2015, 1–4, Early Online
Reconsidering the ‘‘decline’’ of medical student empathy as reported in studies using the Jefferson Scale of Physician Empathy-Student version (JSPE-S) SUE ROFF University of Dundee and Education Consultant, UK
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Abstract Introduction: The suggestion that empathy ‘‘declines’’ or ‘‘erodes’’ as students progress through medical school has largely rested on observations reported from Jefferson Medical College in the United States using the Jefferson Scale of Physician Empathy (JSPE) developed by Hojat and colleagues. Now that the student version of JSPE has been administered to medical students in more than a dozen countries, it is timely to consider whether or not the Jefferson ‘‘case study’’ and the conclusions drawn from it are generalisable. Methods: A literature research was conducted on MEDLINE in mid-2014 to identify studies reporting administrations of the Student version of JPSE (JSPE-S) to cohorts of medical students and the means for studies and their sub-parts conducted in Japan, South Korea, China, Kuwait, India, Iran, UK, USA, Australia, Brazil, Colombia, the Dominican Republic and Portugal. Results: The means of these studies from a dozen countries outside the USA consistently cluster round 75% out of the possible maximum of 140 unlike the early Jefferson studies (although the later Jefferson means are also 5120). Conclusions: These observations may support Costa et al.’s contention that ‘‘a latent growth model suggests that empathy of medical students does not decline over time’’ (p. 509) – or at least not significantly. But in order to understand the maturation process of medical students and trainees we need to develop more sophisticated, integrated models that combine culturallysensitive concepts of emotional intelligence and moral reasoning with far more refined understandings of the nature of empathy required for the safe practice of patient-centred medicine.
Introduction
Practice points
Neumann et al. (2011) reviewed 18 studies concerning trainee empathy from January 1990 to January 2010. Eleven of these 18 reports were related to medical students and seven to residents. They concluded that ‘‘Three longitudinal and six cross-sectional studies of medical students demonstrated a significant (emphasis added) decrease in empathy during medical education; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency’’. Eight of the 11 student studies were from the USA, as were all the seven resident studies. Four of the student studies used the Jefferson Scale of Physician Empathy-Student (JSPE-S) as did one of the resident studies, although neither the Kataoka et al. (2009) JSPE-S report nor that from Lee et al. (2009) was included.
Methods Hemmerdinger et al. (2007) conducted a systematic review of 36 different instruments to measure empathy of which they
JSPE-S data can be usefully compared to results from more than a dozen countries beyond the initial Jefferson results. We need integrated models combining culturallysensitive concepts of emotional intelligence and moral reasoning with refined understandings of the nature of empathy required for the safe practice of patient-centred medicine to map the process of developing medical student professional identity.
considered (see their Additional File 3) the JSPE to be ‘‘The most heavily researched test and specifically designed from scratch for the assessment of physician empathy’’. A literature research was conducted on MEDLINE in mid2014 to identify studies reporting administrations of the Student version of JSPE (JSPE-S) to cohorts of medical students and the means for various studies and their sub-parts were extracted from them.
Correspondence: Sue Roff, Centre for Medical Education, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, Scotland, UK. Tel: 44 0 1382 381952; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/000001–4 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1009022
1
S. Roff
Table 1. JSPE-S means 2009–2014.
