4 Education for Health Volume 26 Issue 1 (April 2013)

Address for correspondence:

Dr. Muneyoshi Aomatsu, Department of Education for Community-Oriented Medicine, Nagoya University Graduate School of Medicine, Nagoya,
Japan 65 Tusurmai-cho, Showa-ku, Nagoya, 466-8550, Japan. E-mail: maomatsu@med.nagoya-u.ac.jp
Medical Students and Residents Conceptual
Structure of Empathy: A Qualitative Study
Muneyoshi Aomatsu
1
, Takashi Otani
2
, Ai Tanaka
1
, Nobutaro Ban
1
, Jan van Dalen
3
1
Department of General Medicine, Faculty of Medicine,
2
Educational Sciences, Graduate School of Education and Human Development,
Nagoya University, Nagoya, Japan,
3
Skillslab, Faculty of Health,
Medicine and Life Science, Maastricht University, Maastricht, The Netherlands
ABSTRACT
Background: Empathy is a crucial component of medicine. However, many studies that have used quantitative methods have revealed
decline of learners empathy during undergraduate and postgraduate medical education. We identifed medical students and residents
conceptual structures of empathy in medicine to examine possible diferences between the groups in how they conceive empathy.
Methods: We conducted a qualitative study with two focus group discussions in which six medical students and seven residents participated
separately. Te transcripts of the focus group discussions were analysed combining qualitative data analysis and theoretical coding. Results:
Medical students and residents had diferent conceptual structures of empathy. While medical students thought that sharing emotions with
patients was essential to showing empathy, residents expressed empathy according to their evaluation of patients physical and mental health
status. If the residents thought that showing empathy was necessary for the care of patients, they could show it, regardless of whether they
shared the patients emotions or not. Conclusions: Te comparison of medical students and residents conceptual structures of empathy
reveals a qualitative diference. Residents show more empathy to their patients by a cognitive decision as clinicians than medical students
do. Communication skills training should consider the qualitative change of students and residents empathy with clinical experience. We
should consider the change when we evaluate learners empathy and introduce methods that cover the qualitative range of empathy.
Keywords: Communication, empathy, medical education, qualitative research
Introduction
The ability of healthcare providers to show empathy to
patients is a principal part of communication skills. Empathy
influences patients outcomes,
[1]
like satisfaction and adherence
to physician advice.
[2,3]
Conveying empathy to patients is also
important in encouraging them to disclose their concerns.
[4,5]
In spite of the importance, a decrease in empathy in medical
Original Research Paper
students and residents during their medical training has
been pointed out.
[6,7]
Other studies have identified positive or
no correlation between students or physicians experiences
and empathy.
[8-11]
Since those studies were cross-sectional,
the findings could be influenced by other factors in the
participants experience. In addition, there is no uniform
definition of empathy, and some studies have identified various
components of empathy. Morse et al. classified components
into four categories: (1) emotive; (2) cognitive; (3) moral and
(4) behavioural.
[12]
The measures used in the previous studies
do not necessarily distinguish the emotive and cognitive
components of empathy.
[13]
Furthermore, some aspects of the
measures used evaluated factors that do not directly relate
to empathy.
[13]
Therefore, it can be fruitful to re-examine the
development of empathy in medical school, using a more
comprehensive understanding of empathy with regard to
its various components. To achieve a fuller understanding of
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Aomatsu, et al.: Conceptual structure of empathy
Education for Health Volume 26 Issue 1 (April 2013) 5
the development of empathy, the interdependency and the
complementarity among the four components need to be
further clarified. The objective of this study was to identify and
compare the comprehensive conceptual structure of medical
students and residents empathy.
Context: Japanese undergraduate medical education consists
of four years of preclinical and two years of clinical education.
Medical students rotate through almost all specialties during
their clinical education. In their preclinical years, students
learn basic clinical skills, such as medical communication
and physical examination, and proficiency of these skills is
evaluated in the Common Achievement Test (CAT) in Year 4.
Students must pass this examination to register in clinical
education, which is composed of skills training and clinical
clerkships. The Department of General Medicine, Nagoya
University Hospital, conducts one and one-half days of medical
communication skills training (including empathy) for Year 5
students during their rotation. The first author (MA) facilitated
a part of the training. A mandatory two-year postgraduate
medical training started in 2004, requiring residents to
rotate in some compulsory and other elective disciplines. The
Nagoya University Hospital conducts one half-day training
for residents as part of their orientation course prior to the
residency program.
