2014, 1–6, Early Online
Empathy in Korean medical students: Findings from a nationwide survey KYUNG HYE PARK1, HYERIN ROH1, DAE HUN SUH2 & MOHAMMADREZA HOJAT3 1
Inje University, Republic of Korea, 2Seoul National University, Republic of Korea, 3Thomas Jefferson University, USA
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Abstract Background: Previous studies on empathy in Korean medical students were conducted on small populations or with different scales of measurement, resulting in low representativeness and generalisability of the findings. Aim: To evaluate empathy in Korean medical students throughout the country and to make suggestions to improve empathy. Methods: The Jefferson Scale of Empathy (JSE) (Korean) was used, and the impact of sex, age, the medical school admission system, and grade of the respondents was investigated. Results: We analyzed 5343 questionnaires and found a mean empathy score of 105.9 12.8. Females and post-baccalaureate students had higher scores as compared with their counterparts. There was a significant difference between the admission systems after controlling for gender. Students from higher grade levels had lower scores than those from the lower grade levels. Conclusions: The JSE score of Korean medical students was lower than that of students in Western countries. The difference of gender and medical school admission system should be considered, and capability to apply empathy to clinical practice should be focused upon in medical training.
Introduction A patient–doctor relationship is based on empathy, which is important to achieve optimal clinical outcomes and for successful practice of medicine (Hojat et al. 2002). However, empathic skills are not acquired automatically during clinical training or applied in clinical practice (Hornblow et al. 2009). Since cognitive skills can be assessed and improved by appropriate longitudinal programmes (Hojat et al. 2013), educators should be aware of the deficiency in cognitive skills when developing training programmes for medical students. The Jefferson Scale of Empathy (JSE) was developed to evaluate physician empathy and it has been used in 60 countries worldwide, receiving international research attention (Hojat et al. 2011). Such studies on the JSE have revealed that the mean empathy score tends to be higher in female students compared with their male counterparts (Alcorta-Garza et al. 2005; Kliszcz et al. 2006; Chen et al. 2007; Ferna´ndez-Olano et al. 2008). Cross-sectional studies revealed that medical students at higher grades had different empathy scores (Chen et al. 2007; Magalha˜es et al. 2011; Shariat & Habibi 2013). However, longitudinal studies have revealed a significant decline in empathy scores in the third year of medical school, when the curriculum shifts to patient-care activities (Hojat et al. 2004, 2009). The previous Korean studies using the Korean version of the JSE were conducted only in one medical school, resulting in poor representativeness and generalisability of the findings (Kim et al. 2004; Lee et al. 2009; Roh et al. 2010). These
Practice points
The JSE-S scores of Korean medical students were similar to other Asian medical students, but lower than those from Western countries. Female students and lower grade students had higher empathy scores. There was significant difference between the empathy scores across medical school admission systems.
studies revealed patterns that were not in keeping with aforementioned trends. There was no gender difference in the empathy scores, and higher empathy scores were observed in higher grade students (Kim et al. 2004; Roh et al. 2010; Hong et al. 2012). The South Korean medical school admission system offers both undergraduate and post-baccalaureate programmes. However, there is little research on the empathy difference between these two systems. Therefore, in the present study, the authors evaluated the empathy scores of medical students throughout the country using the JSE. The following research questions were explored: (1) in comparison with their counterparts from other countries, do the mean empathy scores of the Korean medical students differ across genders and educational grade levels? (2) Do the empathy scores differ between the types of medical school admission systems? (3) What is the reason for low scores on specific components or items? (4) Based on this
Correspondence: HyeRin Roh, Department of Medical Education, Inje University College of Medicine, Busan, Republic of Korea. Tel: 82 51 890 8811; Fax: 82 51 893 9600; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–6 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.956058
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Table 1. Demographic characteristics of the respondents.
information, what strategies can we develop for medical communication education to improve empathy in Korean medical students?
Variables Sex Male Female Age (years) (mean, standard deviation) Medical school admission system Undergraduate programme Post-baccalaureate programme Medical school admission system and gendera Undergraduate programme Male Female Post-baccalaureate programme Male Female Medical school admission system and ageb Age in undergraduate programme Age in post-baccalaureate programme Grade 1st 2nd 3rd 4th Total
Methods
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Participants This study was approved by the institutional review board for human subjects at Inje University, South Korea. The South Korean medical school admission system offers undergraduate and post-baccalaureate programmes. Therefore, for the present study, we targeted all first to fourth year medical students from both types of programmes across the country. The crosssectional study was performed in the second semester at the end of 2012. The total number of medical students in South Korea was 14,070 in 2012, out of which 7412 students (52.7%) had enrolled in undergraduate programmes.
Instruments The students’ version of the JSE (JSE-S) was used to evaluate the empathy levels of the participants. The JSE-S was translated into Korean in 2010 and was reported to have a Cronbach’s alpha of 0.84 (Roh et al. 2010). The questionnaire also collected details of the participants, such as sex, age, medical school admission system, and educational grade level.
Statistical analyses The differences in gender and admission system were evaluated using t-tests, and Pearson correlation analysis was performed to assess the relationship between age and empathy score. Analysis of variance (ANOVA) with the Dunnett T3 post hoc test was used to compare empathy scores across grade levels. Analysis of covariance (ANCOVA) was used to analyze the difference between the medical school admission systems after adjusting for gender and age. The Statistical Package for the Social Sciences (ver. 19.0, SPSS Inc., Chicago, IL) was used for the analyses, and the significance was declared at p50.05.
