Maintenance of empathy levels among first and final year medical students: a cross sectional study

Introduction

Carl Rogers, one of the founders of the humanist school of psychology, states that empathy is:

"To sense the patient’s private world as if it were your own but without ever losing the "as if" quality…..to accurately sense the feelings and personal meanings the patient is experiencing and communicating…"¹

Empathy plays a crucial role in the physician-patient therapeutic relationship². Patient satisfaction and their compliance with treatment improve when their physician understands them better³. In a recent survey, patients of physicians who had scored high in empathy, reported better disease control and prognosis, in comparison to patients of physicians with low empathy scores^4,5.

Empathy is as important for medical students as it is for physicians. Interestingly, there seems to be a decline in empathy levels during medical training as reported by Tavakol et al. and Pederson et al^6,7. Of the many reasons given to explain this phenomenon, it was reported that, as they progressed through medical school, a number of medical students were starting to become more cynical about life in academia and the medical profession.

The purpose of this study was to quantify empathy levels amongst medical students in the first and the final year of their medical curriculum at a medical university in Karachi, Pakistan.

Materials and methods

Results

Of the 177 surveys distributed, 171 were completed and returned. The responders represent 88% of the total body of students in first and fifth year of Ziauddin Medical College.

Figure 1 displays the distribution of EQ scores in the two groups. A comparative analysis revealed that the mean scores for fifth year students (40.85 ± 9.833) were almost equivalent to the first year students (40.70 ± 9.497).

Figure 1.Empathy Quotient (EQ) scores in first and final year medical students.

EQ scores were not significantly different between year groups.

Our analysis of the EQ score for first years revealed that 67.7% of the students had class 2 scores while the remaining 19.8% and 12.5% students scored within classes 1 and 3, respectively. Similarly, the majority of fifth years had class 2 scores (73.3%) while the remaining students obtained class 1, 3 and 4 scores (18.7%, 6.7% and 1.3%), respectively. However, a non-significant association was found between the year of study with EQ scores (P=0.401), as shown in Table 2.

We found no association between age and EQ scores (P=0.77).

Table 3 shows the empathy score classification according to gender in both years. According to the data, females had a higher mean score (85%) compared to their male counter parts (75%) when both year groups were combined. These results were also consistent with our findings between sexes within each year group. Female mean scores were 42 ± 9.60 while males were 38.7 ± 9.358 (P=0.03).

Discussion

To the best of our knowledge, our study is one of the first to assess empathy amongst medical students in Pakistan. Our results display novel findings, with adequate empathy levels in both first year and final year medical students. Contrary to various studies, which state that empathy decreases as the level of medical education increases^5,6, in our study students in their final year had adequate empathy levels similar to students in first year. This is in support of results obtained in previous Japanese and Korean studies^13,14. Morling and Lamoreaux¹⁵ have reported that Asians have more ‘collectivistic and less individualistic social cultures’ than Westerners, and a possible parallel can be drawn between our results and those seen in other culturally similar Asian countries such as Japan and Korea.

The empathy scores recorded amongst senior medical students in our study could also be a result of cohort effects. The emphasis placed during medical training o medical ethics, a considerate attitude towards the patient’s wellbeing and a concentration on a patient centered approach may increase empathy. Furthermore, after the second year of medical school, there is constant patient exposure where students are required to learn history-taking skills and regular examinations that build the student’s professional attitude and approach to gaining patient cooperation, factors that may enhance student empathy. Subjects such as behavioral sciences and medical ethics are taught in the third year of medicine; integrating behavioral sciences at the undergraduate levels can help doctors-in-training to have a better understanding of behavioral issues in clinical settings later on¹⁶. Hence, the training obtained throughout medical school may persuade students to implement a sympathetic manner in their interpersonal relationships with patients. It is also worth noting that in Pakistan a great deal of emphasis is placed on apt history taking, focused clinical examinations and particularly minimal lab tests to arrive at a diagnosis. The majority of the population is underprivileged and cannot afford the expense of treatment let alone costly diagnostic tests. Hence, the lack of ‘computer based diagnostic and therapeutic technology’¹⁷ enables physicians and the students shadowing them to rely mainly on good patient interaction and clinical expertise.

In contrast, the literature often shows a positive association of empathy with respect to age. The younger year groups may be less exposed to clinical situations and may hold more idealistic views when starting out in their medical education. Stressors such as academic performance, long work hours^18–26, lack of sleep and subsequent increases in responsibility with age are all contributory factors to a decrease in empathy^12,27,28. It has been suggested by Rosenfield and Jones²⁹ that a high emphasis is placed on the student’s ability to objectively assess the patient and to maintain a professional and neutral approach. This may all contribute to a decrease in empathy with over the course of medical training.

Through our results, it was also found that females are more empathic than males in both year groups, a finding that is consistent with many international studies^30–33.

Women show a greater understanding of the emotional support that the patient may need and generally tend to give a higher significance to developing inter-personal relationships with patients^34–37, whereas men tend to assign greater significance to authority, independence and control³⁸.

Many reasons have been cited for greater empathy levels in females, including the suggestion that women have evolved to be more gentle and compassionate towards their offspring than their male counterparts³⁰, and hence demonstrate better communication skills and a higher level of understanding towards their offspring. A possible connection can be drawn here, as offspring and patients both require care.

There were several limitations to our research. Due to the cross-sectional nature of our study, we were only able to examine empathy levels in year 1 and year 5. It would be of interest to measure how empathy varies each year throughout the five years of medical school using a prospective longitudinal study design. Secondly, it may also be that the candidates own self-perception influences his/her choices while filling out the questionnaires and this may vary from the actual behavior that is implemented in their everyday interactions. Thirdly, our study only focuses on students attending a private medical school in Pakistan. The results cannot be generalized for all medical colleges and a greater coverage of different medical schools and a larger study population are needed to validate our results further. It is also important to note that other characteristics such as cultural backgrounds and specialty preferences can have an impact on empathy levels; previous research has shown that students opting for ‘people oriented specialties’ show higher empathy levels than those who prefer ‘technology oriented specialties’¹⁷.

The strengths of our study include an appropriate sample size, which represents 88% of the sample population. Our research is the first of its kind in Pakistan and assesses multiple variables such as age, gender and year of education.

Recommendations

It would be valuable to carry out a prospective study where students are followed annually from the beginning of first year until graduation, to give a true representation of change in empathy levels. Other variables such as cultural backgrounds and specialty preferences should be noted.

Conclusion

Medicine is a field where interpersonal skills and concern for others are of key importance, for it is a field whose very core is based on service to humanity. It is thus essential that empathy should be nurtured in medical students rather than eroded away with time and clinical exposure. It was surprising to see that a large majority of both first years and fifth years maintained adequate empathy levels despite no significant emphasis placed on the matter throughout the medical curriculum. Gender differences were significant and further research needs to be carried out to determine reasons for this. Our research paves the way for further research to be carried out with Pakistani medical students, which may further justify our results and identify additional influencing variables.