Report
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Kataoka et al. (2009) Japan Lee et al. (2009) South Korea Roh et al. (2010) South Korea Hong et al. (2013) South Korea MedColl1 MedColl2 MedSch1 MedSch2 Wen et al. (2013) China Rahimi-Madiseh et al. (2010) Iran Hasan et al. (2013) Kuwait Hegazi and Wilson (2013) Australia Williams et al. (2014) Australia Tavakol et al. (2011) UK Magalhaes et al. (2011) Portugal Costa et al. (2013) Portugal Goncalves-Pereira et al. (2013) Portugal Paro et al. (2012) Brazil Shashikumar et al.(2014) India Shariat and Habibi (2013) Iran
N
1st year
2nd year
3rd year
4th year
5th year
98.5 104.7
103.8 108.6
105.0 109.6
102.8
355
5.1 (102)
5.1 (102)
5.0 (100)
5.5 (106)
104.6
113
104.57
107.05
108.52
106.96
113 120 120 753
107.36
108.43 107.79 109.58 109.19
109.31 109.05 110.17 110.5
111.34 111.11 111.24 112.12
108.88 109.23 110.09 109.6
179
106.0
102.0
106.5
105.2
106.0
264 404
100.8
104.3
110.9
108.0
105.1 111.0
53
110.92 5.48 (109.6)
476
110.31
77
108.7
202
110.00
5.47 (109.4)
5.47 (109.4)
5.54 (110.8)
1187
107.85
(103.88) (107.63)
(105.14) 103.4
5.4 (108)
104.6 109.44
(109.44) 118.21
111.2
111.2
110.0
296 488
107.8
Mean
378 292
853
105.4
6th year
100.52
102.76
97.93
Large 106 Small 101.6 Total 105.5 f122 m119 120.6
Data collected during OSCE 102.68
Data collected during OSCE
114.95 102.91
Large 98.8 Small 100.00 Totals 99.7
101.4 inc interns
Hojat et al. (2002a,b) f173 Jefferson m198 125 123.1 Hojat et al. (2004) Jefferson Hojat et al. (2009) 227–154 115.5 115.5 109.1 109.1 Jefferson 2002–08 Berg et al. (2011) 176 110.4 (f) Jefferson 2008 106.4 (m) Hojat et al. (2013) 248 113.0/pre-115.2/post-2nd year intervention Jefferson 112.6 controls Chen et al. (2012) 1116 112.97–116.02 Boston Narva´ez et al. (2014) reported data from 1838 respondents in three schools in Columbia and one in the Dominican Republic, with school means ranging from 101.68–107.68 See also Table 1 in Costaet al. (2013)
Results
Discussion
The JSPE-S scores extracted from studies conducted in Japan, South Korea, China, Kuwait, India, Iran, UK, USA, Australia, Brazil, Colombia, the Dominican Republic and Portugal are listed in Table 1 together with the earliest reports from Jefferson College by Hojat et al. (2002a,b, 2004). Some means were reported on the 1–7 Likert scale and were converted by the present researcher to the 20–140 scoring system used by most reports. The means of these studies from a dozen countries outside the USA consistently cluster round 75% out of the possible maximum of 140 unlike the early Jefferson studies (although the later Jefferson means are also 5120).
With the exception of 1st year Japanese students in Kataoka et al.’s (2009) study, 4th year Indian students in Shashikumar et al.’s (2014) study and 6th year Iranian students in Shariat and Habibi’s (2013) study, all the above means (excluding the 2002 and 2004 reports from Jefferson but including later reports from Jefferson) are in the range 100–120/140 or 5/7 on the Likert scale. They are distributed over only 15% (70–85%) of the possible 140 maximum score, predominantly in the range 100–110/140 (71–79%) or ‘‘low 5’’ on the 7-point scale. All the studies except Shashikumar et al.’s (2014) report from India and Shariat and Habibi’s (2013) from Iran show a trend towards incline rather than decline of empathy as
2
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Reconsidering the ‘‘decline’’ of empathy
‘‘measured’’ by the JSPE-S self-report instrument. Shashikumar et al. (2014) note that the ‘‘The curriculum in India differs from western countries in that clinical rotation starts from second year itself and from Korea and Japan in that there is no humanities content in the curriculum’’ (p. 180). They report that ‘‘the female students had no significant decline across various semesters and it was the male students who showed the significant decline in third and seventh semesters’’ (p. 181). Shariat and Habibi (2013) collected data from 17 Iranian medical schools and they comment that while the decreasing trend of empathy took place in both large and small universities it occurred at different times. ‘‘In large universities the erosion of empathy took place in transition from preclinical to clinical training, whereas in the small universities, it happened after some years of clinical training and the beginning of the internship period’’. They suggest that one reason may be that ‘‘interns in large universities almost always work under the supervision of residents, but in small universities, interns should bear the main responsibility of the patients themselves’’ (p. e917). Early clinical exposure occurs at different points in different countries and the 3rd year is different, for example, in a 4 year US curriculum than a 5–6 year UK curriculum; the experience may also be different for ‘‘mature entry’’ students than for ‘‘traditional school leaver entrants’’. Interestingly, in their Kuwaiti study Hasan et al. (2013) report that they ‘‘found a weaker positive correlation between stress levels and empathy scores, indicating that those with higher stress are more empathetic than those with low stress scores’’ (p. 388).
