Measuring empathy in medical students, gender differences and level of medical education: An identification of a taxonomy of students

http://riem.facmed.unam.mx

ORIGINAL

ARTICLE

Measuring

empathy

in

medical

students,

gender

differences

and

level

of

medical

education:

An

identification

of

a

taxonomy

of

students

Marta

Isabel

Ferreira

Duarte

,

Mário

Lino

Barata

Raposo,

Paulo

Joaquim

Fonseca

da

Silva

Farinha

Rodrigues,

Miguel

Castelo

Branco

Received7January2016;accepted29April2016

Availableonline2July2016

KEYWORDS Empathy; Medicalstudents; JSPE-spv

Abstract

Introduction:Empathy is themediating role ofthephysician---patient relationship. Through thisprocessthepractitionerseekstounderstandthepatient’sframeofreferenceandalsoto establisharelationshipofopenness,mutualrespect,trustanddeepunderstanding.

Objective: Thisstudyaimstoanalyzetheperceptionsofmedicalstudentsontheimportance ofempathyinthedoctor---patientrelationship,andtoanalyzethegenderdifferencesandin thedifferentyearsofthecourse.Itisalsointendedtoidentifyataxonomyofstudentsbased ontheirperceptionsofempathy.

Methods:Thiscross-sectionalstudywasconductedonundergraduatemedicalstudents.Atotal of208medicalstudentsrespondedtotheJeffersonScaleofPhysicianEmpathy---Student Por-tugueseVersion(JSPE-spv).PrincipalComponentsAnalysiswithvarimaxrotationwasusedto identifythenumberandcompositionsofemergedfactors.Thescoresoftheretainedfactors were submitted toacluster analysis toidentifydifferent groups ofstudents,basedonthe dimension of empathy. A One-way Anova analysis and post-hoc tests of Tukey supported theidentifiedcluster.

Results:This study shows statisticallysignificant differences betweengenders, i.e.,female individualsshowhigherscoresthanmaleindividuals.Empathyincreasesoverthecourse,but with no statistically significant differences. Six factors emerged from factor analysis, and threeofthemareempathy dimensionsfound inotherstudies:‘‘adoptionofperspectives’’, ‘‘compassionate care’’, and‘‘standing inthe patients shoes’’.Cluster analysis dividedthe studentsintofivegroupsaccordingtothedimensionsofempathyidentified.

∗_{Correspondingauthorat:AvenidaInfanteD.Henrique,6200-506Covilhã,Portugal.Tel.:+351275329007;fax:+351275329099.} E-mailaddress:[email protected](M.I.F.Duarte).

PeerReviewundertheresponsibilityofUniversidadNacionalAutónomadeMéxico.

http://dx.doi.org/10.1016/j.riem.2016.04.007

2007-5057/©2016UniversidadNacionalAutónomadeMéxico,FacultaddeMedicina.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Conclusions:In thismedical schoolinPortugal,itmay be concludedthat womenaremore empatheticthanmen,andempathygrowsthroughoutthecourse.Itisrecommendedtocarry outalongitudinalstudy,inordertofollowtheevolutionofthesestudents,aswellastoanalyze factorsthatcontributetotheincreaseinempathycharacteristics.

©2016UniversidadNacionalAutónomadeMéxico,FacultaddeMedicina.Thisisanopenaccess articleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALABRASCLAVE Empatía;

Estudiantes demedicina; JSPE-spv

Medirlaempatíaenestudiantesdemedicina,lasdiferenciasporgéneroynivel

deeducaciónmédica:identificacióndeunataxonomíadelosestudiantes

Resumen

Introducción:La empatíaes elpapelmediadordela relaciónmédico-paciente.A travésde este procesoel profesional buscaentender elmarco dereferencia delpaciente y también paraestablecerunarelacióndetransparencia,elrespetomutuo,laconfianzaylacomprensión profunda.