Theoretical framework: We use Morses classification
[12]
as a
framework to analyse the development of medical students
and residents empathy during their medical education.
The classification is described as: (1) emotive: The ability to
subjectively experience and share in anothers psychological
state and emotions; (2) moral: An internal altruistic force that
motivates the practice of empathy; (3) cognitive: The intellectual
ability to identify and understand anothers emotions and
perspective from an objective stance and (4) behavioural:
Communicative response to convey understanding of anothers
perspective. Our study was designed to reveal how medical
students and residents understand empathy composed of
several components, and to compare their constructive
components of empathy in different phases of their training.
Methods
Participants: Recruitment of study participants was done
through convenience sampling. Year 5 medical students of
our 6-year curriculum, who had finished skills training and
the clinical clerkship in the Department of General Medicine,
as well as residents of Nagoya University Hospital were asked
by the first author (MA) to participate in the study. The six
medical students were from a class of 106 Year 5 students.
The seven residents were from a cohort of 22 residents. All
residents had graduated from different medical schools. Four
were in their first year of training, while two had graduated
from universities and received a bachelor in social and human
sciences before their entry to medical school. The study was
approved by the Ethical Committee of Nagoya University,
School of Medicine.
Data collection: Qualitative methods were chosen to allow in-
depth exploration of the participants views on the topic of
empathy and its components. Specifically, we used Focus Group
Discussions as a data collection method. Homogeneous focus
groups will not suffer much from a power imbalance between
the researcher and participants.
[14]
Since the researcher was
an attending physician, and consequently higher in rank
and status than the participants, we judged Focus Group
Discussions to be more appropriate than personal interviews
to collect opinions. The interview scheme to guide the focus
group discussions is available from the first author, upon
request.
Two focus group discussions were conducted, with medical
students and residents participating separately. The
participants were initially asked the open-ended question:
What do you think about the role of empathy in clinical
practice?. Based on the responses to this first question, the
moderator (MA) added specific questions to deepen discussion
among the participants. Examples of these questions: What
do you think about the difference of empathy in medical
communication and empathy in communication with your
friends? and How do you feel you have been taught
about empathy in undergraduate medical education?. Each
focus group discussion lasted about 80 minutes. They were
audio- and video-recorded with participants permission. The
facilitator wrote the transcripts of the records immediately
after the recording.
Data analysis: The transcripts were analysed according to
the Steps for Coding and Theorization method (SCAT),
[15]
a
sequential and thematic qualitative data analysis technique.
It consists of steps of coding from open to selective, a story-
line writing using the final selective codes, and writing
theories from the story-line. We chose this approach for its
explicit process of analysis, the characteristic that the process
integrates the qualitative data analysis with the theoretical
coding, and for its efficiency and validity of theorisation from
relatively small scale data. The principal researcher engaged
in each step of the analysis and a co-researcher (AT) read the
transcripts and the results of the analysis as an independent
auditor to assess dependability and confirmability of the
analysis.
[16]
Finally, we identified the conceptual structure of
empathy that medical students and residents reported.
Results
The median age of participating students was 24; three of the
six were female. Among residents, the median age was 27,
with two of the seven being female.
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Aomatsu, et al.: Conceptual structure of empathy
6 Education for Health Volume 26 Issue 1 (April 2013)
Realisation about empathy: Both medical students and residents
considered showing empathy to patients to be important
for good healthcare. They especially valued the emotive
component of empathy, in other words feeling patients
suffering as their own.
I think it may be important to stand in the patients position
without being conscious of my role as a physician (Student
6, 160).
I think it is appropriate to tell a patient that they are not
the only person feeling like that (Resident 3, 102).
Although medical students and residents had similar
realisations, they had different conceptual structures of
empathy conveyed to a patient [Figures 1 and 2].
Difference in conceptual structure of empathy between medical
students and residents: Although both medical students and
residents conceptualisation of empathy demonstrated Morses
four components, their conceptual structures differed. Medical
students thought showing empathy to a patient was important
(moral component), but sharing the patients feeling (emotive
component) was indispensable for actual conveyance of
empathy (behavioural component).
