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Empathy in medical students as related to specialty interest, personality, and perceptions of mother and father
Personality and Individual Differences 39 (2005) 1205–1215 www.elsevier.com/locate/paid
Empathy in medical students as related to specialty interest, personality, and perceptions of mother and father Mohammadreza Hojat a,*, Marvin Zuckerman a,b, Mike Magee c, Salvatore Mangione a, Thomas Nasca a, Michael Vergare a, Joseph S. Gonnella a
a
Jefferson Medical College of Thomas Jefferson University, Center for Research in Medical Education and Health Care, 1025 Walnut Street, Philadelphia, PA 19107, USA b University of Delaware, Newark, DE 19716, USA c Pfizer, Inc. New York, NY 10017, USA Received 27 January 2004; received in revised form 1 April 2005; accepted 18 April 2005 Available online 1 July 2005
Abstract This study was designed to examine relationships between empathy, specialty interest, personality and perceptions of mother and father. Participants were 422 first-year medical students who completed the Jefferson Scale of Physician Empathy (JSPE), and the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ, short form). They also reported their specialty interest and their perceptions of early relationships with their parents. Results showed that women outscored men on the empathy scale. Also, we found that higher scores on the JSPE were associated with studentsÕ interest in people-oriented specialties (as opposed to procedure- and technology-oriented specialties), higher level of satisfaction with early maternal relationship, higher sociability and lower aggressive-hostility scores. Controlling for gender and social desirability did not change the general pattern of findings. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: Empathy; Specialty; Personality; Mother; Father
*
Corresponding author. Tel.: +1 215 955 9459; fax: +1 215 923 6939. E-mail address: mohammadreza.hojat@jefferson.edu (M. Hojat).
0191-8869/$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2005.04.007
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1. Introduction Although empathy has been discussed as an important element in therapeutic relationships in psychoanalysis and psychotherapy, empirical research on empathy in the patient care environment is scarce due to the ambiguity in conceptualization and definition of the term (Price & Archbold, 1997; Stephan & Finlay, 1999; Thornton & Thornton, 1995) as well as an absence of a psychometrically sound instrument specific for measuring empathy among medical students and physicians (Evans, Stanley, & Burrows, 1993; Kunyk & Olson, 2001). There are several research tools for measuring empathy in the general population (e.g., HoganÕs empathy scale, (Hogan, 1969) DavisÕs Interpersonal Reactivity Index, IRI, (Davis, 1983), and Mehrabian and EpsteinÕs emotional empathy (Mehrabian & Epstein, 1972)) and among nurses that we described elsewhere (Fields et al., 2004; Hojat, Gonnella, Mangione, Nasca, & Magee, 2003). None of these tools was specifically developed to measure empathy among medical students or physicians and, therefore, may not capture the essence of an empathic relationship in patient care situations. In recognition of a need for an operational measure of empathy among medical students and physicians in patient care situations, our research team developed the Jefferson Scale of Physician Empathy (Hojat et al., 2003, 2002c, 2001b) which will be described later. Empathy in patient care is defined as: ‘‘a cognitive attribute that involves an ability to understand the patientÕs inner experiences and perspective and a capability to communicate this understanding.’’ (Hojat et al., 2002c, p. 1564). Empathy can be linked to other variables such as gender, personality measures, early experiences with parents and the family environment, and later socialeducational experiences. The gender differences in favor of women, in perception of emotions (Brown & Dunn, 1996) and in empathic understanding (Litvack-Miller, McDougall, & Romney, 1997) have been observed in children and adults alike (Eisenberg & Strayer, 1987; Hojat et al., 2002a, 2002b, 2001b). Many developmental scholars have proposed that the quality of early relationships with parents is a significant factor in the development of a capability for interpersonal relationships. In the studies of early interpersonal relationships, and particularly in the original formulation of attachment theory (Bowlby, 1982) the emphasis was placed on relationships with the mother who is usually a primary caregiver in all primate species. The role of the father in the majority of these studies has been overlooked (Hojat, 1998). Some empirical data provide a reason for the greater emphasis placed on maternal over paternal roles in the developmental research. Collins and Read (1990) found that perceptions of the warm caregiving style of the mother were significantly correlated with higher self-esteem, better social adjustment, and more trust and altruism but such associations were not found for fathers. In a more recent study with medical students, it was found that perception of positive early relationships with the mother was a predictor of personality attributes such as higher self-esteem, more satisfactory peer-relationships, less loneliness, less depression, less anxiety, and more resiliency in dealing with stressful life events, but such associations were not found for perceptions of early relationships with the father (Hojat, 1998). In another study with physicians in residency training (Hojat, Glaser, & Veloski, 1996), a significant link was found between perceptions of early relationships with the mother and the clinical competence area of interpersonal relations and attitudes but such was not found with perceptions of early relationships with the father.