Objetivo:Este estudiotiene como objetivo analizar laspercepcionesde losestudiantes de medicinaacercadelaimportanciadelaempatíaenlarelaciónmédico-pacienteyanalizarla existenciadediferenciasdegéneroyenlosdiferentesa˜nosdelacarrera.Tambiénsepretende identificarunataxonomíadelosestudiantesbasadaensuspercepcionesdelaempatía. Método: Esteestudiotransversalsellevóacaboentrelosestudiantesdepregradodemedicina. Untotalde208estudiantesdemedicinarespondióalaEscalaJeffersondeempatíamédicadel estudianteversiónenportugués.Seutilizóanálisisdecomponentesprincipalesconrotación varimaxparaidentificarelnúmeroycomposicióndefactoressurgido.Laspuntuacionesdelos factoresretenidosfueronsometidosaunanálisisdeclustersparaidentificardiferentesgrupos deestudiantesbasadosenla dimensióndelaempatía.Un análisisOneway-ANOVAylostest post-hocdeTukeyhansoportadolaagrupaciónidentificada.

Resultados: Esteestudiopresentadiferenciasestadísticamentesignificativasentrelosgéneros, esdecir,losindividuosfemeninosrevelanpuntuaciones másaltasquelosindividuosdesexo masculino,laempatíaaumentaduranteelcurso,perosindiferenciasestadísticamente significa-tivas.Seisfactoresemergierondelanálisisfactorialytresdeellossondimensionesdeempatía queseencuentranenotrosestudios:«laadopcióndeperspectivas»,«atenciónhumanitaria»y «colocarseenlugardelosotros».Elanálisisdeclustersdividealosalumnosencincogrupos, deacuerdoconlasdimensionesdelaempatíaidentificadas.

Conclusiones:Esposibleconcluirque,enestaescuelademedicinaenPortugal,lasmujeres sonmásempáticasqueloshombres,y,amedidaqueatraviesanlosdiferentesa˜nosenelcurso engeneral,laempatíacrece.Serecomiendallevaracabounestudiolongitudinal,conelfinde seguirlaevolucióndeestosestudiantesyanalizarlosfactoresquecontribuyenparaelaumento delascaracterísticasdeempatía.

© 2016 Universidad Nacional Autónoma de México, Facultad de Medicina. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/ by-nc-nd/4.0/).

Introduction

Empathyhasbeendescribed inliteratureasthemost fre-quentlymentioned attributeof thehumanisticphysician.1

Sinceit isatermconsidered ambiguous,severalattempts emergedoverthetimetodefinethisconcept.

Several researchers presented similar definitions for empathy.Gianakos2 _{described empathy as ‘‘theability of}

physicianstoimaginethattheyarethepatientwhohascome tothemforhelp.’’

This definitionincludes fourdimensions: emotive (abil-ity to imagine patients’ emotions/perspectives); moral

(physicians’ internal motivation to empathize); cognitive

(intellectual ability to identify and understand patients’

emotions/perspectives); behavioral (ability to convey understanding ofthoseemotionsandperspectivesbackto thepatient).3,4

Hojat5 _{defines empathy as one of the most important}

ingredients in creatinga goodrelation between physician andpatient.Thisauthorpresentsthisconceptin the con-textofpatientcareasfollows:‘‘empathyisapredominantly

cognitive (rather thanemotional) attribute that involves

anunderstanding(ratherthanfeeling)ofexperiences,

con-cerns and perspectives of the patient, combined with a

capacitytocommunicatethisunderstanding.’’

Kohut emphasizes the importance of empathy as an observational method tuned to the man’s inner life and experienceasclosetotheactivityofcollectinginformation

and how powerful emotional bond between people.6

Evidence-basedstudies showedthat effective empathetic patientcare is associatedwithimproved health care out-comes.

Empathyconsistsintheabilityandcapacityofthe doc-tortowalkhimselfinthepatient’sshoesandseetheworld from their perspective and then be able to convey this understandingverbalandnonverbal,anditisimportantthat thephysiciankeepstrackofhimself,keepinganemotional distancesoasnottointerferewiththeirprofessional respon-sibilitiesandobligations.2

Considering empathy as a cognitive trait or attribute desirableinpractitioners,wecanquestionthedesirability ofmakinganassessmentrelatedtotheexistenceofthis con-structalongthelearningorevenimplementitasanintegral aspect of the admissionof students tomedicalschool. In astudy byHemmerdinger,7_{where theauthorconducteda}

literaturereviewontheapplicationofempathymeasuring testsinphysicians andmedicaltrainees,itwasconcluded thatempathyisaqualitythatisrelevant.

