Empathy among undergraduate medical students: A cross-sectional study in one Malaysian public medical school.

Background: Empathy is one of the cardinal components for physician-patient relationships, optimal outcomes in patient care, improved patient satisfaction, greater adherence to therapy, and lower malpractice liability. It is also considered an essential quality for health-care professionals to practice medicine. The aim of the present study was to assess the empathy level of medical students of Universiti Pertahanan Nasional Malaysia (UPNM) National Defense University of Malaysia, Kuala Lumpur, Malaysia.
Methods: This was a cross-sectional study conducted in 2017 which recruited medical students of UPNM. The Empathy Quotient, a self-reported questionnaire, was utilized for data collection. The total empathy score of the questionnaire is 80.
Results: Majority of the respondents were male (60.9%), year-V students (26.6%), Malay (70.5%), and cadet officer (69.6%). The overall mean score achieved by the respondents was 36.76 ± 9.18, and 74.4% of the respondents scored more than 30. The empathy scores of the students were significantly affected by the gender (t = 2.371; df = 205; P < 0.05), year of study (F = 2.553; df = 4/202; P < 0.05), and examination grades (F = 3.488; df = 2/204; P < 0.05). The findings showed that female students are more empathetic than their male counterparts. Further, the post hoc Tukey test analysis revealed that Year-V students are more empathetic than their junior counterparts and students who got highest grade are more empathetic. Conclusions: To improve the empathy level of the UPNM medical students, appropriate educational strategies and interventions should be designed and implemented in the curriculum to inculcate, maintain, and enhance empathy.

INTRODUCTION

Empathy is one of the cardinal components for physician–patient relationships, optimal outcomes in patient care, and is often considered an important quality for health-care professionals.[123] Sir William Osler, a Canadian physician and the father of modern medicine, stated that “the physician needs a clear head and a kind heart; his work is arduous and complex, requiring the exercise of the very highest faculties of the mind, while constantly appealing to the emotions and finer feelings.”[4] Furthermore, he pronounced “be careful, when you get into practice, to cultivate equally well your hearts and your heads.”[5]

Medicine at its essential is a human service profession.[6] Medical and health care is principally driven by physician- and disease-centered approach for the last few hundred years.[7] Over the years of the commencement of the patient-centered tactic, physicians began to incorporate the patients’ perception as one of the treatment outcomes.[8910] By and large, a patient-centered approach is linked to an improved understanding of the medical problems.[1011] The patient-centered approach has been marked as “the physician tries to enter the patient's world, to see the illness through the patient's eyes.”[12] Nourishing humanistic values in general increases and augments interpersonal expertise and empathy precisely considered as dominant, important proficiency for professional practice, and identified as the most influential element of clinical practice, although it is often disregarded by practitioners.[61314] In terms of patient care, empathy is defined as “a cognitive attribute that involves an ability to understand the patient's pain, suffering, and perspective combined with a capability to communicate this understanding and an intention to help.”[15] In general, empathy has been defined concisely as the proper conjecture of the patient.[16] Research studies have made known that “warm, empathic style” by physicians during interacting and talking with patients is linked with better quality treatment outcomes,[17] such as augmented compliance with medical commendations,[1819] lessened pain,[20] reduced recovery time,[21] as well as amplified patient satisfaction,[192223] increased patients’ empowerment,[24] enhanced patients’ perception of their social support network,[224] and declined medical legal process.[2526] Furthermore, Professor Teresa Hellín has described that “to attend those who suffer, a physician must possess not only the scientific knowledge and technical abilities but also an understanding of human nature. The patient is not just a group of symptoms, damaged organs, and altered emotions. The patient is a human being, at the same time worried and hopeful, who is searching for relief, help, and trust. The importance of an intimate relationship between patient and physician can never be overstated because in most cases an accurate diagnosis, as well as an effective treatment, relies directly on the quality of this relationship.”[27] Clinician empathy is a strategic skill to interact and communicate with patients, and hence, develops and ensures patient-centered care; a wide-ranging line of action for clinical work that has emerged in the previous 20 years plus time and that lead to formulating and encompassed in many codes of conduct and guiding principles adopted and implemented by medical schools around the world.[282930]

Multiple research studies reported that empathy level is declining during medical school education and that one's attributes related to empathy, such as humanitarianism, enthusiasm, and idealism, also decreased.[63132333435363738] There are several studies conducted regarding empathy among Malaysian medical students.[39404142] Thus far, no data are available regarding empathy level among medical students of Universiti Pertahanan Nasional Malaysia (UPNM), National Defense University of Malaysia. The aim of the present study was to assess the empathy level of medical students of UPNM.

MATERIALS AND METHODS

Study design

This was a cross-sectional study.

Study population

The study populations were medical students of the UPNM, Kuala Lumpur, Malaysia.

Study period

Data were collected between February and April 2017.

Sampling method and sample size

Universal sampling method was adopted.