If I can share a patients complaint naturally and understand
the patients situation, then I will show empathy to the patient
(Student 3, 397 and 402).
When medical students could not share a patients feeling,
they tried to compare and find similarity between their past
experiences and the patients current situation for the inference
of the patients feeling (cognitive component). If the students
could infer the patients feeling, they made the inference an
opportunity to share the patients feeling and show empathy.
for example, when a patient experiences sleeplessness
because of abdominal pain, I could say sleeplessness is
actual suffering naturally, imaging my experience that the
abdominal pain restricts my housework and felt inconvenient
(Student 3, 467).
However, medical students reported showing empathy in
objective structured clinical examination (OSCE)-circumstances
regardless of sharing emotions, because they knew that
showing empathy resulted in a higher score.
We formulated rules for medical communication through
communication skills training. According to what a patient
says, I think like This is the moment to show empathy, Lets
ask an open ended question here. These are like a manual or
a game (Student 4, 286).
The higher score, resulting from an empathetic attitude,
without sharing a patients emotion, seemed to be a message
to the students that puts less emphasis on the emotional
component of empathy. As a result, their empathy relying on
the emotional component would be inhibited.
While the moral component was also an important starting
point for the residents empathy, the interrelation among the
four components they reported was different from students
empathy. When showing empathy, residents more frequently
referred to the cognitive component than medical students.
They showed empathy to a patient when they thought it
necessary according to the analysis of the patients illness or
background, regardless of whether they could share feeling
with the patient or not.
When a patient complained of a symptom so much, I
understand that the patient is worried about their illness
being underestimated. Therefore, I empathise with some
exaggeration (Resident 3, 107).
Even if a patient is aggressive, I try to understand the reason
of the behaviour, asking about the past course. Then I think of
the reason (Resident 6, 253).
The residents thought that the progress of their clinical
experience caused insensitivity for patients suffering, therefore
they could not share the patients feelings the way they could
as medical students. Complementing the insensitivity, they
Figure 1: Students Concept of Empathy, Grey arrows indicate the
inuence of each component on the others. A white arrow indicates
the inhibition to show empathy
Figure 2: Residents Concept of Empathy, Grey arrows indicate the
inuence of each component on the others. The width of the arrows
shows the strength of the inuence. A white arrow indicates the
inhibition to show empathy
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Aomatsu, et al.: Conceptual structure of empathy
Education for Health Volume 26 Issue 1 (April 2013) 7
used the cognitive component more frequently.
It is a bad influence of experiencing clinical practice that I
cannot empathise with a patient, although I could empathise to
a similar patient when I just started my postgraduate training
(Resident 3, 111).
Actually, I cannot react to a patients suffering like a medical
student (Resident 5, 130).
Thus, the residents compensated for the decrease in empathy
based on the emotive component by empathy based on the
cognitive component, and the residents reflection about their
daily practices brought the compensation.
I can understand patients anxieties as well as when I was a
student, but I find that I cannot empathise with the patients by
sharing their emotion as a student. So, I want to compensate
for it by saying some words or showing empathetic attitude
to them (Resident 3, 144).
Comparison of medical students and residents: In addition to the
difference in conceptual structures, the residents empathy
was different from the students in the moral component.
Although both the residents and the students recognised
that empathy for a patient was important to healthcare, the
students gave up empathising when they could not share
emotion with a patient.
Although, it is written in a textbook that showing empathy is
important, I think that to show or not to show empathy depends
on the situation. Frankly, I rather think not to show empathy
is better than to show when I feel difficulty (Student 3, 397).
However, the residents recognised conveying empathy to
patients in consideration of their illness or anxiety as one of the
professional roles, even if they themselves felt difficulty. Thus,
the residents had a stronger motivation than the students; in
other words, the residents had a stronger developed moral
component.
Sometimes we meet patients with unreasonable complaints
in our sense, but we should construct therapeutic relationships
as professionals, even with such patients (Resident 5, 215).
Discussion
We examined how medical students and residents report
their understanding of empathy and the differences between
their conceptual structures of empathy. As a theoretical
framework, we adopted Morses classification of components
composing empathy: (1) emotive; (2) cognitive; (3) moral and
(4) behavioural. We found that both groups recognised the
emotive component as an important part of empathy.