Aimingatthedevelopmentofaproperassessmenttool for evaluating the level of empathy in medical students, Hojatetal.,8,9 _{researchersatJeffersonMedicalCollegein}

theUnitedStates,createdtheStudentVersionofJefferson ScaleofPhysicianEmpathy.Thisscale,including20itemsto measurethethreeunderlyingconstructsofempathy (com-passionatecare,perspectivetakingandstandinginpatient’s shoes),hasproventohavesatisfactorypsychometric prop-erties.

UsingtheJSPE-svseveralinterestingfindingshavebeen reported, for example, it is possible to analyze scores according to gender, specialty, and evolution of empathy over the yearsof medicalschool and similarities and dif-ferences among the countries.10 _{The differences among}

the countries suggested that cultures or medical educa-tion systems influence measurements and outcomes of empathy.5

Somestudiesshowthattheempathymeanscoresdecline during university medical education.11---15 _{However, more}

recently,otherstudiespresentresultswherethisdecrease isnotobserved.Forexample,inJapan,KoreaandPortugal thelevelsofempathyincreaseinseniorstudents.16---18_Inthe

studywithIranianmedicalstudents,theempathyincreases fromthe3rd yearand therewasadecreasefromthe 1st tothe2ndyear.19 _{Thisfindingseemstobetheoppositeof}

Hojat’slongitudinalfindingswhichshowedthatasignificant declineoccursinthethirdyearofmedicalschool.15

All studies present the same conclusions about female and male differences of empathy mean scores. Women obtainhigherscoresofempathythanmen.5,9,10,13,16,18,20---23

Thepurposeofthisstudywastoanalyzetheperception of medical students about the importance of empathy in thephysician---patient relationship andtoverifythe exist-enceof differencesin gender andthe evolution over the course. It is also intended toidentify a taxonomy of stu-dentsbasedontheirperceptionsofempathy.Inthisstudy wetestedthreehypotheses:H1---femalemedicalstudents showhigherscoresofempathythanmen.H2---medical stu-dentsscoresofempathydeclineoverthecourse.H3---based onthedimensionsofempathyidentifieditispossibletofind ataxonomyofstudentswithdifferentemphasisrelatedto theempathy.

Methods

Participants

312 medical students were involved on a voluntary basis and have not been compensated for their participation, andstudentswereassuredabouttheconfidentialityoftheir answers.Basedonanon-linesurveyatotalof208answers werereturned.

Instruments

Theinstrumenttomeasureempathyinmedicalstudentswas basedonthestudentversionoftheJeffersonScaleof Physi-cianEmpathy(JSPE-sv),whichincludes20itemsina7point Likert-typescale(1---stronglydisagree,7---stronglyagree). ThetranslationandadaptationofJSPE-svwasproposed in a Portuguese publication by Magalhães et al.24 _There

were10reverseitemswhoseresponseswerescored accord-ingly,from1---stronglyagreeto7---stronglydisagree.The totalscorewasobtained bysumming allitems (maximum score=140), where higher values meanhigher degrees of empathy.

Proceduresandstatisticalanalysis

ThestudywasapprovedbytheDeanoftheFacultyofHealth Sciences.TheJSPE-spvwasdistributedtotheselected popu-lationusingthefacultymailing-list.Thedatacollectionwas performedusingaweb,assuringthe anonymityand confi-dentialityoftheanswers.Thedatawasthansubmittedto astatisticalanalysis,descriptiveandmultivariateusingthe packageSPSS---version19.

Thedataanalysiswasconductedcomputingfirstthesum oftheitemtotalscoreoftheJSPE-spvfortwosubsamples offemale andmale, calculating themean andapplyinga

t-testandanANOVATesttocalculatethesignificanceofthe

meansofthedifferentyearsstudents.Second,afactor anal-ysiswasperformed followingthenextsteps:(a)Bartlett’s test of the sphericity and the KMO --- Kaiser---Meyer---Olkin measure of sampling adequacy were determined to mea-sure the goodness of factor analysis. (b) The principal componentanalysiswasruntoextractthenumberof com-ponents. (c)The retained componentswere submitted to avarimaxrotationandfollowingthecriteriaofeigenvalue >1,25 _{six main factors were retained. In addition, factor}

coefficientsgreaterthan0.4wereusedtomakethe inter-pretationofsuggestedcomponents.Toanalyzetheinternal consistency of these factors the test of alpha Cronbach wasused.