Conclusions The means of these studies from a dozen countries outside the USA consistently cluster round 75% out of the possible maximum of 140 unlike the early Jefferson studies (although the later Jefferson means are also 5120). Hojat et al. (2002a,b) reported a mean JSPE score of 120 for 704 physicians associated with the Jefferson Health System in the greater Philadelphia area. Suh et al. (2012) reported that the mean JSPE score of 229 Korean physicians was 98.2 while Kataoka et al. (2012) reported a mean of 110.4 for 285 female Japanese physicians. Di Lillo et al. (2009) reported a mean JSPE score for 289 Italian physicians of 115.1. These means for practising physicians may indicate different national cultures for the practice of medicine which would be consonant with both different resource bases for health care delivery and different organisational cultures such as Hofstede (1991) mapped in his study of IBM employees around the world. Gaufberg et al. (2010) note that recurring themes in studies of the ‘‘hidden curriculum’’ of medical education include ‘‘the loss of idealism, the prominence of hierarchy, the adoption of a ritualized professional identity, and emotional neutralization’’ (p. 1709). While these may become negative features in medical education and health care delivery, they also have constructive implications. An idealistic (often 520 year old) novice may be over-empathetic – grounded theory research generating items for inclusion in the Dundee Polyprofessionalism Inventory (Proto-Clinical) from two
reference groups of senior UK medical practitioners included both lack of empathy and ‘‘over-empathetic to patients, without regard to health resource restrictions or boundary maintenance’’ (Roff & Dherwani 2011). Formation of medical professional identity requires the ability to establish and maintain boundaries between patient and doctor. It very probably requires a degree of emotional neutralization. As in all professions, there is a hierarchy of competence in the practice of Medicine and this needs to be safeguarded with a degree of organisational hierarchy even at some cost to some learners’ amour propre. There is general agreement – even by Colliver et al. (2010b) – that ‘‘the JSPE is based on an extensive research base and has a solid psychometric foundation – possibly the most researched and widely used instrument in medical education’’ (p. 1813). But are items like ‘‘Physicians should try to think like their patients in order to render better care’’ or ‘‘Physicians should try to stand in their patients’ shoes when providing care to them’’ really sufficiently subtle and nuanced to capture the range of reality in medical practice – for instance being told as a student in the first clinical rotation to hold down a baby being investigated for meningitis while a lumbar puncture is performed; or a 10 year old who has had several lumbar punctures and is screaming his refusal to have another; or a learning-disabled adult? These observations may support Costa et al.’s (2013) contention that ‘‘a latent growth model suggests that empathy of medical students does not decline over time’’ (p. 509) – or at least not significantly. Colliver et al. (2010a) also concluded from their review of student and intern empathy measure reports that ‘‘Reports of the decline of empathy during medical education are greatly exaggerated’’ (p. 588). But in order to understand the maturation process of medical students and trainees we will need to develop more sophisticated, integrated models that combine culturally-sensitive concepts of emotional intelligence and moral reasoning with far more refined understandings of the nature of empathy required for the safe practice of patient-centred medicine.
Notes on contributor SUE ROFF, MA, taught in the Centre for Medical Education, University of Dundee for 20 years and is now a Part-time Tutor there and an Education Consultant.
Declaration of interest: The author has no conflict of interest in relation to this paper.
References Berg K, Majdan JF, Berg D, Veloski J, Hojat M. 2011. Medical students’ selfreported empathy and simulated patients’ assessment of student empathy: An analysis by gender and ethnicity. Acad Med 86(8):984–988. Chen DCR, Kirshenbaum DS, Yan J, Kirshenbaum E, Aseltine RH. 2012. Characterizing changes in student empathy throughout medical school. Med Teac 34:305–311.