Results A total of 14,070 questionnaires were distributed across 41 medical schools in South Korea, of which 5521 questionnaires were returned from 26 medical schools. The response rate was 39.2%. Of these 178 questionnaires were excluded from the sample due to incomplete demographic data. Consequently 5343 questionnaires were finally included in the analysis. This sample comprised 3287 male students (61.5%), and 2719 students from undergraduate programmes (50.9%). The mean age of the respondents was 26.4 years (Table 1). The Cronbach’s alpha coefficient in our study was 0.83. The mean total score on the Korean JSE-S was 105.90 12.80 (Table 2). The mean score on perspective taking (PT) was 55.56 7.54 (79.37%) that on compassionate care (CC) was 42.64 6.50 (76.14%) and that on standing in the patient’s shoes (SP) was 7.71 2.37 (55.07%) (Table 2). With reference to individual items, the highest score was 6.06, 2
a
No. (%) 3287 (61.5) 2056 (38.5) 26.4 (3.31) 2719 (50.9) 2624 (49.1)
1958 (72.0) 761 (28.0) 1329 (50.6) 1295 (49.4) 24.54 (2.32) 28.27 (3.10) 1494 1419 1316 1114 5343
(28.0) (26.6) (24.6) (20.8) (100.0)
p50.001, Pearson’s chi-squared test. p50.001, t-test.
b
on item 2 in PT. The lowest score was on item 6, followed by item 3, both in SP (3.64 and 4.06, respectively). Furthermore, item 14 in CC and 18 in CC had scores below 4.5 (Table 3). The mean total score and the mean score on CC of female students were higher than those of male students (p50.001, p50.001, respectively) (Table 2). Age and total score showed almost no correlation (r ¼ 0.040, p ¼ 0.005). Students from the post-baccalaureate programme had a higher mean total score compared with students from the undergraduate programme (p50.001) (Table 2). Further, it was observed that the postbaccalaureate students had a higher mean score on PT and SP compared with their undergraduate counterparts (p50.001) (Table 2). Because more female students and a higher mean age in post-baccalaureate students were found, ANCOVA was used to compare the scores across the two admission systems, after adjusting for gender and age. The analysis revealed that there was no age effect on empathy scores across the admission systems; however, significant gender effects were observed. In addition, a significant difference was found between the two systems after controlling for gender (p ¼ 0.012). With reference to the grade level of the students, the mean total scores ranked in the following descending order: second year first year third year, and fourth year (p50.001) (Table 2). This indicated that the students in the higher grades seemed to exhibit lower empathy scores. Post-hoc comparisons revealed that the fourth year students had scored lower than the first and second year students, and the third year students had scored lower than the second year students. In addition, the fourth year students had significantly lower scores on CC and SP when compared with the first or second year students, and the third year students had significantly lower scores on PT when compared with the second year students (Table 2).
Empathy in Korean medical students
Table 2. Korean JSE-S scores according to variables.
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Variables Sex Male Female p value F test T test Medical school admission system Undergraduate program Post-baccalaureate programme p value F test T test Undergraduate program and gender Male Female p value F test T test Post-baccalaureate program and gender Male Female p value F test T test Grade level 1st 2nd 3rd 4th p value, ANOVA Total
Total
Perspective taking
Compassionate care
Standing in patient’s shoes
105.25 (13.37)a 106.95 (11.74)
55.45 (7.82) 55.72 (7.07)
42.13 (6.81)a 43.46 (5.86)
7.66 (2.44) 7.77 (2.24)
50.001 50.001
50.001 0.199
50.001 50.001
105.15 (13.11)b 106.69 (12.41)
55.04 (7.62)b 56.09 (7.42)
42.51 (6.67) 42.78 (6.30)
0.007 50.001
0.539 50.001
104.79 (13.58)a 106.06 (11.78)
55.05 (7.88) 55.03 (6.90)
42.16 (6.94)a 43.41 (5.82)
7.58 (2.48) 7.61 (2.27)
50.001 0.016
50.001 0.946
50.001 50.001
0.018 0.707
105.92 (13.03)a 107.48 (11.69)
56.05 (7.69) 56.13 (7.13)
42.09 (6.62)a 43.48 (5.88)
7.79 (2.38) 7.87 (2.23)
50.001 0.001 106.41 (12.39)c 106.77 (12.28)c,d 105.18 (12.59) 104.97 (14.04) 50.001 105.90 (12.80)
0.025 0.141
0.058 0.792
0.016 50.001
55.78 (7.39) 55.80 (7.17)d 55.05 (7.50) 55.54 (8.19) 0.032 55.56 (7.54)
42.95 (6.16)c 43.11 (6.25)c,d 42.46 (6.38) 41.86 (7.25) 50.001 42.64 (6.49)
50.001 0.085 7.59 (2.42)b 7.83 (2.31) 0.001 50.001
50.001 0.360 7.68 (2.38) 7.86 (2.40)c 7.68 (2.37) 7.57 (2.31) 0.018 7.71 (2.37)
Mean (standard deviation) has been presented, unless specified otherwise. a p50.001, t-test, when compared with females. b p50.001, t-test, when compared with medical school admission system. c p50.05, post-hoc test after ANOVA, when compared with fourth year students. d p50.05, post-hoc test after ANOVA, when compared with third year students.