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Empathy is a personal attribute that is relevant to interpersonal relationships. Therefore, significant correlations between empathy scores and personality measures of human relationships are expected. For example, one would expect a positive link between empathy and personality factors that promote interpersonal relationships such as sociability and general activity. Conversely, negative links between empathy and personality traits that hamper interpersonal relationships such as aggression, hostility, neuroticism, and impulsiveness would be expected. A number of factors contribute to medical studentsÕ choice of specialty. For example, role models, market forces, societal demands, influence by family, friends and others, educational experiences, and personal qualities can contribute individually or interactively to the choice. It is common in medical education research to classify specialties into ‘‘people-oriented’’ (e.g., primary care specialties such as family medicine, general internal medicine, general pediatrics), ‘‘technology-oriented’’ (e.g., pathology, radiology, anesthesiology) or ‘‘procedure-oriented’’ (e.g., surgery and surgical subspecialties) (Hojat et al., 2002b, 2002c, 2001a; Lieu, Schroeder, & Altman, 1989) It would be reasonable to expect that those who are attracted to the ‘‘people-oriented’’ specialties would be more interpersonally oriented than those who are attracted to ‘‘technology’’ or ‘‘procedure-oriented’’ specialties. 1.1. Purpose This study, approved by the Institutional Review Board, was designed to test the following four research hypotheses involving the empathy scale used in this study: 1. Women would outscore men on empathy. 2. Medical students who are interested in pursuing people-oriented specialties would score higher on empathy than their classmates who are interested in the procedure-oriented or technology-oriented specialties. 3. Students who perceive a high level of satisfaction with early maternal relationships would score higher on empathy than those with lower levels of satisfaction, but no relationships between empathy and perceived paternal relationships would be found. 4. Empathy scores will be positively related to measures of sociability and activity, and negatively to measures of impulsive sensation seeking, aggression-hostility, and neuroticism.
2. Method 2.1. Participants Study participants were 422 first-year students (in 2002 and 2003) at a private medical school in Philadelphia, Pennsylvania, USA, representing 95% of all entering classes in that time period. There were 215 men (51%) and 207 (49%) women in the study sample, who voluntarily completed the survey in the orientation day.
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2.2. Instruments The following research instruments were used in this study. 2.2.1. The Jefferson Scale of Physician Empathy (JSPE) This scale was developed to measure empathy among medical students and physicians. The JSPE was constructed based on an extensive review of the literature, followed by pilot studies with samples of medical students, residents, practicing physicians and nurses. Both qualitative (Delphi technique) and quantitative (psychometrics) methods were used in the development and refinement of the JSPE (Hojat et al., 2002c, 2001b). The JSPE includes 20 items answered on a 7-point Likert-type scale (1 = Strongly Disagree, 7 = Strongly Agree). Psychometric evidence in support of the construct validity was reported (Hojat et al., 2002c, 2001b). The scale contains three factors of ‘‘perspective taking’’, ‘‘compassionate care’’, and ‘‘standing in the patientÕs shoes’’ that were determined by factor analysis. Also, criterionrelated validity (convergent and discriminant), internal consistency reliability (coefficient of alpha in the 0.80 s), and test-retest reliability (r = 0.65 with 3–4 month interval between test) of the scale have been reported (Hojat et al., 2003, 2002c, 2001b). The JSPE scores can range from a minimum of 20 to a maximum of 140. The higher the score, the more empathic a personÕs orientation. Two versions of the JSPE are available. One which was used in this study is the studentÕs version (S-Version) developed for measuring studentsÕ orientation toward empathetic relationships with patients. A sample item is: ‘‘Physicians should try to stand in their patientÕs shoes when providing care to them.’’ Another slightly modified version was developed for practicing health professionals (HP-Version) to measure their empathy in actual patient care situations (Hojat et al., 2003, 2002c). (Copies of both versions are available from the authors.) 2.2.2. The Zuckerman–Kuhlman personality questionnaire—short form (ZKPQ-S) This personality questionnaire was developed to measure basic factors of personality or temperament that have a strong biological-evolutionary basis (Zuckerman, 2002). There are five personality scales in this questionnaire: (1) Impulsive Sensation Seeking (ImpSS), described as a tendency to act quickly on impulse without thinking, often in response to a need for thrills and excitement. (2) Neuroticism-Anxiety (N-Anx), described as a tendency to be tense and become easily upset. (3) Aggression-Hostility (Agg-Host), described as a tendency to express verbal aggression, and show rudeness, thoughtlessness, vengefulness, spitefulness, a quick temper and impatient behavior. (4) Sociability (SY), described as a tendency to interact with others, enjoying being with others and intolerance for social isolation. (5) Activity (Act), described as a tendency to be active, to prefer challenging work, and impatience or restlessness when there is nothing to do. In addition, there is another scale called ‘‘Infrequency’’ in the ZKPQ that was developed to detect intentionally false answers by identifying subjects making responses unlikely to be true. This scale is intended only to screen out invalid test records and can be considered as an indicator of social desirability tendency. 2.2.3. Specialty interest survey StudentsÕ specialty interest was determined by asking them to choose one of the four groups of physician–patient encounters that matched their interest. The groups were as follow: (A) Proce-
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dure-oriented specialties defined as performing specialized diagnostic procedures or basic applied laboratory research and major contact with colleagues not patients, primarily hospital based (e.g., radiology, pathology). (B) Technology-oriented specialties defined as performing highly skilled and specialized therapeutic techniques or procedures, serving as an expert consultant, primarily hospital based with some office activities (e.g., orthopedic surgery, neurosurgery, ophthalmology). (C) Non-primary care specialties defined as providing episodic or long-term care of a certain and limited number of medical problems and a mix of ambulatory and hospital-based practice (e.g., cardiology, gastroenterology, dermatology, emergence medicine, psychiatry, obstetrics/gynecology). (D) Primary care or ‘‘people-oriented’’ specialties defined as providing first encounter health/illness appraisal and preventative education and intervention, episodic and long-term comprehensive care of a wide variety of medical conditions, primarily office-based (e.g., family medicine, general internal medicine, general pediatrics). 2.2.4. Perceptions of satisfaction with relationships with parents questionnaire Perceptions of early relationships with the mother were estimated by calculating an index based on responses to the following three items: (1) To the best of your knowledge, as a child when you had personal problems you went to your mother. (2) To the best of your memory, as a child your mother understood you. (3) To the best of your knowledge, as a child your mother devoted sufficient time to you. Each item was answered on a 4-point Likert-type scale (1 = Strongly Disagree, 4 = Strongly Agree). Perceptions of relationships with the father were calculated by replacing the word mother with father in each of the three aforementioned items. The alpha reliability for the measure of perceptions of relationships with the mother was 0.95, and for relationships with the father was 0.89 among medical students (Hojat, 1996). These items were developed to give an estimate of perceived parental sensitivity (Moran, Pederson, Pettit, & Krupka, 1992). In particular, the items were intended to measure perceptions of parents as secure bases for the child in trouble (item 1); parentsÕ empathic concern and social-emotional closeness (item 2); and parentsÕ attentiveness, involvement and devotion (item 3) (Hojat, Borenstein, & Shapurian, 1990). A higher index indicates a more favorable perception of the parent.