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Colliver JA, Conlee MJ, Verhulst SJ, Dorsey JK. 2010a. Reports of the decline of empathy during medical education are greatly exaggerated: A reexamination of the research. Acad Med 85(4):588–593. Colliver JA, Conlee MJ, Verhulst SJ, Dorsey JK. 2010b. Letter to the editor. Acad Med 85(12):1813–1814. Costa P, Magalhaes E, Costa MJ. 2013. A latent growth model suggests that empathy of medical students does not decline over time. Adv Health Sci Educ 18:509–522. Di Lillo M, Cicchetti A, Scalzo A, Taroni F, Hojat, M. 2009. The Jefferson scale of physician empathy: Preliminary psychometrics and group comparisons in Italian physicians. Acad Med 84(9):1198–1202. Gaufberg EH, Batladen M, Sands R, Bell SG. 2010. The hidden curriculum: What can we learn from third-year medical student narrative reflections? Acad Med 85(11):1709–1715. Goncalves-Pereira M, Trancas B, Loureiro J, Papoila A, Caldas-de-Almeida JM. 2013. Empathy as relation to movitations for medicine in a sample of first-year medical students. Psychol Rep 112(1):73–88. Hasan S, Al-Sharqawi N, Dashti F, AbdulAziz M, Abdullah A, Shukkur M, Bouhaimed M, Thalib L. 2013. Level of empathy among medical students in Kuwait University, Kuwait. Med Princ Pract 3(22): 385–389. Hegazi I, Wilson I. 2013. Maintaining empathy in medical school: It is possible. Med Teach 35(12):1002–1008. Hemmerdinger JM, Stoddart SDR, Lilford RJ. 2007. A systematic review of tests of empathy in medicine. BMC Med Educ 7:24. Hofstede G. 1991. Cultures and organizations. UK: McGraw-Hill International Ltd. Hojat M, Axelrod D, Spandorfer J, Mangione S. 2013. Enhancing and sustaining empathy in medical students. Med Teach 35:996–1001. Hojat M, Gonnella JS, Mangione S, Nasca TJ, Veloski JJ, Erdmann JB, Callahan C, Magee M. 2002a. Empathy in medical students as related to clinical competence, gender and academic performance. Med Educ 36: 522–527. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. 2002b. Physician empathy: Definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry 159(9):1563–1569. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, Magee M. 2004. An empirical study of decline in empathy in medical school. Med Educ 38:934–941. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. 2009. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med 84:1182–1191. Hong M, Lee WH, Park JH, Moon TY, Moon DS, Lee SM, Bahn GH. 2013. Changes of empathy in medical college and medical school students: 1-Year follow up study. BMC Med Educ 2012(12):122. Kataoka HU, Koide N, Hojat M, Gonnella S. 2012. Measurement and correlates of empathy among female Japanese physicians. BMC Med Educ 12(8):48. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. 2009. Measurement of empathy among Japanese medical students: Psychometrics and score
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differences by gender and level of medical education. Acad Med 84(9):1192–1197. 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(2):117–124. Magalhaes E, Salgueira AP, Costa P, Costa MJ. 2011. Empathy in senior and first year medical students: A cross-sectional study. BMC Med Educ 11:52. Narva´ez VPD, Palacio LMA, Magister SEC, Silva MG, Castillo JA, Bilbao JL, Acosta JI. 2014. Empathic orientation among medical students from three universities in Barranquilla, Colombia and one university in the Dominican Republic. Arch Argent Pediatr 112(1):41–49. Neumann M, Edelhauser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, Haramati A, Scheffer C. 2011. Empathy decline and its reasons: A systematic review of studies with medical students and residents. Acad Med 86(8):996–1009. Paro HB, Daud-Galloti RM, Tiberio IC, Pinto RM, Martins MA. 2012. Brazilian version of the Jefferson Scale of Empathy; Psychometric properties and factor analysis. BMC Med Educ 12:73. 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(11):e471–e478. Roff S, Dherwani K. 2011. Development of inventory for polyprofessionalism lapses at the proto-professional stage of health professions education together with recommended responses. Med Teach 33(3):239–243. 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(3):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. Shashikumar R, Chaudhary R, Ryali VS, Bhat PS, Srivasatava K, Prakash J, Basannar D. 2014. Cross sectional assessment of empathy among undergraduates from a medical college. Med J Armed Forces India 70(2):179–185. Suh DH, Hong JS, Lee DH, Gonnella JS, Hojat M. 2012. The Jefferson Scale of Physician Empathy: A preliminary psychometric study and group comparisons in Korean physicians. Med Teach 34(6):e464–e468. Tavakol S, Dennick R, Tavakol M. 2011. Empathy in UK medical students: Differences by gender, medical year and specialty interest. Educ Prim Care 22:297–303. Wen D, Ma X, Li H, Liu Z, Xian B, Liu Y. 2013. Empathy in Chinese medical students: Psychometric characteristics and differences by gender and year of medical education. BMC Med Educ 13:130. Williams B, Brown T, Boyle MJ, Palermo C, Nestel D, Brightwell R, McCall L, Russo V. 2014. Empathy levels among health professional students: A cross-sectional study at two universities in Australia. Adv Med Educ Pract 5:107–113.