Discussion In the present study, the mean empathy score of Korean medical students was higher for female than for male students, in keeping with other studies (Alcorta-Garza et al. 2005; Kliszcz et al. 2006; Chen et al. 2007; Ferna´ndez-Olano et al. 2008). In addition, higher empathy scores were found among lower grade level and post-baccalaureate students. In terms of the three components of the JSE-S, the sample exhibited the highest mean score on PT, while the score on SP was significantly lower when compared with the scores on the other categories.
Comparison with other countries The JSE-S scores of the Korean medical students found in the present study were lower than that of their counterparts in Western countries. Asian medical students have relatively low empathy scores because of the variation in people’s sentiments and empathy, which is influenced by the culture of each country (Kataoka et al. 2009; Rahimi-Madiseh et al. 2010; Roh et al. 2010; Hong et al. 2012). The communicative culture of Asia is not dependant on non-verbal communication, such as facial expression and hand gestures, which might suppress empathic communication (Park 1980). In addition, for years, a calm, unemotional, and less assertive attitude has been
considered a virtue in Korea. Another reason for the lower empathy scores in the present study could be that the highschool students who want to attend medical school have to score high in mathematics and science subjects in the entrance examination, which is similar to Japan (Kataoka et al. 2009). The Program for International Student Assessment (PISA) test showed that Korean students secured the highest scores in mathematics, but a very low percentage of Korean students exhibited good engagement skills, drive, and self-belief (PISA 2012, Results in Focus 2013).
Grade and empathy Our research demonstrated that the empathy of medical students declines significantly across the higher grades in medical school, similar to previous studies (Chen et al. 2007; Magalha˜es et al. 2011; Shariat & Habibi 2013). This trend could be due to a lack of role models, a high volume of material to learn, lack of sleep, time pressure, and a demanding and hostile educational environment (Hojat et al. 2009). When this study was conducted, the third and fourth year students had already experienced an undesirable medical environment during their clinical work, in which Korean physicians have insufficient time to build an empathic rapport with the patient because they are expected to see many patients within a short time to meet the needs of the Korean health care system. It is
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Table 3. Mean scores on each item of the JSE-S (Korean).
Item no. Perspective taking 2 4 9 20 13 16
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10 5 17 15 Compassionate care 11
7 12 19 1 8 14 18 Standing in the patient’s shoes 3 6
Item
Score
Patients feel better when their physicians understand their feelings Understanding body language is as important as verbal communication in physician–patient relationships Physicians should try to stand in their patients’ shoes when providing care I believe that empathy is an important therapeutic factor in medical treatment Physicians should try to understand what is going on in their patients’ minds by paying attention to their non-verbal cues and body language Physicians’ understanding of the emotional status of their patients, as well as that of their families is one important component of the physician–patient relationship Patients value a physician’s understanding of their feelings which is therapeutic in its own right A physician’s sense of humor contributes to a better clinical outcome Physicians should try to think like their patients in order to render better care Empathy is a therapeutic skill without which the physician’s success is limited Patients’ illnesses can be cured only by medical or surgical treatment; therefore, physicians’ emotional ties with their patients do not have a significant influence in medical or surgical treatment Attention to patients’ emotions is not important in history taking Asking patients about what is happening in their personal lives is not helpful in understanding their physical complaints I do not enjoy reading non-medical literature or the arts Physicians’ understanding of their patients’ feelings and the feelings of their patients’ families do not influence medical or surgical treatment Attentiveness to patients’ personal experiences does not influence treatment outcomes I believe that emotion has no place in the treatment of medical illness Physicians should not allow themselves to be influenced by strong personal bonds between their patients and their family members It is difficult for a physician to view things from patients’ perspectives Because people are different, it is difficult to see things from patients’ perspectives
not surprising that the empathy score of Korean physicians, as measured by the JSE, was very low (98.2), which was substantially lower than that of Korean medical students (Roh et al. 2010; Suh et al. 2012). Medical students might consider the physicians with low empathy as their role models during their clinical work.
6.06 5.96 5.92 5.83 5.79 5.71 5.50 5.12 5.02 4.64 5.91
5.87 5.70 5.68 5.64 5.59 4.16 4.09
4.06 3.64
motivation, and emotional stability (Park et al. 2006). On one hand, selection through interview is important to reduce the number of students with inferior communication skills (Dahlin et al. 2012). On the other hand, the major criterion of the entrance procedures for the undergraduate students is based on a high school grading scale and the Korean scholastic aptitude test score.