3. Statistical analyses For gender comparison, the t-test (one-tailed) was used, and for comparing empathy scores of students with different specialty interest, analysis of variance (ANOVA) was used, followed by the Duncan post hoc multiple comparisons. The distribution of the indices of perceptions of the mother and the father were extremely skewed toward higher scores. When distributions are extremely skewed, the correlations cannot attain their maximal values, and the true relationship among variables cannot be captured (Carrol, 1961). Therefore, instead of correlational analysis, we classified the sample into three groups based on the indices of perceived relationships with the mother and separately with the father. The ANOVA was used to compare empathy scores among those with high (approximately one standard deviation above the mean), moderate, or low (approximately one standard deviation below the mean) on the index of relationships with the parent.
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4. Results Prior to statistical analyses, we examined the distribution of the ‘‘Infrequency’’ scale of the ZKPQ to detect the proportion of students who gave invalid responses to the questionnaire. Data for the students (n = 22, 4.9% of the total sample) who scored greater than 3 on this scale were discarded from statistical analyses for the questionable validity of their record, or for carelessly responding to the questionnaire without regard to truth (Zuckerman, 2002). The means, standard deviations of the empathy scores and summary results of statistical analyses for the remaining sample in different comparison groups are reported in Table 1. 4.1. Gender comparison As shown in the table, women scored significantly higher on empathy than men (t(420) = 4.58, p < 0.01). The effect size estimate for the gender difference was 0.43 (Cohen, 1987). This finding confirmed the first hypothesis predicting higher empathy among women than men. 4.2. Specialty interest Results reported in Table 1 indicate that students who were interested in pursuing their future medical practice in ‘‘people-oriented’’ (primary care) (n = 104, 64% women) specialties obtained
Table 1 Comparisons of the Jefferson Scale of Physician Empathy scores for first-year medical students Groups
N
M
SD
p
Group differences
Gender A: Men B: Women
215 207
111.6 115.9
10.4 8.9
<0.01a
B>A
Specialty interest A: Procedure Oriented B: Technology Oriented C: Non-primary Care D: Primary Care
34 127 148 104
108.4 112.0 114.4 116.6
10.1 10.3 9.9 8.6
<0.01b
D>B>A
Level of satisfaction with mother A: High 111 B: Moderate 219 C: Low 90
116.2 112.3 114.3
9.7 9.3 11.4
<0.01b
A>C=B
Level of satisfaction with father A: High B: Moderate C: Low
113.8 113.6 113.9
11.5 9.0 10.5
NSb
A=B=C
98 212 110
N = Number of students; M = Mean; SD = Standard deviation; NS = Non-significant. a By one-tail t-test. b By analysis of variance.
