Professional Documents
Culture Documents
Abstract
Purpose
Empathy is a key element of patient
physician communication; it is relevant to
and positively influences patients health.
The authors systematically reviewed the
literature to investigate changes in
trainee empathy and reasons for those
changes during medical school and
residency.
Method
The authors conducted a systematic
search of studies concerning trainee
empathy published from January 1990 to
January 2010, using manual methods
and the PubMed, EMBASE, and PsycINFO
databases. They independently reviewed
and selected quantitative and qualitative
studies for inclusion. Intervention studies,
Results
Eighteen studies met the inclusion
criteria: 11 on medical students and 7 on
residents. Three longitudinal and six
cross-sectional studies of medical
students demonstrated a significant
decrease in empathy during medical
school; 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. The studies
pointed to the clinical practice phase of
Conclusions
The results of the reviewed studies,
especially those with longitudinal data,
suggest that empathy decline during
medical school and residency
compromises striving toward
professionalism and may threaten
health care quality. Theory-based
investigations of the factors that
contribute to empathy decline among
trainees and improvement of the
validity of self-assessment methods are
necessary for further research.
996
Empathy
Table 1
Key Words and Medical Subject Heading (MeSH) Terms Used in Searches of the
PubMed, EMBASE, and PsycINFO Electronic Databases
Key words
Empathy, emotional intelligence
Empathy
Medical
education
Change
.........................................................................................................................................................................................................
.........................................................................................................................................................................................................
Method
Data sources
During June 2009 to February 2010, three
of us (M.N., C.S., D.T.) performed a
systematic review of the literature to
identify original articles reporting
quantitative and qualitative investigations
of the determinants of, development of,
and changes in empathy during medical
school and residency. We searched the
PubMed, EMBASE, and PsycINFO
electronic databases using the National
Library of Medicines Medical Subject
Heading terms empathy, medical
education, and change (see Table 1). We
also conducted a manual search of
reprint files, reference sections of review
articles, and other publications.
Eligible studies were those published
from January 1990 through January 2010
in English with a sample size of 30 or
more. We excluded from our review
intervention studies intended to enhance
empathy because they were recently
analyzed in a review by Stepien and
Baernstein.37 We also excluded studies on
the psychometric qualities of different
empathy measures because such studies
were recently reviewed by Hemmerdinger
et al38 and Pedersen.39
Data extraction
Three of us (M.N., C.S., D.T.) identified
relevant publications from the generated
list by examining publication titles and
abstracts and reading the entire article if
in doubt. We excluded publications that
MeSH terms
Study characteristics
We identified 669 unique studies. Among
those, 18 studies satisfied all inclusion
and no exclusion criteria (see Figure 1).
Eleven investigated empathy during
medical school, and 7 studied empathy
during residency (Appendix 1). Nearly all
of the studies were conducted in the
United States, with the exception of 1
study conducted in Poland40 and 2 in the
United Kingdom.41,42 All 18 studies were
based on standardized questionnaires or
surveys with students and residents and
exclusively used tools for self-assessment
of empathy.
Changes in empathy during medical
school and residency
None of the 18 studies documented
increases in trainees self-assessed
997
Empathy
Studies included*
PubMed
n=438
EMBASE
n=202
Reasons for
exclusion
PsycINFO
n=29
571 Did not apply to
key question
98 Abstracts
reviewed
66 Abstracts excluded
did not apply to key question (n=18)
nursing study (n=15)
intervention study n=33
23 Articles
reviewed
5 Articles excluded
did not apply to key question (n=5)
18 Articles included
in the review
Figure 1 Flowchart showing the study inclusion process. * Empathy, medical education, and
change were used as Medical Subject Heading search terms to conduct the electronic database
searches (see Table 1).
998
Empathy
999
Empathy
Figure 2 Model of reasons contributing to a decline in empathy during medical school and
residency. MS indicates medical student; R, resident; QoL, quality of life.
1000
Empathy
Conclusions
1001
Empathy
1002
17
18
References
1 Simpson M, Buckman R, Stewart M, et al.
Doctorpatient communication: The
Toronto Consensus Statement. BMJ. 1991;
303:13851387.
2 DiBlasi Z, Harkness E, Ernst E, Georgiou A,
Kleijnen J. Influence of context effects on
health outcomes: A systematic review.
Lancet. 2001;357:757762.
3 Stewart MA. Effective physicianpatient
communication and health outcomes: A
review. CMAJ. 1995;152:14231433.
4 Stewart M, Brown JB, Donner A, et al. The
impact of patient-centered care on
outcomes. J Fam Pract. 2000;49:796 804.
5 Griffin SJ, Kinmouth A, Veltman M, Grant J,
Stewart M. Effect on health-related
outcomes of interventions to alter the
interaction between patients and
practitioners: A systematic review of trials.
Ann Fam Med. 2004;2:595608.
6 Mercer SW, Reynolds WJ. Empathy and
quality of care. Br J Gen Pract.
2002;52(suppl):S9 S13.
7 Squier RW. A model of empathic
understanding and adherence to treatment
regimens in practitionerpatient
relationships. Soc Sci Med. 1990;30:
325329.