Medical school admission system and empathy
Subanalysis of JSE
In the present study, the empathy score was significantly higher in the students of the post-baccalaureate programme compared with those of the undergraduate programme, even after controlling for age and gender. This result indicates that post-baccalaureate students might have different characteristics when compared with undergraduate students. They could have mature and obvious motivation for learning, in-depth academic experience, and qualifications because they choose to be a medical doctor after finishing their four years of college. In addition, students with diverse backgrounds and experiences tend to mature earlier, and would have effective clinical skills (Jervie Sefton 2004). It is expected that their empathic ability would be outstanding. Another explanation is the difference in the process of admission to the medical school. The Korean post-baccalaureate programme adopts multiple methods of selection of students, including the Medical Education Eligibility Test, Grade Point Average in college, an English test score, and an in-depth interview to evaluate communication skills,
PT is the core cognitive ingredient of empathy and the tendency to adopt the views of the other person, which comes from an altruistic motivation (Hojat et al. 2001; Hojat 2007). On one hand, our study as well as others reported that PT score was highest among the three components (Alcorta-Garza et al. 2005; Kataoka et al. 2009; Shariat & Habibi 2013). On the other hand, both the present and other studies showed very low SP score (Rahimi-Madiseh et al. 2010; Kataoka et al. 2012; Paro et al. 2012). SP is the personal attribute of empathy (Hojat et al. 2001), in other words, a high SP score means that medical students tend to think like patients. Our findings suggest that Korean medical students have a cognitive understanding of the patient’s perspectives, but have difficulties in applying empathy to clinical experiences and treating a patient by putting themselves in the patient’s position. CC covers emotions in patient care and understanding the patient’s experience, feelings, and clues (Hojat 2007). The low score in item 14 could indicate that Korean medical students are afraid of interventions in clinical encounters. In addition,
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Empathy in Korean medical students
Korean society is influenced by the Confucian culture; therefore, family relationships are interdependent. However, a low score on item 18 indicates that medical students’ encounters with patients may be affected by this culture. In other words, medical students fail to take the patients’ circumstances or family into consideration. This phenomenon might ultimately stem from an empathy deficiency.
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Limitations Our study has several limitations. Being a cross-sectional study, it is unclear if the accumulated experience of each medical student has any effects on empathy. Further, the response rate was low (39.2%) from only 26 medical schools. However, our survey had a 99% confidence level and a margin of error of 1.37%. Therefore, we believe that our findings are generalizable to a certain degree. Finally, each medical school might have a different environment and curriculum. Whether their programmes already included courses on medical communication, which may have influenced the empathy scores of the medical students, was not investigated in depth.
MOHAMMADREZA HOJAT, PhD, is a Research professor of Psychiatry and Human Behavior at Jefferson Medical College of Thomas Jefferson University, Philadelphia, USA.
Glossary Empathy: The capacity to understand what another is experiencing from within the frame of reference of that other person; the capacity to sample the feelings of another or to put oneself in another’s shoes. Jefferson Scale of Empathy: The Jefferson Scale of Empathy (JSE 20 items) was specifically developed for measuring empathy in the context of medical education and patient care, relying on the conceptualization of empathy as a predominantly cognitive attribute (as opposed to affective or emotional) that involves an understanding (as opposed to feeling) of the patients’ pain, experiences, concerns, and perspectives, combined with a capacity to communicate this understanding and an intention to help.
Suggestions for medical education Educators should incorporate empathy skills into the medical curriculum through courses devoted to communication skills, considering the differences across genders and admission systems. Furthermore, considering the low SP score, the capability to apply empathy to clinical practice should be focused on. Long-term strategies to improve and maintain empathy should be established to prevent empathy decline through the medical school years, especially during the years involving clinical work. In addition, physicians working as professors in university hospitals should undergo development programmes to make them good role models for medical students. The selection method for undergraduate medical students should be reformed to include various methods to evaluate communication skills, motivation, and emotional stability.
Conclusion The empathy score of Korean medical students was lower in male students, higher grades, and undergraduate students. Educators should develop longitudinal programmes for empathy training, focusing on gender, grade, medical school admission systems, and low capability to apply empathy to clinical practice.
Notes on contributors KYUNG HYE PARK, MD, PhD, is an Assistant Professor in Emergency Medicine at Inje University College of Medicine, Busan, Korea. HYERIN ROH, MD, PhD, is an Associate Professor in Medical Education at Inje University College of Medicine, Busan, Korea. DAE HUN SUH, MD, PhD, is a Professor in Dermatology at Seoul National University College of Medicine, Seoul, Korea.
Declaration of interest: The authors report that they have no declarations of interest.
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Hong M, Lee WH, Park JH, Yoon TY, Moon DS, Lee SM, Bahn GH. 2012. Changes of empathy in medical college and medical school students: 1-year follow up study. BMC Med Educ 12:122–126. Hornblow A, Kidson M, Ironside W. 2009. Empathic processes: Perception by medical students of patients’ anxiety and depression. Med Educ 22: 15–18. Jervie Sefton A. 2004. Graduate entry to medical school. Med Educ 38: 1132–1134. Kataoka HU, Koide N, Hojat M, Gonnella JS. 2012. Measurement and correlates of empathy among female Japanese physicians. BMC Med Educ 12:48–53. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. 2009. Measurement of empathy among Japanese medical students: Psychometrics and score differences by gender and level of medical education. Acad Med 84: 1192–1197. Kim IS, Kim YH, Chang HI. 2004. An investigation on reliability and validity of the Korean medical students’ empathy rating scale. Kor J Psychopathol 13:9–15. Kliszcz J, Nowicka-Sauer K, Trzeciak B, Nowak P, Sadowska A. 2006. Empathy in health care providers – validation study of the polish version of the Jefferson Scale of Empathy. Adv Med Sci 51: 219–225. Lee BK, Bahn GH, Lee WH, Park JH, Yoon TY, Baek SB. 2009. The relationship between empathy and medical education system, grades, and personality in medical college students and medical school students. Korean J Med Educ 21:117–124.