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the highest empathy mean score. The differences were statistically significant (F(409,3) = 7.93, p < 0.01). The DuncanÕs post hoc mean comparison test indicated that the empathy mean score for the students who were interested in ‘‘people-oriented’’ specialties was significantly greater than other students who were interested in either ‘‘procedure-’’ (n = 34, 44% women) or ‘‘technologyoriented’’ (n = 127, 32% women) specialties. The effect size estimate for mean differences between groups interested in primary care and ‘‘procedure-oriented’’ specialties was 0.81. This is a large effect size confirming that the obtained difference is not only statistically significant, but it is also practically (clinically) important (Cohen, 1987; Hojat & Xu, 2004). The effect size estimate for mean difference between students interested in primary care and technology-oriented specialties was moderate (0.46). These findings confirm our second hypothesis of greater empathy scores in those who are interested in ‘‘people-oriented’’ specialties compared to others. 4.2.1. Controlling for gender effect The proportion of women interest in technology-oriented specialties (32%) was half of the percentage of women (64%) who were interested in the primary care specialties. The differences in proportions of women in the aforementioned specialties were statistically significant (v2ð3Þ ¼ 25.23, p < 0.01). Because of the significant gender differences we found in empathy scores and the disproportionate gender composition among students who were interested in different specialties, we statistically controlled the effect of gender using analysis of covariance (ANCOVA) in which gender was considered as the covariate. No significant changes in patterns of previous findings were observed (adjusted F(408,4) = 5.71, p < 0.01). Therefore, gender had no influence on the pattern of findings. 4.2.2. Satisfaction with parents As shown in Table 1, the differences in empathy scores among the three groups with different levels of satisfaction with their mothers were statistically significant (F(417,2) = 5.88, p < 0.01). Those who were highly satisfied with their childhood relationships with their mother obtained a significantly higher empathy mean score than the rest of their classmates, although the effect size estimates of the differences were not large (<0.30). The statistically significant differences confirmed the third research hypothesis concerning a positive association between a higher level of satisfaction with early relationships with the mother and empathy scores. In additional analysis we used ANCOVA to control for gender effect on the pattern of the findings reported in Table 1, and found no significant change of results (adjusted F(416,3) = 5.13, p < 0.01). Satisfaction with paternal relationships was not associated with empathy scores. These findings confirm the third research hypothesis. 4.2.3. Empathy and personality measures We correlated scores of the JSPE with the five personality scales of the ZKPQ. Significant correlations of low magnitudes were found between empathy and Sociability (r = 0.15, p < 0.01) and Aggression-Hostility scores (r = 0.13, p < 0.01). No significant correlations were found between empathy and the other three ZKPQ scales. These findings weakly support the fourth research hypothesis concerning relationships between empathy and personality measures.
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5. Discussion The findings of this study generally suggest that empathy among medical students is a function of gender, and early relations with the mother. These findings are limited to one medical school, and more research is needed to assure the generalization of these findings with a more representative sample of medical students from different schools. The results are also consistent with our previous findings (Hojat et al., 2002a, 2002b, 2001b), and with findings reported by other researchers (Davis, 1983; Eisenberg & Lennon, 1983; Hogan, 1969; Jose, 1989). The findings are in agreement with other studies regarding primary care physiciansÕ patient-oriented approach, (Batenburg, Smal, Lodder, & de Melker, 1999; Truax, Altmann, & Millis, 1974) and empathy (Newton et al., 2000). The findings concerning significant differences in empathy among medical students with different career interests are important in addressing the issue raised in one of our previous studies (Hojat et al., 2002c) in which we found a significant difference in empathy scores among physicians who were practicing psychiatry, general internal medicine, emergency medicine, and family medicine and general pediatrics, compared to physicians in anesthesiology, orthopedic surgery, neurosurgery, and radiology. In that study we speculated that the observed differences in empathy scores among those physicians could be explained by two reasons. First, the differences could be a reflection of physiciansÕ personality and interpersonal orientation developed prior to medical school that prompted them to pursue a specialty that requires a close interpersonal relationship with the patients (e.g., ‘‘people-oriented’’ specialties). Second, differences could be a result of training during medical education. For example, in some medical school clerkships, in particular residency training programs (internal medicine, family medicine, pediatrics) more emphasis is placed on interpersonal skill training and patient–physician relationships, and therefore, more empathic orientations could be expected to develop among those exposed to interpersonal skills development education. The findings of this study suggest that the first speculation can be feasible, although this study does not provide evidence that the second speculation or the combined effect of both should be rejected. The findings that perceptions of early relationships with the mother in childhood, compared to those with the father, have a more significant link to a an indicator of pro-social behavior are consistent with the tenet of the attachment theory (Ainsworth, 1985a, 1985b; Bowlby, 1982, 1988) and with previous research findings (Baydar & Brooks-Gunn, 1991; Collins & Read, 1990; Henwood & Solano, 1994; Hojat, 1998; Hojat et al., 1996; Rothbaum & Weisz, 1994). According to Zuckerman (2002) the scales of the ZKPQ were developed to reflect personality traits that have strong biological-evolutionary basis. Although empathy may have some evolutionary (Page & Novak, 2002; Preston & de Waal, 2002), biological (Brothers, 1989; Wolf, Gales, & Shane, 2001), and heritability components (Matthews, Batson, Horn, & Rosenman, 1981; Rushton, Fulker, Neale, Nias, & Eysenck, 1986) a developmental view of empathy suggests that empathy could also be based on early life experiences with primary care givers (Fonagy, 2001; Laible & Thompson, 1998). Therefore, a strong link between empathy in health care environment and stable biologically-based personality traits may not be expected. According to the American Board of Internal Medicine (ABIM) the ‘‘public has the right to expect humanistic behavior in its physicians’’ (ABIM, 1983). Therefore, evaluation of physiciansÕ humanistic qualities, including empathy, is recommended by medical professional organizations.
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Also, the Association of American Medical Colleges (AAMC) has included the development of empathy among the educational objectives of medical schools (for the Web address contact the author, MH). These recommendations combined with our previous research findings indicate that medical studentsÕ empathy scores were significantly associated with the facultyÕs evaluations of studentsÕ clinical competence in core clerkships (Hojat et al., 2002a) suggest that attention to measuring and improving empathy during medical education by offering targeted programs is important for enhancing clinical skills. Findings of the present study that the degree of empathy at the beginning of medical education is significantly associated with specialty preference can have implications for predicting the likelihood of future career choice of medical students.
Acknowledgments This study was supported in part by a grant from Pfizer Medical Humanities Initiative, Pfizer, Inc. New York. The authors thank Dorissa Bolinski for her editorial assistance.