Third,usingaclusteranalysiswetriedtofindataxonomy ofstudentsrelatedwiththedifferentdimensionsof empa-thyidentifiedinfactoranalysis.Tomakethisanalysis,the scoresoftheretainedfactorsareusedinsteadofthe orig-inalvariables.FollowingtheopinionofDouglasandRhee26

thisprocedure wasusedwith success in many studies. In fact,despite losingsomeinformation, however,showsthe advantageof generating orthogonaldimensions for subse-quentanalysis.Thisreducesthepotentialproblemsresulting fromtheinterdependenceoftheoriginaldata.

Table1 Descriptionofstudyparticipants.

Gender Frequency Frequency(%)

Female 148 71.2

Male 60 28.8

Total 208 100.0

Medicalschoolyear Frequency Frequency(%)

1styear 75 36.1

3rdyear 66 31.7

6thyear 67 32.2

Total 208 100.0

UsingthemethodofWard’sclustering,25_wedetermined

thenumberofclusterstoretain,examiningthedendogram andthedecreaseinthevalueofthesumofsquarederrors, asitpassesfromonegroupofclustertoanother.Once cho-sen the number of groups were used as a validation, an analysisofvarianceOneway-Anova,andthepost-hoctests ofTukey.

Results

Descriptiveanalysis

The final sample wascomposed of208 students who rep-resent66.6% of thepopulation (Table 1).There were148 females (71.2%) and 60 males (28.8%) and the age mean of the students was 21.38 years and standard deviation 2.77.Consideringtheyearsofenrollment,studentsare dis-tributedasfollows:75inthe1styear,64inthe3rdyearand 67inthe6thyear.

In terms of comparison by gender (see Table 2) the empathy scores of female students (mean=116.41; SD=10.47)werehigherthanthescoresofthemalestudents (mean=109.45, SD=10.42; t=4.348, p<0.000).A statisti-callysignificantmaineffectfor genderwasfound.Table2

comparestheresultsobtainedfromthedemographic back-groundof medicalschoolyear. As shownin thetable,the empathy scores mean increases slowly from 112.85 in thefirstyear,to113.74inthethirdyearandto116.78inthe sixthyear.However,theAnovaTestshowsthattherewasno statisticallysignificanteffect.

Multivariateanalysis

The summary results of factor analysis of data for the 20 itemsofJSPE-spv arereportedin Table3.As shown in

Table 3 were retained six factors, each one with

eigen-value greater than 1, accounting for a total of 57.04% of a total variation before rotation. The acceptability test (KMO=0.788andBartlettTest=931.51,df=190,sig=0.000) proved that the factor analysisis meaningful and accept-able.Ontheother handthereliabilityanalysisofinternal factorscalculatedbytheCronbach’salphashowedavalue greaterthan0.5forallfactorsexceptfactor6,whichwas composed byonly oneitem.The compositionof different factorsisanalyzedconsideringtheitemsassociated,witha valuegreaterthan0.4.

The factors 1, 2 and 5 are interpreted as con-structs ‘‘compassionate care’’, ‘‘perspective taking’’ and ‘‘standinginthepatientshoes’’,verywellsupportedbythe literaturereview.Thefactor1,whichaccountedfor14.44% of thevariance,can belabeledas‘‘compassionatecare’’

basedonthecontentsofthesixitems(1,7,8,11,12,19).All theseitemsalsoemergedasthecompassionatecarefactor intheothersstudies,5,10,16,18,19_{exceptfortheitem19.}

Thefactor 2 accounted 10.64%of the variance,a con-structof‘‘perspectivetaking’’basedonthecontentsofthe fouritems(9,10,13,17).Alltheseitemsalsoemergedas perspectivetakingfactorinthestudiesofHojat,5

Alcorta-Garza10_andKataoka16_.