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Magalha˜es E, Salgueira AP, Costa P, Costa MJ. 2011. Empathy in senior year and first year medical students: A cross-sectional study. BMC Med Educ. 11:52–58. Park KH, Hong DH, Oh JH, Park YB, Shin DJ, Lee YD. 2006. The analysis of academic achievements of students at Gachon medical school. Korean J Med Educ 18:289–296. Park MS. 1980. Observation on nonverbal communication across cultures. Language Linguist 6:63–79. Paro HB, Daud-Gallotti RM, Tibe´rio IC, Pinto RM, Martins MA. 2012. Brazilian version of the Jefferson Scale of Empathy: Psychometric properties and factor analysis. BMC Med Educ 12:73–79. PISA. 2012. Results in focus. What 15-year-olds know and what they can do with what why know. [Accessed 6 Dec 2013] Available from: http:// www.oecd.org/pisa/keyfindings/pisa-2012-results-overview.pdf. Rahimi-Madiseh M, Tavakol M, Dennick R, Nasiri J. 2010. Empathy in Iranian medical students: A preliminary psychometric analysis and differences by gender and year of medical school. Med Teach 32:471–478. Roh MS, Hahm BJ, Lee DH, Suh DH. 2010. Evaluation of empathy among Korean medical students: A cross-sectional study using the Korean version of the Jefferson scale of physician empathy. Teach Learn Med 22:167–171. Shariat SV, Habibi M. 2013. Empathy in Iranian medical students: Measurement model of the Jefferson Scale of Empathy. Med Teach 35:e913–e918. Suh DH, Hong JS, Lee DH, Gonnella JS, Hojat M. 2012. The Jefferson scale of physician empathy: A preliminary psychometric study and group. Med Teach 34:e464–e468.
Empathy in Korean medical students: Findings from a nationwide survey KYUNG HYE PARK1, HYERIN ROH1, DAE HUN SUH2 & MOHAMMADREZA HOJAT3 1
Inje University, Republic of Korea, 2Seoul National University, Republic of Korea, 3Thomas Jefferson University, USA
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Abstract Background: Previous studies on empathy in Korean medical students were conducted on small populations or with different scales of measurement, resulting in low representativeness and generalisability of the findings. Aim: To evaluate empathy in Korean medical students throughout the country and to make suggestions to improve empathy. Methods: The Jefferson Scale of Empathy (JSE) (Korean) was used, and the impact of sex, age, the medical school admission system, and grade of the respondents was investigated. Results: We analyzed 5343 questionnaires and found a mean empathy score of 105.9 12.8. Females and post-baccalaureate students had higher scores as compared with their counterparts. There was a significant difference between the admission systems after controlling for gender. Students from higher grade levels had lower scores than those from the lower grade levels. Conclusions: The JSE score of Korean medical students was lower than that of students in Western countries. The difference of gender and medical school admission system should be considered, and capability to apply empathy to clinical practice should be focused upon in medical training.
Introduction A patient–doctor relationship is based on empathy, which is important to achieve optimal clinical outcomes and for successful practice of medicine (Hojat et al. 2002). However, empathic skills are not acquired automatically during clinical training or applied in clinical practice (Hornblow et al. 2009). Since cognitive skills can be assessed and improved by appropriate longitudinal programmes (Hojat et al. 2013), educators should be aware of the deficiency in cognitive skills when developing training programmes for medical students. The Jefferson Scale of Empathy (JSE) was developed to evaluate physician empathy and it has been used in 60 countries worldwide, receiving international research attention (Hojat et al. 2011). Such studies on the JSE have revealed that the mean empathy score tends to be higher in female students compared with their male counterparts (Alcorta-Garza et al. 2005; Kliszcz et al. 2006; Chen et al. 2007; Ferna´ndez-Olano et al. 2008). Cross-sectional studies revealed that medical students at higher grades had different empathy scores (Chen et al. 2007; Magalha˜es et al. 2011; Shariat & Habibi 2013). However, longitudinal studies have revealed a significant decline in empathy scores in the third year of medical school, when the curriculum shifts to patient-care activities (Hojat et al. 2004, 2009). The previous Korean studies using the Korean version of the JSE were conducted only in one medical school, resulting in poor representativeness and generalisability of the findings (Kim et al. 2004; Lee et al. 2009; Roh et al. 2010). These
Practice points
The JSE-S scores of Korean medical students were similar to other Asian medical students, but lower than those from Western countries. Female students and lower grade students had higher empathy scores. There was significant difference between the empathy scores across medical school admission systems.
studies revealed patterns that were not in keeping with aforementioned trends. There was no gender difference in the empathy scores, and higher empathy scores were observed in higher grade students (Kim et al. 2004; Roh et al. 2010; Hong et al. 2012). The South Korean medical school admission system offers both undergraduate and post-baccalaureate programmes. However, there is little research on the empathy difference between these two systems. Therefore, in the present study, the authors evaluated the empathy scores of medical students throughout the country using the JSE. The following research questions were explored: (1) in comparison with their counterparts from other countries, do the mean empathy scores of the Korean medical students differ across genders and educational grade levels? (2) Do the empathy scores differ between the types of medical school admission systems? (3) What is the reason for low scores on specific components or items? (4) Based on this
Correspondence: HyeRin Roh, Department of Medical Education, Inje University College of Medicine, Busan, Republic of Korea. Tel: 82 51 890 8811; Fax: 82 51 893 9600; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/000001–6 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.956058
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Table 1. Demographic characteristics of the respondents.
information, what strategies can we develop for medical communication education to improve empathy in Korean medical students?