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Empathy in medical students as related to specialty interest, personality, and perceptions of mother and father Mohammadreza Hojat a,*, Marvin Zuckerman a,b, Mike Magee c, Salvatore Mangione a, Thomas Nasca a, Michael Vergare a, Joseph S. Gonnella a
a
Jefferson Medical College of Thomas Jefferson University, Center for Research in Medical Education and Health Care, 1025 Walnut Street, Philadelphia, PA 19107, USA b University of Delaware, Newark, DE 19716, USA c Pfizer, Inc. New York, NY 10017, USA Received 27 January 2004; received in revised form 1 April 2005; accepted 18 April 2005 Available online 1 July 2005
Abstract This study was designed to examine relationships between empathy, specialty interest, personality and perceptions of mother and father. Participants were 422 first-year medical students who completed the Jefferson Scale of Physician Empathy (JSPE), and the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ, short form). They also reported their specialty interest and their perceptions of early relationships with their parents. Results showed that women outscored men on the empathy scale. Also, we found that higher scores on the JSPE were associated with studentsÕ interest in people-oriented specialties (as opposed to procedure- and technology-oriented specialties), higher level of satisfaction with early maternal relationship, higher sociability and lower aggressive-hostility scores. Controlling for gender and social desirability did not change the general pattern of findings. Ó 2005 Elsevier Ltd. All rights reserved. Keywords: Empathy; Specialty; Personality; Mother; Father
*
Corresponding author. Tel.: +1 215 955 9459; fax: +1 215 923 6939. E-mail address: mohammadreza.hojat@jefferson.edu (M. Hojat).
0191-8869/$ - see front matter Ó 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2005.04.007
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1. Introduction Although empathy has been discussed as an important element in therapeutic relationships in psychoanalysis and psychotherapy, empirical research on empathy in the patient care environment is scarce due to the ambiguity in conceptualization and definition of the term (Price & Archbold, 1997; Stephan & Finlay, 1999; Thornton & Thornton, 1995) as well as an absence of a psychometrically sound instrument specific for measuring empathy among medical students and physicians (Evans, Stanley, & Burrows, 1993; Kunyk & Olson, 2001). There are several research tools for measuring empathy in the general population (e.g., HoganÕs empathy scale, (Hogan, 1969) DavisÕs Interpersonal Reactivity Index, IRI, (Davis, 1983), and Mehrabian and EpsteinÕs emotional empathy (Mehrabian & Epstein, 1972)) and among nurses that we described elsewhere (Fields et al., 2004; Hojat, Gonnella, Mangione, Nasca, & Magee, 2003). None of these tools was specifically developed to measure empathy among medical students or physicians and, therefore, may not capture the essence of an empathic relationship in patient care situations. In recognition of a need for an operational measure of empathy among medical students and physicians in patient care situations, our research team developed the Jefferson Scale of Physician Empathy (Hojat et al., 2003, 2002c, 2001b) which will be described later. Empathy in patient care is defined as: ‘‘a cognitive attribute that involves an ability to understand the patientÕs inner experiences and perspective and a capability to communicate this understanding.’’ (Hojat et al., 2002c, p. 1564). Empathy can be linked to other variables such as gender, personality measures, early experiences with parents and the family environment, and later socialeducational experiences. The gender differences in favor of women, in perception of emotions (Brown & Dunn, 1996) and in empathic understanding (Litvack-Miller, McDougall, & Romney, 1997) have been observed in children and adults alike (Eisenberg & Strayer, 1987; Hojat et al., 2002a, 2002b, 2001b). Many developmental scholars have proposed that the quality of early relationships with parents is a significant factor in the development of a capability for interpersonal relationships. In the studies of early interpersonal relationships, and particularly in the original formulation of attachment theory (Bowlby, 1982) the emphasis was placed on relationships with the mother who is usually a primary caregiver in all primate species. The role of the father in the majority of these studies has been overlooked (Hojat, 1998). Some empirical data provide a reason for the greater emphasis placed on maternal over paternal roles in the developmental research. Collins and Read (1990) found that perceptions of the warm caregiving style of the mother were significantly correlated with higher self-esteem, better social adjustment, and more trust and altruism but such associations were not found for fathers. In a more recent study with medical students, it was found that perception of positive early relationships with the mother was a predictor of personality attributes such as higher self-esteem, more satisfactory peer-relationships, less loneliness, less depression, less anxiety, and more resiliency in dealing with stressful life events, but such associations were not found for perceptions of early relationships with the father (Hojat, 1998). In another study with physicians in residency training (Hojat, Glaser, & Veloski, 1996), a significant link was found between perceptions of early relationships with the mother and the clinical competence area of interpersonal relations and attitudes but such was not found with perceptions of early relationships with the father.
