (63%), Year 2 = 192 (67%), Year 3 = 203 (61%), Year 4 = 203 (61%), and Year 5 = 190 (57%). The data from 291 (87%) students who completed at least two questionnaires over the period of study were included in the analysis; excluding students who had only completed one questionnaire during the study period minimized the data being influenced by intercalating students joining a cohort partway through the 5-year course. There were 116 (40%) male and 175 female students. Age on admission at Year 1 was ≤20 years of age for 154 (53%) of the students and 21 years of age or older for 137 students.
There were no differences between the two age groups in empathy score for any of their 5 years of training. In contrast, there was a tendency for female students to have higher empathy scores compared to male students in each of the 5 years, with scores being significantly different in Years 2 (median: males = 108 and females = 113), 3 (median: males = 107 and females = 110), and 4 (median: males = 106 and females = 112).
As the primary aim of this study was to investigate changes in empathy over time, further analysis was conducted on the 66 (20%) students who completed a questionnaire at the start of Year 1 and then again at the end of each of the following 4 years of their medical training (i.e., students who completed the JSPE during all 5 years of their medical training).
There were 29 (44%) male and 37 female students; 35 (53%) of the students were ≤ 20 years old when they commenced the course in Year 1 and 31 of the students were ≥21 years. Statistical analysis indicated that empathy was highest at the start of Year 1 but declined to a low in Year 3, before beginning to rise again in the later years of the course (P< 0.001) [Table 1]. Specifically, the empathy score in Year 3 was significantly lower than the score in Years 1, 4, and 5, and the empathy score in Year 2 was significantly lower than the score in Year 1 (with no differences between Years 2 and 3; between Years 2, 4, and 5; or between Years 1, 4, and 5).
|Table 1: Mean (standard deviation) and median total empathy scores over time (n=66)|
Click here to view
| Discussion|| |
The results of our longitudinal study suggest that medical students' empathy fluctuates during their undergraduate medical education with empathy being highest at the start of the medical training, declining to a low in Year 3 of a 5-year MBBS course and then rising again in Years 4 and 5. Differences in age of students at admission did not show any changes in empathy at the different measurement points. Our results showed a tendency for female students to have higher empathy scores compared to male students in each of the 5 years, with scores being significantly different in Years 2, 3, and 4.
The finding that medical students' empathy is at its highest at the beginning of the medical course is in accordance with the majority of the most recent research evidence in this area.,,,,, This finding is unsurprising and can be explained by the fact that Norwich Medical School selects its students on the basis of their empathetic attitudes during the admission interview.
The finding that empathy declines as students' progress through the course is also in accordance with a large number of studies. The students at Norwich Medical School are exposed to health care services and patients from the start of their studies. Research has shown that expression and conceptualization of empathy changes with experience., The early and ongoing patient contact students are exposed to at Norwich Medical School may have an earlier impact on psychological factors such as sharing emotions with patients, difficulties separating the affective from the cognitive components of empathy, and the need for detachment which affect how empathy develops, compared to students undertaking more traditional medical studies with later clinical exposure. The “hidden curriculum” and cynicism/loss of idealism could also play a role in the decline of empathy in the middle of the curriculum. Nevertheless, this finding of a mid-course decline is disappointing for a medical school that provides heavy academic input and expensive resources to teach and reinforce empathy through PBL, IPL, clinical communication teaching, OSCE assessments, marking reflective writing, and early patient contact. This said, our study's other key finding of empathy rising again in Years 4 and 5 (which is also in alignment with most of the recent longitudinal studies,,,) could be the result of these same interventions to teach and reinforce empathy. Thus, whilst we do not know the reason for the changes in empathy throughout the 5 year MBBS, there is no reason to argue the methods being used to support the development of empathy at Norwich Medical School throughout the full 5 years of training are ineffective. The reasons why empathy increases again in the final years of undergraduate training after a midcourse decline merit further research, as do the optimum learning experiences for maintaining empathy.
Our finding that differences in age of students at admission did not show any changes in empathy at the different measurement points is also in alignment with other studies. The tendency for female students in our sample to have higher empathy scores compared to male students in each of the 5 years is also consistent with the majority of most recent studies in this area.,,,,,,,,, Our subsample of students who completed the JSPE for all of the 5 years was not large enough to investigate longitudinal variation by gender systematically. However, median empathy scores by gender for the full sample suggested that male students were not experiencing the return to a Year 1 level of empathy at the same rate as the female students. As such, studies with specific interventions targeted at increasing empathy in male students might be warranted in the future.
One limitation of this study is that although the response rate at each individual data collection point was acceptable (57%–67%), in accordance with other longitudinal research, the number of students who completed a questionnaire for all 5 years was low at 20% (n = 66). The JSPE questionnaire was handed out at a single communication skills session each year; if students were not in attendance (e.g., due to illness) for that session then there was no other opportunity to complete it and so there would be no data from that student for that year. Furthermore, at Norwich Medical School, a large number of students intercalate between Years 4 and 5 to undertake a research year; as the study only looked at two cohorts of students, some of these students were then lost from the study. In addition, as completion of the questionnaire was voluntary in each of the 5 years, it could be that more empathetic students were self-selected in the study as some students became bored with completing the questionnaire each year. Another potential limitation to the study is the use of a self-report scale to measure empathy. It might be argued that such a scale does not adequately capture a complex psychological construct such as empathy. However, such scales are the most appropriate measures for comparing large numbers of students. Finally, our study was a single-center longitudinal project, which might limit the generalizability of results.
Our results suggest that medical students' empathy changes over time during their undergraduate medical education. Longitudinal analysis of data from the same students over 5 years indicated that empathy was highest at the start of medical training but declined during Years 2 and 3 to a low in Year 3. Empathy rose again in Years 4 and 5, which is encouraging. It is unknown whether empathy would continue to increase during postgraduate training to reach the Year 1 level or even higher, or whether instead it would decline again; further research is needed to examine empathy levels into postgraduate training.
We would like to thank our students and our clinical communication tutors for their participation in the study. We would also like to thank Ms. Carrie Rodomar, Head Librarian at the University of Nicosia Medical School for her assistance with literature searches.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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