Variables Sex Male Female Age (years) (mean, standard deviation) Medical school admission system Undergraduate programme Post-baccalaureate programme Medical school admission system and gendera Undergraduate programme Male Female Post-baccalaureate programme Male Female Medical school admission system and ageb Age in undergraduate programme Age in post-baccalaureate programme Grade 1st 2nd 3rd 4th Total
Methods
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Participants This study was approved by the institutional review board for human subjects at Inje University, South Korea. The South Korean medical school admission system offers undergraduate and post-baccalaureate programmes. Therefore, for the present study, we targeted all first to fourth year medical students from both types of programmes across the country. The crosssectional study was performed in the second semester at the end of 2012. The total number of medical students in South Korea was 14,070 in 2012, out of which 7412 students (52.7%) had enrolled in undergraduate programmes.
Instruments The students’ version of the JSE (JSE-S) was used to evaluate the empathy levels of the participants. The JSE-S was translated into Korean in 2010 and was reported to have a Cronbach’s alpha of 0.84 (Roh et al. 2010). The questionnaire also collected details of the participants, such as sex, age, medical school admission system, and educational grade level.
Statistical analyses The differences in gender and admission system were evaluated using t-tests, and Pearson correlation analysis was performed to assess the relationship between age and empathy score. Analysis of variance (ANOVA) with the Dunnett T3 post hoc test was used to compare empathy scores across grade levels. Analysis of covariance (ANCOVA) was used to analyze the difference between the medical school admission systems after adjusting for gender and age. The Statistical Package for the Social Sciences (ver. 19.0, SPSS Inc., Chicago, IL) was used for the analyses, and the significance was declared at p50.05.
Results A total of 14,070 questionnaires were distributed across 41 medical schools in South Korea, of which 5521 questionnaires were returned from 26 medical schools. The response rate was 39.2%. Of these 178 questionnaires were excluded from the sample due to incomplete demographic data. Consequently 5343 questionnaires were finally included in the analysis. This sample comprised 3287 male students (61.5%), and 2719 students from undergraduate programmes (50.9%). The mean age of the respondents was 26.4 years (Table 1). The Cronbach’s alpha coefficient in our study was 0.83. The mean total score on the Korean JSE-S was 105.90 12.80 (Table 2). The mean score on perspective taking (PT) was 55.56 7.54 (79.37%) that on compassionate care (CC) was 42.64 6.50 (76.14%) and that on standing in the patient’s shoes (SP) was 7.71 2.37 (55.07%) (Table 2). With reference to individual items, the highest score was 6.06, 2
a
No. (%) 3287 (61.5) 2056 (38.5) 26.4 (3.31) 2719 (50.9) 2624 (49.1)
1958 (72.0) 761 (28.0) 1329 (50.6) 1295 (49.4) 24.54 (2.32) 28.27 (3.10) 1494 1419 1316 1114 5343
(28.0) (26.6) (24.6) (20.8) (100.0)
p50.001, Pearson’s chi-squared test. p50.001, t-test.
b
on item 2 in PT. The lowest score was on item 6, followed by item 3, both in SP (3.64 and 4.06, respectively). Furthermore, item 14 in CC and 18 in CC had scores below 4.5 (Table 3). The mean total score and the mean score on CC of female students were higher than those of male students (p50.001, p50.001, respectively) (Table 2). Age and total score showed almost no correlation (r ¼ 0.040, p ¼ 0.005). Students from the post-baccalaureate programme had a higher mean total score compared with students from the undergraduate programme (p50.001) (Table 2). Further, it was observed that the postbaccalaureate students had a higher mean score on PT and SP compared with their undergraduate counterparts (p50.001) (Table 2). Because more female students and a higher mean age in post-baccalaureate students were found, ANCOVA was used to compare the scores across the two admission systems, after adjusting for gender and age. The analysis revealed that there was no age effect on empathy scores across the admission systems; however, significant gender effects were observed. In addition, a significant difference was found between the two systems after controlling for gender (p ¼ 0.012). With reference to the grade level of the students, the mean total scores ranked in the following descending order: second year first year third year, and fourth year (p50.001) (Table 2). This indicated that the students in the higher grades seemed to exhibit lower empathy scores. Post-hoc comparisons revealed that the fourth year students had scored lower than the first and second year students, and the third year students had scored lower than the second year students. In addition, the fourth year students had significantly lower scores on CC and SP when compared with the first or second year students, and the third year students had significantly lower scores on PT when compared with the second year students (Table 2).
Empathy in Korean medical students
Table 2. Korean JSE-S scores according to variables.