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Empathy is a personal attribute that is relevant to interpersonal relationships. Therefore, significant correlations between empathy scores and personality measures of human relationships are expected. For example, one would expect a positive link between empathy and personality factors that promote interpersonal relationships such as sociability and general activity. Conversely, negative links between empathy and personality traits that hamper interpersonal relationships such as aggression, hostility, neuroticism, and impulsiveness would be expected. A number of factors contribute to medical studentsÕ choice of specialty. For example, role models, market forces, societal demands, influence by family, friends and others, educational experiences, and personal qualities can contribute individually or interactively to the choice. It is common in medical education research to classify specialties into ‘‘people-oriented’’ (e.g., primary care specialties such as family medicine, general internal medicine, general pediatrics), ‘‘technology-oriented’’ (e.g., pathology, radiology, anesthesiology) or ‘‘procedure-oriented’’ (e.g., surgery and surgical subspecialties) (Hojat et al., 2002b, 2002c, 2001a; Lieu, Schroeder, & Altman, 1989) It would be reasonable to expect that those who are attracted to the ‘‘people-oriented’’ specialties would be more interpersonally oriented than those who are attracted to ‘‘technology’’ or ‘‘procedure-oriented’’ specialties. 1.1. Purpose This study, approved by the Institutional Review Board, was designed to test the following four research hypotheses involving the empathy scale used in this study: 1. Women would outscore men on empathy. 2. Medical students who are interested in pursuing people-oriented specialties would score higher on empathy than their classmates who are interested in the procedure-oriented or technology-oriented specialties. 3. Students who perceive a high level of satisfaction with early maternal relationships would score higher on empathy than those with lower levels of satisfaction, but no relationships between empathy and perceived paternal relationships would be found. 4. Empathy scores will be positively related to measures of sociability and activity, and negatively to measures of impulsive sensation seeking, aggression-hostility, and neuroticism.
2. Method 2.1. Participants Study participants were 422 first-year students (in 2002 and 2003) at a private medical school in Philadelphia, Pennsylvania, USA, representing 95% of all entering classes in that time period. There were 215 men (51%) and 207 (49%) women in the study sample, who voluntarily completed the survey in the orientation day.
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2.2. Instruments The following research instruments were used in this study. 2.2.1. The Jefferson Scale of Physician Empathy (JSPE) This scale was developed to measure empathy among medical students and physicians. The JSPE was constructed based on an extensive review of the literature, followed by pilot studies with samples of medical students, residents, practicing physicians and nurses. Both qualitative (Delphi technique) and quantitative (psychometrics) methods were used in the development and refinement of the JSPE (Hojat et al., 2002c, 2001b). The JSPE includes 20 items answered on a 7-point Likert-type scale (1 = Strongly Disagree, 7 = Strongly Agree). Psychometric evidence in support of the construct validity was reported (Hojat et al., 2002c, 2001b). The scale contains three factors of ‘‘perspective taking’’, ‘‘compassionate care’’, and ‘‘standing in the patientÕs shoes’’ that were determined by factor analysis. Also, criterionrelated validity (convergent and discriminant), internal consistency reliability (coefficient of alpha in the 0.80 s), and test-retest reliability (r = 0.65 with 3–4 month interval between test) of the scale have been reported (Hojat et al., 2003, 2002c, 2001b). The JSPE scores can range from a minimum of 20 to a maximum of 140. The higher the score, the more empathic a personÕs orientation. Two versions of the JSPE are available. One which was used in this study is the studentÕs version (S-Version) developed for measuring studentsÕ orientation toward empathetic relationships with patients. A sample item is: ‘‘Physicians should try to stand in their patientÕs shoes when providing care to them.’’ Another slightly modified version was developed for practicing health professionals (HP-Version) to measure their empathy in actual patient care situations (Hojat et al., 2003, 2002c). (Copies of both versions are available from the authors.) 2.2.2. The Zuckerman–Kuhlman personality questionnaire—short form (ZKPQ-S) This personality questionnaire was developed to measure basic factors of personality or temperament that have a strong biological-evolutionary basis (Zuckerman, 2002). There are five personality scales in this questionnaire: (1) Impulsive Sensation Seeking (ImpSS), described as a tendency to act quickly on impulse without thinking, often in response to a need for thrills and excitement. (2) Neuroticism-Anxiety (N-Anx), described as a tendency to be tense and become easily upset. (3) Aggression-Hostility (Agg-Host), described as a tendency to express verbal aggression, and show rudeness, thoughtlessness, vengefulness, spitefulness, a quick temper and impatient behavior. (4) Sociability (SY), described as a tendency to interact with others, enjoying being with others and intolerance for social isolation. (5) Activity (Act), described as a tendency to be active, to prefer challenging work, and impatience or restlessness when there is nothing to do. In addition, there is another scale called ‘‘Infrequency’’ in the ZKPQ that was developed to detect intentionally false answers by identifying subjects making responses unlikely to be true. This scale is intended only to screen out invalid test records and can be considered as an indicator of social desirability tendency. 2.2.3. Specialty interest survey StudentsÕ specialty interest was determined by asking them to choose one of the four groups of physician–patient encounters that matched their interest. The groups were as follow: (A) Proce-
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dure-oriented specialties defined as performing specialized diagnostic procedures or basic applied laboratory research and major contact with colleagues not patients, primarily hospital based (e.g., radiology, pathology). (B) Technology-oriented specialties defined as performing highly skilled and specialized therapeutic techniques or procedures, serving as an expert consultant, primarily hospital based with some office activities (e.g., orthopedic surgery, neurosurgery, ophthalmology). (C) Non-primary care specialties defined as providing episodic or long-term care of a certain and limited number of medical problems and a mix of ambulatory and hospital-based practice (e.g., cardiology, gastroenterology, dermatology, emergence medicine, psychiatry, obstetrics/gynecology). (D) Primary care or ‘‘people-oriented’’ specialties defined as providing first encounter health/illness appraisal and preventative education and intervention, episodic and long-term comprehensive care of a wide variety of medical conditions, primarily office-based (e.g., family medicine, general internal medicine, general pediatrics). 2.2.4. Perceptions of satisfaction with relationships with parents questionnaire Perceptions of early relationships with the mother were estimated by calculating an index based on responses to the following three items: (1) To the best of your knowledge, as a child when you had personal problems you went to your mother. (2) To the best of your memory, as a child your mother understood you. (3) To the best of your knowledge, as a child your mother devoted sufficient time to you. Each item was answered on a 4-point Likert-type scale (1 = Strongly Disagree, 4 = Strongly Agree). Perceptions of relationships with the father were calculated by replacing the word mother with father in each of the three aforementioned items. The alpha reliability for the measure of perceptions of relationships with the mother was 0.95, and for relationships with the father was 0.89 among medical students (Hojat, 1996). These items were developed to give an estimate of perceived parental sensitivity (Moran, Pederson, Pettit, & Krupka, 1992). In particular, the items were intended to measure perceptions of parents as secure bases for the child in trouble (item 1); parentsÕ empathic concern and social-emotional closeness (item 2); and parentsÕ attentiveness, involvement and devotion (item 3) (Hojat, Borenstein, & Shapurian, 1990). A higher index indicates a more favorable perception of the parent.