8 Maguire P, Faulkner A, Booth K, Elliot C,
Hiller V. Helping cancer patients disclose
their concerns. Eur J Cancer Care. 1996;32A:
78 81.
9 Coulehan J, Platt F, Egner B, et al. Let me
see if I have this right : Words that build
empathy. Ann Intern Med. 2001;135:
221227.
10 Beckman HB, Frankel RM. Training
practitioners to communicate effectively in
cancer care: It is the relationship that
counts. Patient Educ Couns. 2003;50:8589.
11 Neumann M, Wirtz M, Bollschweiler E,
Warm M, Wolf J, Pfaff H. Psychometric
evaluation of the German version of the
Consultation and Relational Empathy
(CARE) measure at the example of cancer
patients [in German]. Psychother
Psychosom Med Psychol. 2008;58:515.
12 Larson EB, Yao Y. Clinical empathy as
emotional labor in the patientphysician
relationship. JAMA. 2005;293:1100 1106.
13 Halpern J. From Detached Concern to
Empathy: Humanizing Medical Practice.
Oxford, UK: Oxford University Press; 2001.
14 Irving P, Dickson D. Empathy: Towards a
conceptual framework for health
professionals. Int J Health Care Qual Assur
Inc Leadersh Health Serv. 2004;17:212220.
15 Neumann M, Wirtz M, Bollschweiler E, et
al. Determinants and patient-reported longterm outcomes of physician empathy in
oncology: A structural equation modelling
approach. Patient Educ Couns. 2007;69:
6375.
16 Kim SS, Kaplowitz S, Johnston MV. The
effects of physician empathy on patient
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Empathy
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
1003
Empathy
81 Edwards PJ, Roberts IG, Clarke MJ, et al.
Methods to increase response rates to
postal questionnaires. Cochrane Database
Syst Rev. 2009;1:DOI: 10.1002/14651858.
MR000008.pub3.
82 McColl E, Jacoby A, Thomas L, et al. Design
and use of questionnaires: A review of best
practice applicable to surveys of health
service staff and patients. Health Technol
Assess. 2001;5:31.
83 Steins G. A diagnostic analysis of empathy
and perspective taking: A validation of the
relationship between both constructs and
implications for measurement [in German].
Diagnostica. 1998;44:117129.
84 Nezu AM, Nezu CM. Evidence-Based
Outcome Research: A Practical Guide to
Conducting Randomized Controlled Trials
for Psychosocial Interventions. New York,
NY: Oxford University Press; 2008.
85 Hojat M, Gonnella J, Nasca T, Mangione S,
Vergare M, Magee M. Physician empathy:
Definition, components, measurement, and
relationship to gender and specialty. Am J
Psychiatry. 2002;159:15631569.
86 Hojat M, Gonnella JS, Mangione S, Nasca
TJ, Magee M. Physician empathy in medical
education and practice: Experience with the
Jefferson Scale of Physician Empathy. Semin
Integr Med. 2003;1:2541.
87 Hojat M, Mangione S, Nasca T, Gonnella J.
Empathy scores in medical school and
ratings of empathic behavior in residency
training 3 years later. J Soc Psychol. 2005;
145:663672.
88 Glaser KM, Markham FW, Adler HM,
McManus RP, Hojat M. Relationships
between scores on the Jefferson Scale of
Physician Empathy, patient perceptions of
physician empathy and humanistic
approaches to patient care: A validity study.
Med Sci Monit. 2007;13:CR291CR294.
89 Chen DC, Pahilan ME, Orlander J.
Comparing a self-administered measure of
empathy with observed behavior among
medical students. J Gen Intern Med. 2010;
25:200 202.
90 Kanning UP. Development and validation of
a German-language version of the
Interpersonal Competence Questionnaire
(ICQ). Eur J Psychol Assess. 2006;22:4351.
91 Aukes LC, Geertsma J, Cohen-Schotanus J,
Zwierstra RP, Slaets J. The development of a
scale to measure personal reflection in
1004
92
93
94
95
96
97
98
99
100
101
102
103
104
Country,
city/state
Study objective*
Study design
Sample size
(response rate)
Scales
Results*
Comments on study
quality
Investigation on empathy
and EI; association
between empathy, EI,
and academic success;
gender research on
empathy and EI
JSPE-S, EI
Single-institution survey
Imbalance between men (n
85) and women (n 188) in
the sample
Cross-sectional survey
of medical students
before medical school
entry and after years
1, 2, 3, and 4
658 (91%)
JSPE-S
USA, Illinois
Investigation on empathy,
spirituality, well-being,
and tolerance, while
taking gender and age
into consideration
Cross-sectional survey
of medical students
before medical school
entry and during years
1, 2, and 4; also
surveyed residents,
faculty physicians, and
alumni
USA,
Philadelphia
Investigation on empathy
and its association with
exam results
Longitudinal survey of
medical students at
the beginning of year
3 and on completion
of year 3
125 (56%)
JSPE-S
......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
Medical students
Author(s), date
published
Appendix 1
Empathy
1005
1006
USA,
Philadelphia
Country,
city/state
Investigation on empathy
Study objective*
Sample size
(response rate)
Study design
JSPE-S
Scales
Comments on study
quality
Results*
Poland
Investigation on empathy
Cross-sectional survey
of first-year and finalyear medical students
BEES, IRI
Single-institution survey
Report was brief and did not
provide detailed statistics
USA,
Arkansas
BEES
Single-institution survey
Newton et al,
200846
USA,
Arkansas
419 (78.3%)
BEES
......................................................................................................................................................................................................................................................................................................................................................................................................................