Reconsidering the ‘‘decline’’ of medical student empathy as reported in studies using the Jefferson Scale of Physician Empathy-Student version (JSPE-S) SUE ROFF University of Dundee and Education Consultant, UK
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Abstract Introduction: The suggestion that empathy ‘‘declines’’ or ‘‘erodes’’ as students progress through medical school has largely rested on observations reported from Jefferson Medical College in the United States using the Jefferson Scale of Physician Empathy (JSPE) developed by Hojat and colleagues. Now that the student version of JSPE has been administered to medical students in more than a dozen countries, it is timely to consider whether or not the Jefferson ‘‘case study’’ and the conclusions drawn from it are generalisable. Methods: A literature research was conducted on MEDLINE in mid-2014 to identify studies reporting administrations of the Student version of JPSE (JSPE-S) to cohorts of medical students and the means for studies and their sub-parts conducted in Japan, South Korea, China, Kuwait, India, Iran, UK, USA, Australia, Brazil, Colombia, the Dominican Republic and Portugal. Results: The means of these studies from a dozen countries outside the USA consistently cluster round 75% out of the possible maximum of 140 unlike the early Jefferson studies (although the later Jefferson means are also 5120). Conclusions: These observations may support Costa et al.’s contention that ‘‘a latent growth model suggests that empathy of medical students does not decline over time’’ (p. 509) – or at least not significantly. But in order to understand the maturation process of medical students and trainees we need to develop more sophisticated, integrated models that combine culturallysensitive concepts of emotional intelligence and moral reasoning with far more refined understandings of the nature of empathy required for the safe practice of patient-centred medicine.
Introduction
Practice points
Neumann et al. (2011) reviewed 18 studies concerning trainee empathy from January 1990 to January 2010. Eleven of these 18 reports were related to medical students and seven to residents. They concluded that ‘‘Three longitudinal and six cross-sectional studies of medical students demonstrated a significant (emphasis added) decrease in empathy during medical education; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency’’. Eight of the 11 student studies were from the USA, as were all the seven resident studies. Four of the student studies used the Jefferson Scale of Physician Empathy-Student (JSPE-S) as did one of the resident studies, although neither the Kataoka et al. (2009) JSPE-S report nor that from Lee et al. (2009) was included.
Methods Hemmerdinger et al. (2007) conducted a systematic review of 36 different instruments to measure empathy of which they
JSPE-S data can be usefully compared to results from more than a dozen countries beyond the initial Jefferson results. We need integrated models combining culturallysensitive concepts of emotional intelligence and moral reasoning with refined understandings of the nature of empathy required for the safe practice of patient-centred medicine to map the process of developing medical student professional identity.
considered (see their Additional File 3) the JSPE to be ‘‘The most heavily researched test and specifically designed from scratch for the assessment of physician empathy’’. A literature research was conducted on MEDLINE in mid2014 to identify studies reporting administrations of the Student version of JSPE (JSPE-S) to cohorts of medical students and the means for various studies and their sub-parts were extracted from them.
Correspondence: Sue Roff, Centre for Medical Education, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, Scotland, UK. Tel: 44 0 1382 381952; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/15/000001–4 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1009022
1
S. Roff
Table 1. JSPE-S means 2009–2014.
Report
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 02/13/15 For personal use only.