3. Statistical analyses For gender comparison, the t-test (one-tailed) was used, and for comparing empathy scores of students with different specialty interest, analysis of variance (ANOVA) was used, followed by the Duncan post hoc multiple comparisons. The distribution of the indices of perceptions of the mother and the father were extremely skewed toward higher scores. When distributions are extremely skewed, the correlations cannot attain their maximal values, and the true relationship among variables cannot be captured (Carrol, 1961). Therefore, instead of correlational analysis, we classified the sample into three groups based on the indices of perceived relationships with the mother and separately with the father. The ANOVA was used to compare empathy scores among those with high (approximately one standard deviation above the mean), moderate, or low (approximately one standard deviation below the mean) on the index of relationships with the parent.
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4. Results Prior to statistical analyses, we examined the distribution of the ‘‘Infrequency’’ scale of the ZKPQ to detect the proportion of students who gave invalid responses to the questionnaire. Data for the students (n = 22, 4.9% of the total sample) who scored greater than 3 on this scale were discarded from statistical analyses for the questionable validity of their record, or for carelessly responding to the questionnaire without regard to truth (Zuckerman, 2002). The means, standard deviations of the empathy scores and summary results of statistical analyses for the remaining sample in different comparison groups are reported in Table 1. 4.1. Gender comparison As shown in the table, women scored significantly higher on empathy than men (t(420) = 4.58, p < 0.01). The effect size estimate for the gender difference was 0.43 (Cohen, 1987). This finding confirmed the first hypothesis predicting higher empathy among women than men. 4.2. Specialty interest Results reported in Table 1 indicate that students who were interested in pursuing their future medical practice in ‘‘people-oriented’’ (primary care) (n = 104, 64% women) specialties obtained
Table 1 Comparisons of the Jefferson Scale of Physician Empathy scores for first-year medical students Groups
N
M
SD
p
Group differences
Gender A: Men B: Women
215 207
111.6 115.9
10.4 8.9
<0.01a
B>A
Specialty interest A: Procedure Oriented B: Technology Oriented C: Non-primary Care D: Primary Care
34 127 148 104
108.4 112.0 114.4 116.6
10.1 10.3 9.9 8.6
<0.01b
D>B>A
Level of satisfaction with mother A: High 111 B: Moderate 219 C: Low 90
116.2 112.3 114.3
9.7 9.3 11.4
<0.01b
A>C=B
Level of satisfaction with father A: High B: Moderate C: Low
113.8 113.6 113.9
11.5 9.0 10.5
NSb
A=B=C
98 212 110
N = Number of students; M = Mean; SD = Standard deviation; NS = Non-significant. a By one-tail t-test. b By analysis of variance.