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Variables Sex Male Female p value F test T test Medical school admission system Undergraduate program Post-baccalaureate programme p value F test T test Undergraduate program and gender Male Female p value F test T test Post-baccalaureate program and gender Male Female p value F test T test Grade level 1st 2nd 3rd 4th p value, ANOVA Total
Total
Perspective taking
Compassionate care
Standing in patient’s shoes
105.25 (13.37)a 106.95 (11.74)
55.45 (7.82) 55.72 (7.07)
42.13 (6.81)a 43.46 (5.86)
7.66 (2.44) 7.77 (2.24)
50.001 50.001
50.001 0.199
50.001 50.001
105.15 (13.11)b 106.69 (12.41)
55.04 (7.62)b 56.09 (7.42)
42.51 (6.67) 42.78 (6.30)
0.007 50.001
0.539 50.001
104.79 (13.58)a 106.06 (11.78)
55.05 (7.88) 55.03 (6.90)
42.16 (6.94)a 43.41 (5.82)
7.58 (2.48) 7.61 (2.27)
50.001 0.016
50.001 0.946
50.001 50.001
0.018 0.707
105.92 (13.03)a 107.48 (11.69)
56.05 (7.69) 56.13 (7.13)
42.09 (6.62)a 43.48 (5.88)
7.79 (2.38) 7.87 (2.23)
50.001 0.001 106.41 (12.39)c 106.77 (12.28)c,d 105.18 (12.59) 104.97 (14.04) 50.001 105.90 (12.80)
0.025 0.141
0.058 0.792
0.016 50.001
55.78 (7.39) 55.80 (7.17)d 55.05 (7.50) 55.54 (8.19) 0.032 55.56 (7.54)
42.95 (6.16)c 43.11 (6.25)c,d 42.46 (6.38) 41.86 (7.25) 50.001 42.64 (6.49)
50.001 0.085 7.59 (2.42)b 7.83 (2.31) 0.001 50.001
50.001 0.360 7.68 (2.38) 7.86 (2.40)c 7.68 (2.37) 7.57 (2.31) 0.018 7.71 (2.37)
Mean (standard deviation) has been presented, unless specified otherwise. a p50.001, t-test, when compared with females. b p50.001, t-test, when compared with medical school admission system. c p50.05, post-hoc test after ANOVA, when compared with fourth year students. d p50.05, post-hoc test after ANOVA, when compared with third year students.
Discussion In the present study, the mean empathy score of Korean medical students was higher for female than for male students, in keeping with other studies (Alcorta-Garza et al. 2005; Kliszcz et al. 2006; Chen et al. 2007; Ferna´ndez-Olano et al. 2008). In addition, higher empathy scores were found among lower grade level and post-baccalaureate students. In terms of the three components of the JSE-S, the sample exhibited the highest mean score on PT, while the score on SP was significantly lower when compared with the scores on the other categories.
Comparison with other countries The JSE-S scores of the Korean medical students found in the present study were lower than that of their counterparts in Western countries. Asian medical students have relatively low empathy scores because of the variation in people’s sentiments and empathy, which is influenced by the culture of each country (Kataoka et al. 2009; Rahimi-Madiseh et al. 2010; Roh et al. 2010; Hong et al. 2012). The communicative culture of Asia is not dependant on non-verbal communication, such as facial expression and hand gestures, which might suppress empathic communication (Park 1980). In addition, for years, a calm, unemotional, and less assertive attitude has been
considered a virtue in Korea. Another reason for the lower empathy scores in the present study could be that the highschool students who want to attend medical school have to score high in mathematics and science subjects in the entrance examination, which is similar to Japan (Kataoka et al. 2009). The Program for International Student Assessment (PISA) test showed that Korean students secured the highest scores in mathematics, but a very low percentage of Korean students exhibited good engagement skills, drive, and self-belief (PISA 2012, Results in Focus 2013).
Grade and empathy Our research demonstrated that the empathy of medical students declines significantly across the higher grades in medical school, similar to previous studies (Chen et al. 2007; Magalha˜es et al. 2011; Shariat & Habibi 2013). This trend could be due to a lack of role models, a high volume of material to learn, lack of sleep, time pressure, and a demanding and hostile educational environment (Hojat et al. 2009). When this study was conducted, the third and fourth year students had already experienced an undesirable medical environment during their clinical work, in which Korean physicians have insufficient time to build an empathic rapport with the patient because they are expected to see many patients within a short time to meet the needs of the Korean health care system. It is
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Table 3. Mean scores on each item of the JSE-S (Korean).
Item no. Perspective taking 2 4 9 20 13 16
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10 5 17 15 Compassionate care 11
7 12 19 1 8 14 18 Standing in the patient’s shoes 3 6
Item
Score
Patients feel better when their physicians understand their feelings Understanding body language is as important as verbal communication in physician–patient relationships Physicians should try to stand in their patients’ shoes when providing care I believe that empathy is an important therapeutic factor in medical treatment Physicians should try to understand what is going on in their patients’ minds by paying attention to their non-verbal cues and body language Physicians’ understanding of the emotional status of their patients, as well as that of their families is one important component of the physician–patient relationship Patients value a physician’s understanding of their feelings which is therapeutic in its own right A physician’s sense of humor contributes to a better clinical outcome Physicians should try to think like their patients in order to render better care Empathy is a therapeutic skill without which the physician’s success is limited Patients’ illnesses can be cured only by medical or surgical treatment; therefore, physicians’ emotional ties with their patients do not have a significant influence in medical or surgical treatment Attention to patients’ emotions is not important in history taking Asking patients about what is happening in their personal lives is not helpful in understanding their physical complaints I do not enjoy reading non-medical literature or the arts Physicians’ understanding of their patients’ feelings and the feelings of their patients’ families do not influence medical or surgical treatment Attentiveness to patients’ personal experiences does not influence treatment outcomes I believe that emotion has no place in the treatment of medical illness Physicians should not allow themselves to be influenced by strong personal bonds between their patients and their family members It is difficult for a physician to view things from patients’ perspectives Because people are different, it is difficult to see things from patients’ perspectives
not surprising that the empathy score of Korean physicians, as measured by the JSE, was very low (98.2), which was substantially lower than that of Korean medical students (Roh et al. 2010; Suh et al. 2012). Medical students might consider the physicians with low empathy as their role models during their clinical work.