Theconstruct‘‘standingin thepatientshoes’’appears infactor5withtwoitems(3,6)andaccounted8.29%ofthe variance.Theitemsinthisconstructemergedinallstudies thatusedtheJSPE-vs.5,10,16,18,19

The factor 3 which accounted 9.4% of the variance, is labeledas‘‘Cognitivedimension’’basedonthecontentsof thefouritems(2,4,15,16).Theinterpretationisbasedon thestudiesofMorse3_{andBenbassatandBaumal.}27

Thefactors4and6,whichdonotappearintheliterature reviewbutareconsideredinthisstudy havinginmindthe hypothesis3,identifygroupsofstudentsandexplaintheir relationwiththeempathydimensionidentified.

Thefactor4,whichaccounted8,53%ofthevariance,is labeledas‘‘Clinicaloutcomes’’,includingitems5,14and 20.Weconsideredthattheitemofthisconstructseemsto indicateinherentcharacteristicsthatmaygivecontribution toclinicalsuccess. The factor6,withoneitem(18),‘‘No

InfluencebyOthers’’explainsitself5.74%ofthevariance.

Table2 GroupcomparisononscoresoftheJSPE-spv.

Gendera _{Mean Standarddeviation Scoreminimum Scoremaximum}

Female(148) 116.41 10.47 76.00 136.00

Male(60) 109.45 10.42 86.00 134.00

Medicalschoolyearb _{Mean Standarddeviation Scoreminimum Scoremaximum}

1styear(144) 112.85 10.46 86.00 131.00

3rdyear(87) 113.74 11.57 80.00 136.00

6thyear(81) 116.78 10.43 76.00 136.00

a_{t(206)=4.348,p=0.000.} b _{F=2.505,p=0.084.}

Table3 PrincipalcomponentswithvarimaxrotationsolutionsofJSPE-svitems.

Item* Factor1 Factor2 Factor3 Factor4 Factor5 Factor6

Compassionatecare

1.Physicians’understandingoftheirpatients’feelingsand thefeelingoftheirpatients’familiesdoesnotinfluence medicalorsurgicaltreatment

0.444 0.432 −0.103 −0.286 −0.206 0.056

7.Attentiontopatients’emotionsisnotimportantinhistory taking

0.602 0.052 0.137 0.112 0.026 0.211 8.Attentivenesstopatients’personalexperiencesdoesnot

influencetreatmentoutcomes

0.676 0.086 0.057 0.199 0.005 0.052 11.Patients’illnessescanbecuredonlybymedicalor

surgicaltreatment;therefore.physicians’emotionalties withtheirpatientsdonothaveasignificantinfluencein medicalorsurgicaltreatment

0.796 0.015 0.175 0.022 0.096 −0.090

12.Askingpatientsaboutwhatishappeningintheirpersonal livesisnothelpfulinunderstandingtheirphysical complaints.

0.493 0.078 0.327 −0.064 0.246 0.184

19.Idonotenjoyreadingnon-medicalliteratureorthearts 0.502 0.065 −0.045 0.367 0.010 −0.447 Perspectivetaking

9.Physiciansshouldtrytostandintheirpatients’shoes whenprovidingcaretothem

0.067 0.766 0.121 0.007 0.097 0.004 10.Patientsvalueaphysician’sunderstandingoftheir

feelingswhichistherapeuticinitsownright

0.387 0.425 0.331 −0.077 −0.124 −0.200 13.Physiciansshouldtrytounderstandwhatisgoingonin

theirpatients’mindsbypayingattentiontotheir non-verbalcuesandbodylanguage

0.158 0.476 0.291 0.086 −0.085 −0.017

17.Physiciansshouldtrytothinkliketheirpatientsinorder torenderbettercare

−0.075 0.789 0.037 0.242 0.049 0.179 Cognitivedimension

2.Patientsfeelbetterwhentheirphysiciansunderstand theirfeelings

−0.068 0.199 0.755 0.046 0.087 −0.011 4.Understandingbodylanguageisasimportantasverbal

communicationinphysician-patientrelationships

0.288 0.011 0.591 0.048 −0.031 0.260 15.Empathyisatherapeuticskillwithoutwhichthe

physician’ssuccessislimited

0.225 0.054 0.384 0.379 −0.100 −0.078 16.Physicians’understandingoftheemotionalstatusof

theirpatients,aswellasthatoftheirfamiliesisone importantcomponentofthephysician-patientrelationship