Kataoka et al. (2009) Japan Lee et al. (2009) South Korea Roh et al. (2010) South Korea Hong et al. (2013) South Korea MedColl1 MedColl2 MedSch1 MedSch2 Wen et al. (2013) China Rahimi-Madiseh et al. (2010) Iran Hasan et al. (2013) Kuwait Hegazi and Wilson (2013) Australia Williams et al. (2014) Australia Tavakol et al. (2011) UK Magalhaes et al. (2011) Portugal Costa et al. (2013) Portugal Goncalves-Pereira et al. (2013) Portugal Paro et al. (2012) Brazil Shashikumar et al.(2014) India Shariat and Habibi (2013) Iran
N
1st year
2nd year
3rd year
4th year
5th year
98.5 104.7
103.8 108.6
105.0 109.6
102.8
355
5.1 (102)
5.1 (102)
5.0 (100)
5.5 (106)
104.6
113
104.57
107.05
108.52
106.96
113 120 120 753
107.36
108.43 107.79 109.58 109.19
109.31 109.05 110.17 110.5
111.34 111.11 111.24 112.12
108.88 109.23 110.09 109.6
179
106.0
102.0
106.5
105.2
106.0
264 404
100.8
104.3
110.9
108.0
105.1 111.0
53
110.92 5.48 (109.6)
476
110.31
77
108.7
202
110.00
5.47 (109.4)
5.47 (109.4)
5.54 (110.8)
1187
107.85
(103.88) (107.63)
(105.14) 103.4
5.4 (108)
104.6 109.44
(109.44) 118.21
111.2
111.2
110.0
296 488
107.8
Mean
378 292
853
105.4
6th year
100.52
102.76
97.93
Large 106 Small 101.6 Total 105.5 f122 m119 120.6
Data collected during OSCE 102.68
Data collected during OSCE
114.95 102.91
Large 98.8 Small 100.00 Totals 99.7
101.4 inc interns
Hojat et al. (2002a,b) f173 Jefferson m198 125 123.1 Hojat et al. (2004) Jefferson Hojat et al. (2009) 227–154 115.5 115.5 109.1 109.1 Jefferson 2002–08 Berg et al. (2011) 176 110.4 (f) Jefferson 2008 106.4 (m) Hojat et al. (2013) 248 113.0/pre-115.2/post-2nd year intervention Jefferson 112.6 controls Chen et al. (2012) 1116 112.97–116.02 Boston Narva´ez et al. (2014) reported data from 1838 respondents in three schools in Columbia and one in the Dominican Republic, with school means ranging from 101.68–107.68 See also Table 1 in Costaet al. (2013)
Results
Discussion
The JSPE-S scores extracted from studies conducted in Japan, South Korea, China, Kuwait, India, Iran, UK, USA, Australia, Brazil, Colombia, the Dominican Republic and Portugal are listed in Table 1 together with the earliest reports from Jefferson College by Hojat et al. (2002a,b, 2004). Some means were reported on the 1–7 Likert scale and were converted by the present researcher to the 20–140 scoring system used by most reports. The means of these studies from a dozen countries outside the USA consistently cluster round 75% out of the possible maximum of 140 unlike the early Jefferson studies (although the later Jefferson means are also 5120).
With the exception of 1st year Japanese students in Kataoka et al.’s (2009) study, 4th year Indian students in Shashikumar et al.’s (2014) study and 6th year Iranian students in Shariat and Habibi’s (2013) study, all the above means (excluding the 2002 and 2004 reports from Jefferson but including later reports from Jefferson) are in the range 100–120/140 or 5/7 on the Likert scale. They are distributed over only 15% (70–85%) of the possible 140 maximum score, predominantly in the range 100–110/140 (71–79%) or ‘‘low 5’’ on the 7-point scale. All the studies except Shashikumar et al.’s (2014) report from India and Shariat and Habibi’s (2013) from Iran show a trend towards incline rather than decline of empathy as
2
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 02/13/15 For personal use only.