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the highest empathy mean score. The differences were statistically significant (F(409,3) = 7.93, p < 0.01). The DuncanÕs post hoc mean comparison test indicated that the empathy mean score for the students who were interested in ‘‘people-oriented’’ specialties was significantly greater than other students who were interested in either ‘‘procedure-’’ (n = 34, 44% women) or ‘‘technologyoriented’’ (n = 127, 32% women) specialties. The effect size estimate for mean differences between groups interested in primary care and ‘‘procedure-oriented’’ specialties was 0.81. This is a large effect size confirming that the obtained difference is not only statistically significant, but it is also practically (clinically) important (Cohen, 1987; Hojat & Xu, 2004). The effect size estimate for mean difference between students interested in primary care and technology-oriented specialties was moderate (0.46). These findings confirm our second hypothesis of greater empathy scores in those who are interested in ‘‘people-oriented’’ specialties compared to others. 4.2.1. Controlling for gender effect The proportion of women interest in technology-oriented specialties (32%) was half of the percentage of women (64%) who were interested in the primary care specialties. The differences in proportions of women in the aforementioned specialties were statistically significant (v2ð3Þ ¼ 25.23, p < 0.01). Because of the significant gender differences we found in empathy scores and the disproportionate gender composition among students who were interested in different specialties, we statistically controlled the effect of gender using analysis of covariance (ANCOVA) in which gender was considered as the covariate. No significant changes in patterns of previous findings were observed (adjusted F(408,4) = 5.71, p < 0.01). Therefore, gender had no influence on the pattern of findings. 4.2.2. Satisfaction with parents As shown in Table 1, the differences in empathy scores among the three groups with different levels of satisfaction with their mothers were statistically significant (F(417,2) = 5.88, p < 0.01). Those who were highly satisfied with their childhood relationships with their mother obtained a significantly higher empathy mean score than the rest of their classmates, although the effect size estimates of the differences were not large (<0.30). The statistically significant differences confirmed the third research hypothesis concerning a positive association between a higher level of satisfaction with early relationships with the mother and empathy scores. In additional analysis we used ANCOVA to control for gender effect on the pattern of the findings reported in Table 1, and found no significant change of results (adjusted F(416,3) = 5.13, p < 0.01). Satisfaction with paternal relationships was not associated with empathy scores. These findings confirm the third research hypothesis. 4.2.3. Empathy and personality measures We correlated scores of the JSPE with the five personality scales of the ZKPQ. Significant correlations of low magnitudes were found between empathy and Sociability (r = 0.15, p < 0.01) and Aggression-Hostility scores (r = 0.13, p < 0.01). No significant correlations were found between empathy and the other three ZKPQ scales. These findings weakly support the fourth research hypothesis concerning relationships between empathy and personality measures.
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5. Discussion The findings of this study generally suggest that empathy among medical students is a function of gender, and early relations with the mother. These findings are limited to one medical school, and more research is needed to assure the generalization of these findings with a more representative sample of medical students from different schools. The results are also consistent with our previous findings (Hojat et al., 2002a, 2002b, 2001b), and with findings reported by other researchers (Davis, 1983; Eisenberg & Lennon, 1983; Hogan, 1969; Jose, 1989). The findings are in agreement with other studies regarding primary care physiciansÕ patient-oriented approach, (Batenburg, Smal, Lodder, & de Melker, 1999; Truax, Altmann, & Millis, 1974) and empathy (Newton et al., 2000). The findings concerning significant differences in empathy among medical students with different career interests are important in addressing the issue raised in one of our previous studies (Hojat et al., 2002c) in which we found a significant difference in empathy scores among physicians who were practicing psychiatry, general internal medicine, emergency medicine, and family medicine and general pediatrics, compared to physicians in anesthesiology, orthopedic surgery, neurosurgery, and radiology. In that study we speculated that the observed differences in empathy scores among those physicians could be explained by two reasons. First, the differences could be a reflection of physiciansÕ personality and interpersonal orientation developed prior to medical school that prompted them to pursue a specialty that requires a close interpersonal relationship with the patients (e.g., ‘‘people-oriented’’ specialties). Second, differences could be a result of training during medical education. For example, in some medical school clerkships, in particular residency training programs (internal medicine, family medicine, pediatrics) more emphasis is placed on interpersonal skill training and patient–physician relationships, and therefore, more empathic orientations could be expected to develop among those exposed to interpersonal skills development education. The findings of this study suggest that the first speculation can be feasible, although this study does not provide evidence that the second speculation or the combined effect of both should be rejected. The findings that perceptions of early relationships with the mother in childhood, compared to those with the father, have a more significant link to a an indicator of pro-social behavior are consistent with the tenet of the attachment theory (Ainsworth, 1985a, 1985b; Bowlby, 1982, 1988) and with previous research findings (Baydar & Brooks-Gunn, 1991; Collins & Read, 1990; Henwood & Solano, 1994; Hojat, 1998; Hojat et al., 1996; Rothbaum & Weisz, 1994). According to Zuckerman (2002) the scales of the ZKPQ were developed to reflect personality traits that have strong biological-evolutionary basis. Although empathy may have some evolutionary (Page & Novak, 2002; Preston & de Waal, 2002), biological (Brothers, 1989; Wolf, Gales, & Shane, 2001), and heritability components (Matthews, Batson, Horn, & Rosenman, 1981; Rushton, Fulker, Neale, Nias, & Eysenck, 1986) a developmental view of empathy suggests that empathy could also be based on early life experiences with primary care givers (Fonagy, 2001; Laible & Thompson, 1998). Therefore, a strong link between empathy in health care environment and stable biologically-based personality traits may not be expected. According to the American Board of Internal Medicine (ABIM) the ‘‘public has the right to expect humanistic behavior in its physicians’’ (ABIM, 1983). Therefore, evaluation of physiciansÕ humanistic qualities, including empathy, is recommended by medical professional organizations.
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Also, the Association of American Medical Colleges (AAMC) has included the development of empathy among the educational objectives of medical schools (for the Web address contact the author, MH). These recommendations combined with our previous research findings indicate that medical studentsÕ empathy scores were significantly associated with the facultyÕs evaluations of studentsÕ clinical competence in core clerkships (Hojat et al., 2002a) suggest that attention to measuring and improving empathy during medical education by offering targeted programs is important for enhancing clinical skills. Findings of the present study that the degree of empathy at the beginning of medical education is significantly associated with specialty preference can have implications for predicting the likelihood of future career choice of medical students.
Acknowledgments This study was supported in part by a grant from Pfizer Medical Humanities Initiative, Pfizer, Inc. New York. The authors thank Dorissa Bolinski for her editorial assistance.
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