0.306 0.324 0.506 0.329 0.089 −0.275

Contributionstoclinicaloutcome

5.Aphysician’ssenseofhumorcontributestoabetter clinicaloutcome

−0.020 0.012 0.118 0.800 −0.071 0.144 14.Ibelievethatemotionhasnoplaceinthetreatmentof

medicalillness

0.381 0.231 −0.129 0.452 0.094 0.084 20.Ibelievethatempathyisanimportanttherapeuticfactor

inmedicaltreatment

0.362 0.298 0.375 0.487 −0.102 −0.163 Standinginthepatient’sshoes

3.Itisadifficultforaphysiciantoviewthingsfrompatients’ perspectives

0.044 −0.007 −0.016 −0.009 0.856 −0.037 6.Becausepeoplearedifferent,itisdifficulttoseethings

frompatients’perspectives

0.081 0.019 0.038 −0.059 0.853 0.019

Noinfluencebyothers

18.Physiciansshouldnotallowthemselvestobeinfluenced bystrongpersonalbondsbetweentheirpatientsandtheir familymembers

0.205 0.117 0.031 0.142 −0.014 0.761

%Variance 14.44 10.64 9.4 8.53 8.29 5.74

AlphaCronbach 0.67 0.65 0.55 0.5 0.72

Clusteranalysis

Inorderto identifydifferent groups of studentsa cluster analysiswasperformedusingasinputthevaluesofthe fac-torsretainedinthefactorialanalysis.

Table 4 shows the results of cluster analysis and the

results of validation techniques, Oneway-Anova that sup-ported the significance of the dimensions of empathy to includethestudentsinidentifiedgroups(p<0.000).Wecan conclude that students can be grouped into five distinct groupswithdifferentperceptionsof identifieddimensions ofempathy.

Group1of theclusteranalysisgroupsthelargest num-berofstudents(101),showingapositiverelationship with the dimensions ‘‘perspective taking’’, ‘‘cognitive dimen-sion’’,‘‘clinicaloutcomes’’,‘‘theinfluencebytheothers’’ andnegative withdimensions ‘‘compassionate care’’ and ‘‘patientstandinginshoes’’.Group2ofthecluster,group of14students,showshighlypositiverelationship withthe dimension‘‘noinfluencebyothers’’andalsopositivewith ‘‘standing in patient shoes’’ and presents negative rela-tion with the other dimensions. Group 3 of the cluster, groupof35students,presentspositiverelationshipwiththe dimension‘‘perspectivetaking’’andnegativeor nullwith the others.Group 4 of the cluster, group of 24 students, shows a positive relationship with ‘‘cognitivedimension’’ and‘‘compassionatecare’’and negativerelationship with the others.Group 5 of the cluster, group of 34 students, presentsapositiverelationshipwiththe‘‘cognitive dimen-sion’’,‘‘clinicaloutcomes’’and‘‘standinginpatientshoes’’ andnegativerelationshipwiththeothers.

The results of post hoc Tukey, comparing the means betweenthedifferentgroups,givestatisticalsupporttothe identifiedclusters.

Discussion

TheJSPE-svis aninstrumentthatwasadaptedtothe Por-tuguese language in a study developed by Magalhães.24

AccordingtoHojat,5_{theJSPEhavepsychometric qualities}

tomeasureempathyinthehealthcaresetting.Theaimof thiscross-sectional researchwasto studythe empathy in thecontextofPortuguesemedicalstudents.

TheCronbachalpha(0.77)estimatedtheinternal consis-tency,forthe20itemsontheJSPE-spv.Incomparison,the alphacoefficientislowerthanthevaluesobtainedinsome studies5,16,17_{andhigherthantheresultspresentedinother}

studies.10,19,28 _{Curiously, this value is equal to the result}

obtainedinstudydevelopedinotherPortugueseFaculty.18

Hypothesis1. Femalemedicalstudentsshowhigherscores ofempathythandomen.