6.06 5.96 5.92 5.83 5.79 5.71 5.50 5.12 5.02 4.64 5.91
5.87 5.70 5.68 5.64 5.59 4.16 4.09
4.06 3.64
motivation, and emotional stability (Park et al. 2006). On one hand, selection through interview is important to reduce the number of students with inferior communication skills (Dahlin et al. 2012). On the other hand, the major criterion of the entrance procedures for the undergraduate students is based on a high school grading scale and the Korean scholastic aptitude test score.
Medical school admission system and empathy
Subanalysis of JSE
In the present study, the empathy score was significantly higher in the students of the post-baccalaureate programme compared with those of the undergraduate programme, even after controlling for age and gender. This result indicates that post-baccalaureate students might have different characteristics when compared with undergraduate students. They could have mature and obvious motivation for learning, in-depth academic experience, and qualifications because they choose to be a medical doctor after finishing their four years of college. In addition, students with diverse backgrounds and experiences tend to mature earlier, and would have effective clinical skills (Jervie Sefton 2004). It is expected that their empathic ability would be outstanding. Another explanation is the difference in the process of admission to the medical school. The Korean post-baccalaureate programme adopts multiple methods of selection of students, including the Medical Education Eligibility Test, Grade Point Average in college, an English test score, and an in-depth interview to evaluate communication skills,
PT is the core cognitive ingredient of empathy and the tendency to adopt the views of the other person, which comes from an altruistic motivation (Hojat et al. 2001; Hojat 2007). On one hand, our study as well as others reported that PT score was highest among the three components (Alcorta-Garza et al. 2005; Kataoka et al. 2009; Shariat & Habibi 2013). On the other hand, both the present and other studies showed very low SP score (Rahimi-Madiseh et al. 2010; Kataoka et al. 2012; Paro et al. 2012). SP is the personal attribute of empathy (Hojat et al. 2001), in other words, a high SP score means that medical students tend to think like patients. Our findings suggest that Korean medical students have a cognitive understanding of the patient’s perspectives, but have difficulties in applying empathy to clinical experiences and treating a patient by putting themselves in the patient’s position. CC covers emotions in patient care and understanding the patient’s experience, feelings, and clues (Hojat 2007). The low score in item 14 could indicate that Korean medical students are afraid of interventions in clinical encounters. In addition,
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Empathy in Korean medical students
Korean society is influenced by the Confucian culture; therefore, family relationships are interdependent. However, a low score on item 18 indicates that medical students’ encounters with patients may be affected by this culture. In other words, medical students fail to take the patients’ circumstances or family into consideration. This phenomenon might ultimately stem from an empathy deficiency.
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Limitations Our study has several limitations. Being a cross-sectional study, it is unclear if the accumulated experience of each medical student has any effects on empathy. Further, the response rate was low (39.2%) from only 26 medical schools. However, our survey had a 99% confidence level and a margin of error of 1.37%. Therefore, we believe that our findings are generalizable to a certain degree. Finally, each medical school might have a different environment and curriculum. Whether their programmes already included courses on medical communication, which may have influenced the empathy scores of the medical students, was not investigated in depth.
MOHAMMADREZA HOJAT, PhD, is a Research professor of Psychiatry and Human Behavior at Jefferson Medical College of Thomas Jefferson University, Philadelphia, USA.
Glossary Empathy: The capacity to understand what another is experiencing from within the frame of reference of that other person; the capacity to sample the feelings of another or to put oneself in another’s shoes. Jefferson Scale of Empathy: The Jefferson Scale of Empathy (JSE 20 items) was specifically developed for measuring empathy in the context of medical education and patient care, relying on the conceptualization of empathy as a predominantly cognitive attribute (as opposed to affective or emotional) that involves an understanding (as opposed to feeling) of the patients’ pain, experiences, concerns, and perspectives, combined with a capacity to communicate this understanding and an intention to help.
Suggestions for medical education Educators should incorporate empathy skills into the medical curriculum through courses devoted to communication skills, considering the differences across genders and admission systems. Furthermore, considering the low SP score, the capability to apply empathy to clinical practice should be focused on. Long-term strategies to improve and maintain empathy should be established to prevent empathy decline through the medical school years, especially during the years involving clinical work. In addition, physicians working as professors in university hospitals should undergo development programmes to make them good role models for medical students. The selection method for undergraduate medical students should be reformed to include various methods to evaluate communication skills, motivation, and emotional stability.
Conclusion The empathy score of Korean medical students was lower in male students, higher grades, and undergraduate students. Educators should develop longitudinal programmes for empathy training, focusing on gender, grade, medical school admission systems, and low capability to apply empathy to clinical practice.
Notes on contributors KYUNG HYE PARK, MD, PhD, is an Assistant Professor in Emergency Medicine at Inje University College of Medicine, Busan, Korea. HYERIN ROH, MD, PhD, is an Associate Professor in Medical Education at Inje University College of Medicine, Busan, Korea. DAE HUN SUH, MD, PhD, is a Professor in Dermatology at Seoul National University College of Medicine, Seoul, Korea.
Declaration of interest: The authors report that they have no declarations of interest.
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