Newton et al,
200050
......................................................................................................................................................................................................................................................................................................................................................................................................................
Kliszcz et al,
199840
......................................................................................................................................................................................................................................................................................................................................................................................................................
Author(s), date
published
Appendix 1, continued
Empathy
USA,
Kentucky
Stratton et al,
200849
Study design
Investigation on
Cross-sectional survey
progressive changes in EI, of medical students
empathy, and distress
during years 1 and 3
Study objective*
64 (68.8%)
Sample size
(response rate)
IRI, TMMS
(EI)
Scales
Comments on study
quality
Results*
USA,
Minnesota
Influence of stress
(professional and private)
and well-being on
empathy
IRI, MBI,
QoL,
depression
(2 items)
UK, London
Association between EI
and students age,
gender, ethnicity, and
stage of study
Cross-sectional survey
of medical students in
all years
263 (12.3%)
EI
Association between
mood and empathy
Longitudinal survey of
internal medicine
residents: 4
measurement time
frames over the course
of one year
60 (by
measurement
period: 1 98%,
2 72%, 3
79%, 4 79%)
IRI, POMS
(mood)
(Appendix continues)
Single-institution survey
......................................................................................................................................................................................................................................................................................................................................................................................................................
Residents
Todres et al,
201042
......................................................................................................................................................................................................................................................................................................................................................................................................................
Thomas et al,
200747
......................................................................................................................................................................................................................................................................................................................................................................................................................
Country,
city/state
Author(s), date
published
Appendix 1, continued
Empathy
1007
1008
USA,
Philadelphia
Association between
mood and empathy
Study objective*
Longitudinal survey of
residents: 6
measurement time
frames across 3 years
Study design
Comments on study
quality
Results*
Scales
60 (by
IRI, POMS
measurement
(mood)
period: 1 98%,
2 72%, 3
79%, 4 79%,
5 94%, 6 95%)
Sample size
(response rate)
USA,
Philadelphia
Investigation on empathy
Cross-sectional and
longitudinal survey of
residents from 3 age
groups
47 (80%)
Sleep
disturbance
(Epworth
Sleepiness
Scale),
depression
(BDI), IRI,
MBI
Single-institution survey
Sample size was relatively
small
USA,
Rochester,
Minn
Association between
empathy and personal
well-being
Cross-sectional survey
of one cohort of
internal medicine
residents
83 (50%)
QoL, IRI,
wellness
promotion
strategies,
worklife
balance
Single-institution survey
Small sample size for
comparing residents with high
(n 19) or low (n 64) levels
of mental well-being
USA,
Rochester,
Minn
Association between
subjectively perceived
medical errors and QoL,
burnout, depression, and
empathy
Longitudinal survey of
residents: every 3
months across 3 years
(Mayo Internal
Medicine Well-Being
Study)
184 (84%)
Selfperceived
medical
errors, QoL,
MBI,
depression,
IRI
(Appendix continues)
Single-institution study
......................................................................................................................................................................................................................................................................................................................................................................................................................
Shanafelt et al,
200557
......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
Mangione et al,
200256
......................................................................................................................................................................................................................................................................................................................................................................................................................
Country,
city/state
Author(s), date
published
Appendix 1, continued
Empathy
USA,
Rochester,
Minn
Country,
city/state
Association between
medical knowledge and
empathy
Study objective*
Sample size
(response rate)
Study design
BEES indicates Balanced Emotional Empathy Scale (self-assessed empathy); BDI, Beck Depression Inventory; EI,
Emotional Intelligence Scale; ESWIM, Empathy, Spirituality, and Wellness in Medicine Scale; IRI, Interpersonal
Reactivity Index (self-assessed empathy); ITE, Internal Medicine In-Training Examination (medical knowledge
measure); JSPE-S, Jefferson Scale for Physician EmpathyStudent Version (relevance of empathy in the physician
patient relationship); MBI, Maslach Burnout Inventory; POMS, Profile of Mood States (mood measure: tension/
anxiety, depression/dejection, fatigue/inertia, confusion/bewilderment, vigor/activity, anger/hostility); QoL,
Quality of Life (various measuring tools); TMMS, Trait Meta-Mood Scale (emotional intelligence measure).
Author(s), date
published
Appendix 1, continued
Results*
ITE
ITE scores increased between years
(medical
1 and 2
knowledge), Progressive decline in empathy
IRI
No connection between medical
knowledge and empathy
Scales
Single-institution survey
Sample size was relatively small
Comments on study
quality
Empathy
1009