In Table 2 we can see that mean females score

was 116.41 and males was 109.45. The t-test of means revealedthatgenderdifferencewasstatisticallysignificant (t(206)=4.348, p=0.000). This result is similar to other studiesandconfirmstheideathatwomenhavehigher empa-thy when compared with men.5,9,10,13,16---18,20---23 _{Thus, the}

Hypothesis1issupported. AccordingHojat6 _women

show-inghigherlevelsofempathymaybeduetotheirmaternal T

able 4 Characteristics of the five groups obtained in the cluster analysis (a). Groups Tukey test (d) Group 1 Group 2 Group 3 Group 4 Group 5 1 ---2 1 ---3 1 ---4 1 ---5 2 ---3 2 ---4 2 ---5 3 ---4 3 ---5 4 ---5 F (sig) (b) Compassionate care − 0.415 − 0.767 − 0.097 0. 099 − 0.888 ** * n.s. ** n.s. * n.s. n.s. ** ** 17 .482 ((.000) P erspective taking 0. 562 − 0.656 0. 146 − 1.502 − 0.488 ** * ** ** ** ** n.s. ** ** ** 48 .250 ((.000) Cognitive dimension 0. 371 − 0.835 − 1.502 0. 289 0. 582 ** ** n.s. n.s. * ** ** ** ** n.s. 64 .871 ((.000) Clinical outcomes 0.013 − 0.925 − 0.036 − 0.466 0. 708 ** n.s. n.s. ** * n.s. ** n.s. ** ** 10 .076 ((.000) Standing in the patient’ s shoes − 0.203 0. 554 0. 009 − 0.575 0. 771 ** n.s. n.s. ** n.s. ** n.s. n.s. ** ** 10 .900 ((.000) No influence by others 0. 087 1.833 − 0.527 − 0.405 − 0.186 ** ** n.s. n.s. ** ** ** n.s. n.s. n.s. 22 .017 ((.000) Number of students (c) 101 14 35 24 34 The values shown correspond to averages. Total number of students = 208. * p < 0.05. ** p < 0.01.

instinct,displayingthesequalitiestowardherinfantsinan eminentdegreeandtheyhaveagreaterperceptionof emo-tionsandaremorereceptivethanmoretoemotionalsignals. Empathyismostlyafemininetrait29_.

Hypothesis2. Medicalstudentsscoresofempathydecline overthecourse.

InTable2wecanseethattheempathyscoresincrease

from112.85in the1styearto112.74 inthe3rdyear and to116.78inthelastyearofthecourse.Nosignificant dif-ferenceswerefound betweenthedifferentyearsusingan ANOVAanalysis(F=2.505,p=0.084). This findingis in the samelineofsomestudies.16---18 _{However,manyother}

stud-iesshowthatmeanempathyscoresdeclineduringmedical education.11---15 _{Thus,weconcludethattheHypothesis2is}

not supported by the results. According toSilver,30,31 _the

humanistic qualities of themedical studentsdecline over thecourse,occurringasanunfortunatedevelopmentof cyn-icism,inoppositiontotheresultsofthisstudy.

Hypothesis3. Basedonthedimensionsofempathy iden-tified it is possible to find a taxonomy of students with differentemphasisrelatedtotheempathy.

After afactorial analysisit waspossibletoidentify six differentdimensionsofempathy.Thestatistical tests sup-portthegoodnessoffactorialanalysis(seeTable3).Three oftheidentifieddimensionsareaccordingtotheliterature review:F1.compassionatecare;F2.perspectivetakingand

F5.standing in patientshoes.Twoother dimensions were

identifiedbutarenotsupportedbytheliteraturethatused theJSPEandcanbecharacterizedas,F4.clinicaloutcomes

andF6.noinfluencebyothers.TheF3.cognitivedimension,

issupportedbyMorse3_{andBenbassatandBaumal.}27_These

lastthreedimensionsareretainedhavinginmindthenext researchstep,i.e.,theclusteranalysis.

According to Hypothesis 3, we tried to find different groups ofstudents thatfollow thedimensions ofempathy identifiedin the factorial analysis. Thus,using thescores ofthefactorsretained,thedatawassubmittedtoa hier-archicalmethodofclustering(Ward),basedontheSquare EuclidianDistance.Thisprocessallowedustoidentifyfive differentgroupsofstudents(seeTable4).