However, the importance of the emotive component showed a
relative decrease with the increase of clinical experience, and
empathy based on the cognitive component took on a major
role. The result implies that the decrease of empathy driven
by the emotive component shown in previous studies does
not necessarily mean a decrease in empathy. Moreover, it also
suggests that we underestimate a physicians empathy if we
do not consider the development of the cognitive component
with progress in clinical training. Pedersen
[13]
also suggests
the similar risk of partial assessment of empathy. The medical
students and the residents were not aware of these changes
through their training. The residents especially attributed the
difficulty in showing empathy by the emotive component to
their insensitiveness to patients suffering, and felt guilty.
Thus, ignorance of the change can result in inappropriately
low self-efficacy among students and residents. Since low
self-efficacy can negatively affect future performance,
[17]
we,
as educators, should discuss the changes in empathy with
learners development as healthcare providers in medical
communication skills programs .
Considering factors contributing to the developmental change
of empathy, the developed moral component seems to be a
major factor. Kohlbergs moral developmental stage
[18]
is a
model describing the extent of moral maturity in six stages:
(1) Heteronomous Morality; (2) Individualism, Instrumental
Purpose and Exchange; (3) Mutual Interpersonal Expectations,
Relationships and Interpersonal Conformity; (4) Social System
and Conscience; (5) Social Contract or Utility and Individual
Rights and (6) Universal Ethical Principles. We compared the
moral components of the residents and students against
these stages. The residents moral component (showing
empathy as professional in response to patients requirement)
corresponds to the fifth stage of Social Contract or Utility and
Individual Rights. In contrast, the students moral component
corresponds to the third stage of Mutual Interpersonal
Expectation, Relationships, and Interpersonal Conformity.
Consequently, the residents had developed a stronger moral
component than the students. The developed moral helps the
residents understand patients background and show empathy
to them, even when the residents cannot share the patients
emotion. The participants did not refer to factors fostering the
development of the moral component.
Comparing the backgrounds of students and residents, we
believe that clinical experiences promote the development
in empathy because that is the greatest difference between
the groups. The residents learned the importance of empathy
as a professional, especially through reflection on their
own clinical practices. Therefore, the findings suggest the
importance of reflection in moral development, supporting
Branch
[19]
who states the importance of critical reflection for
moral development.
A limitation of the study is that it uses data collected from a
convenience sample of learners from a single university. The
variety of universities that the residents had graduated from
might reflect differences in undergraduate education about
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Aomatsu, et al.: Conceptual structure of empathy
8 Education for Health Volume 26 Issue 1 (April 2013)
empathy among the universities. More focus groups would
have to be added to analyse the interrelation among the
conceptual structures of empathy, the change of the structures
by clinical experiences and factors affecting the change. Another
limitation is the narrow range of the residents experiences
as physicians. Therefore, focus groups for more experienced
physicians are also necessary to verify a relationship between
physicians experiences and the development of the cognitive
component-centred empathy. However, the present study is
exploratory in nature, attempting to construct a conceptual
framework to establish the structures of empathy of medical
students and physicians. Therefore, further research is required
to investigate whether the models of empathy can be adapted
to other medical students and professionals.
Overall, this study has shown that medical students and
residents concepts about empathy consist of the same four
components. Although both students and residents consider
empathy important in clinical medicine, the structures of the
concepts differ between them. The difference suggests that
empathy of medicals students and residents does not simply
decline but it changes qualitatively in clinical practice. As factors
contributing to the change of empathy, we identify reflection on
clinical behaviours and the development of the moral component.
These results suggest that consideration for not only the
emotive component but also the other three components is
necessary when physicians empathy is assessed, especially in
the case of experienced physicians. The suggestion is consistent
with the conclusions of a previous study that assessment
from various viewpoints is necessary for empathy.
[20]

However, previous studies have revealed a low correlation
between physicians self-assessment and actual clinical
competencies.
[21-23]
Therefore, we have to introduce assessment
from other people, for example patients,
[24]
for a more valid
assessment of physician empathy.
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How to cite this article: Aomatsu M, Otani T, Tanaka A, Ban N, Dalen Jv.
Medical students' and residents' conceptual structure of empathy: A qualitative
study. Educ Health 2013;26:4-8.
Source of Support: Nil. Conict of Interest: No.
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