Reconsidering the ‘‘decline’’ of empathy
‘‘measured’’ by the JSPE-S self-report instrument. Shashikumar et al. (2014) note that the ‘‘The curriculum in India differs from western countries in that clinical rotation starts from second year itself and from Korea and Japan in that there is no humanities content in the curriculum’’ (p. 180). They report that ‘‘the female students had no significant decline across various semesters and it was the male students who showed the significant decline in third and seventh semesters’’ (p. 181). Shariat and Habibi (2013) collected data from 17 Iranian medical schools and they comment that while the decreasing trend of empathy took place in both large and small universities it occurred at different times. ‘‘In large universities the erosion of empathy took place in transition from preclinical to clinical training, whereas in the small universities, it happened after some years of clinical training and the beginning of the internship period’’. They suggest that one reason may be that ‘‘interns in large universities almost always work under the supervision of residents, but in small universities, interns should bear the main responsibility of the patients themselves’’ (p. e917). Early clinical exposure occurs at different points in different countries and the 3rd year is different, for example, in a 4 year US curriculum than a 5–6 year UK curriculum; the experience may also be different for ‘‘mature entry’’ students than for ‘‘traditional school leaver entrants’’. Interestingly, in their Kuwaiti study Hasan et al. (2013) report that they ‘‘found a weaker positive correlation between stress levels and empathy scores, indicating that those with higher stress are more empathetic than those with low stress scores’’ (p. 388).
Conclusions The means of these studies from a dozen countries outside the USA consistently cluster round 75% out of the possible maximum of 140 unlike the early Jefferson studies (although the later Jefferson means are also 5120). Hojat et al. (2002a,b) reported a mean JSPE score of 120 for 704 physicians associated with the Jefferson Health System in the greater Philadelphia area. Suh et al. (2012) reported that the mean JSPE score of 229 Korean physicians was 98.2 while Kataoka et al. (2012) reported a mean of 110.4 for 285 female Japanese physicians. Di Lillo et al. (2009) reported a mean JSPE score for 289 Italian physicians of 115.1. These means for practising physicians may indicate different national cultures for the practice of medicine which would be consonant with both different resource bases for health care delivery and different organisational cultures such as Hofstede (1991) mapped in his study of IBM employees around the world. Gaufberg et al. (2010) note that recurring themes in studies of the ‘‘hidden curriculum’’ of medical education include ‘‘the loss of idealism, the prominence of hierarchy, the adoption of a ritualized professional identity, and emotional neutralization’’ (p. 1709). While these may become negative features in medical education and health care delivery, they also have constructive implications. An idealistic (often 520 year old) novice may be over-empathetic – grounded theory research generating items for inclusion in the Dundee Polyprofessionalism Inventory (Proto-Clinical) from two
reference groups of senior UK medical practitioners included both lack of empathy and ‘‘over-empathetic to patients, without regard to health resource restrictions or boundary maintenance’’ (Roff & Dherwani 2011). Formation of medical professional identity requires the ability to establish and maintain boundaries between patient and doctor. It very probably requires a degree of emotional neutralization. As in all professions, there is a hierarchy of competence in the practice of Medicine and this needs to be safeguarded with a degree of organisational hierarchy even at some cost to some learners’ amour propre. There is general agreement – even by Colliver et al. (2010b) – that ‘‘the JSPE is based on an extensive research base and has a solid psychometric foundation – possibly the most researched and widely used instrument in medical education’’ (p. 1813). But are items like ‘‘Physicians should try to think like their patients in order to render better care’’ or ‘‘Physicians should try to stand in their patients’ shoes when providing care to them’’ really sufficiently subtle and nuanced to capture the range of reality in medical practice – for instance being told as a student in the first clinical rotation to hold down a baby being investigated for meningitis while a lumbar puncture is performed; or a 10 year old who has had several lumbar punctures and is screaming his refusal to have another; or a learning-disabled adult? These observations may support Costa et al.’s (2013) contention that ‘‘a latent growth model suggests that empathy of medical students does not decline over time’’ (p. 509) – or at least not significantly. Colliver et al. (2010a) also concluded from their review of student and intern empathy measure reports that ‘‘Reports of the decline of empathy during medical education are greatly exaggerated’’ (p. 588). But in order to understand the maturation process of medical students and trainees we will need to develop more sophisticated, integrated models that combine culturally-sensitive concepts of emotional intelligence and moral reasoning with far more refined understandings of the nature of empathy required for the safe practice of patient-centred medicine.
Notes on contributor SUE ROFF, MA, taught in the Centre for Medical Education, University of Dundee for 20 years and is now a Part-time Tutor there and an Education Consultant.
Declaration of interest: The author has no conflict of interest in relation to this paper.
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