The F valuesassociated tothe dimensions of empathy obtainedthroughanANOVAanalysis(p<0.000)indicatethat theempathydimensionsarehighlysignificanttoinclude stu-dents in the groups. We use the Post Hoc Tests of Tukey toconfirm thatthe differencesbetween groupmeans are significant. Thus,it is possibletosay thatHypothesis 3is supported.

Also, we tried tofind same relationships between the groups identified in cluster analysis and the characteris-ticsofthesample ofstudents,namely genderandyearin medicalschool(seeTable5).Itispossible tosaythat the distribution of students’ gender by the groups that were identifiedis statisticallysignificant,asthechi-squaretest proves.

In the case of females, it is possible to see that they arestronglyrelatedwithgroup1,andthisgroupismainly positiverelatedwiththedimension‘‘perspectivetaking’’. Significantgenderdifferenceswereobservedinthefavorof

Table 5 Comparingthe cluster with gender andyear in

medicalschool. G1 G2 G3 G4 G5 Female(148) 84 5 17 12 30 Male(60) 17 9 18 12 4 Total 101 14 35 24 34 2_{=34.432;sig=0.000} 1styear(75) 33 7 18 5 12 3rdyear(66) 39 5 5 13 4 6thyear(67) 29 2 12 6 18 Total 101 14 35 24 34 2_{=24.681;sig=0.002}

womenparticularlyonthisdimension.9_{Thefemalestudents}

alsoshowahigherassociation withthegroup5 character-izedbyitspositivelyrelationwith‘‘cognitivedimension’’, ‘‘clinicaloutcomes’’and‘‘standinginpatientshoes’’.

Inthecase ofmalestudents,theyrevealhigher repre-sentation in group 2 where a positivelyrelation withthe dimensions‘‘standinginpatientshoes’’and‘‘noinfluence byothers’’exists(Tables4and5).Menaremoreinclinedto presentrationalsolutions withlow measuresof emotional supportandunderstanding.32

Takingintoaccountthedistributionofstudentsoverthe courseandthegroups identifiedinthe clusteranalysis,it waspossibletoverifytheirdistributionbyvariousgroups, supportedbythechi-squareanalysis.

Conclusions

Thestudycarriedoutinacollegeofhealthsciences involv-inga sample of students fromthe 1st, 3rdand 6thyears ofmedicalschool,soughttoapplythescaleJSPE-sv trans-latedandvalidatedinthePortugueselanguage,toseehow medicalstudentsperceivetheimportanceofempathyinthe doctor---patientrelationship.

Ourresultssuggestedthatwomen,whencomparedwith men,showhighervaluesofempathy.Asstudentsprogress in the course there is a greater appreciation of empa-thy,whichcontradictssomeinternationalstudies,although notstatisticallysupported.Afactoranalysisidentifies sev-eraldimensionsofempathy.Aclusteranalysisallowedthe inclusion of students into different groups with different associationsto the dimensions of empathy identified cor-respondingtotaxonomyofstudents.

In the future, it will be interesting to monitorize theimportance attributedto empathy by thesestudents, throughalongitudinalanalysis.Itwillalsobeinterestingto seewhethertheimportancegiventoempathyvaries accord-ingtomedicalspecialty.

Ethical

responsibilities

Protection of human and animal subjects.The authors statethatforthisinvestigationnoexperimentsonhumans oranimalshavebeenperformed.

Confidentialityofdata.Theauthorsdeclarethattheyhave followedtheethicalprotocolsforthedatapublicationfrom patientsorstudyparticipantsoftheInstitution.

Righttoprivacyandinformedconsent.Theauthorsstate thatinthis papernodata frompatients or participantsis described.Moreoverallthepatientsandparticipantswere informedofthepurposeoftheinvestigation.

Funding

Nofinancialsupportwasprovided.

Authors’

contribution

MIFD contributed towards data collection, statistical processingandwritingofthearticle.MLBR,PJFSFRandMCB wereinvolvedintherevisionandcorrectionofthearticle.

Conflict

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

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