Techniques of data collection

The Empathy Quotient (EQ), a self-reported questionnaire, was utilized for the data collection.[43] The total score of empathy of the questionnaire is 80. Each item scores 1 point if the respondent records the empathic behavior mildly or 2 points if the respondent records the behavior strongly. A cutoff point equal to or fewer than 30 points is used to separate the group of students. This questionnaire is a straightforward score because it does not depend on any interpretation.[43] The necessary permission was obtained from the Department of Psychiatry, Autism Research Centre (ARC), the University of Cambridge, UK (http://www.autismresearchcentre.com/arc_tests). The questionnaire was pretested and validated with 25 medical students (5 from each year) who did not participate in the primary study. The Cronbach's alpha was calculated as 0.551 and convergent validity as −0.008–0.533. For convergent validity, most of the items correlated moderately to excellent to their own domain (P < 0.05).[44]

Data analysis and interpretation

Collected data were treated with t-test and one-way ANOVA (F-test) followed by post hoc Turkey test analysis with SPSS version 24 (IBM Corporation, Armonk, NY, USA).

Ethical consideration

This research was approved by the Centre for Research and Innovation Management, UPNM, Kuala Lumpur, Malaysia (Code of Research: UPNM/2016/SF/SKK/03, Memo No: UPNM [PPPI] 16.01/06/019 [02], December 22, 2016). The study population had been explained about the objectives of the study and informed written consent was obtained before questionnaires were distributed. Additionally, it was also informed that the data later will be utilized for publication. The students also ensured that the study participation is totally voluntary and anonymous and the information would be confidential.

RESULTS

The details of sociodemographic profiles and the empathy scores of the respondents are depicted in Table 1. All 207 students responded to the questionnaire. Majority of the respondents were male (60.9%), Year-V students (26.6%), Malay (70.5%), and cadet officer (69.6%). The overall mean score achieved by the respondents was 36.76 ± 9.18 (range: minimum 15 and maximum 63) and 74.4% of the respondents scored more than 30.

Table 1

Sociodemographic profiles and the empathy scores of the respondents

Variables	Respondents (%)	Empathy scores±SD	Level of significance
Sex
Male	126 (60.9)	35.56±9.18	<0.05
Female	81 (39.1)	38.63±8.93
Year of study
Year-I	41 (19.8)	35.88±7.84	<0.05
Year-II	37 (17.9)	35.51±8.92
Year-III	37 (17.9)	35.43±8.38
Year-IV	37 (17.9)	35.38±10.17
Year-V	55 (26.6)	40.09±9.58
Religion
Islam	148 (71.5)	36.16±8.77	>0.05
Buddha	47 (22.7)	42±10.05
Hindu	12 (5.8)	37.34±9.93
Race
Malay	146 (70.5)	36.03±8.76	>0.05
Indian	48 (23.2)	41.92±9.63
Chinese	13 (6.3)	37.58±9.97
Preuniversity education
Matriculation	24 (11.6)	38.17±6.01	>0.05
Foundation course	183 (88.4)	36.58±9.51
Categories of students
Cadet officer	144 (69.6)	36.78±9.83	>0.05
Territorial army	14 (6.8)	37.57±6.04
Civil student	49 (23.7)	36.49±7.96
Exam grades
A	22 (10.6)	39.73±9.18	<0.05
B	142 (68.6)	37.18±9.12
C	43 (20.8)	33.88±8.85
Total	207 (100)	36.76±9.18

SD=Standard deviation

The empathy scores of the students were significantly affected (t = 2.371; df = 205; P < 0.05) by the gender, i.e., female students are more empathetic than their male counterparts. F-test showed a significant effect of year of study (F = 2.553; df 4/202; P < 0.05) and exam grades (F = 3.488; df 2/204; P < 0.05) on empathy scores. Further, the post hoc Tukey test analysis for the year of study revealed that Year-V students differ significantly with Year-I to Year-IV students (P < 0.05), which indicates that Year-V are more empathetic than their junior counterparts. The post hoc Tukey test analysis for the exam grades was found to be significantly different between empathy scores of those students who got Grade A and Grade C (P < 0.05), which indicated that those who got the highest grade are more empathetic.

DISCUSSION

This EQ questionnaire possessed Cronbach's alpha of 0.80 which can be considered as a good reliability index for local context.[44] The overall empathy score (36.76 ± 9.18) of the respondents in this study was low when compared with that of an earlier study we conducted in Bangladesh with dental students (39.4 ± 8.7) using the EQ questionnaire.[45] A recent study conducted among medical students from the Faculty of Medicine, University of Lleida in Spain also showed higher empathy scores (50) using similar instrument.[46] Our study showed that female students score slightly but significantly higher on the EQ than their male counterparts. This supports a series of earlier studies reporting female superiority on empathy scales in medical schools in Malaysia[4042] and around the world.[364647484950] However, studies using the two most popularly used instruments in empathy research and medical education context, the Jefferson Scale of Physician Empathy (JSPE)[31323347484950515253545556] and the Interpersonal Reactivity Index,[51] showed mixed results in correlating the levels of empathy with gender. In the present study, 18.4% of males and 7.2% of females scored equal to or fewer than 30 points (cutoff score), which is much higher than Baron-Cohen et al's. study[43] which reported the development of the EQ questionnaire (14% and 4%, respectively). In comparison to Baron-Cohen et al's. study,[43] fewer students in the present study scored in the “super-empathic range” (i.e., equal to or more than 62 points, 7.7% vs. 1.5%).

Most of the studies in the literature suggested that empathy diminishes after the 3rd year of medical school.[3132333435363738] This research found that Year-V students had significantly higher levels of empathy than junior class students. One meta-analysis on the empathy levels of medical students, interns, and residents analyzed studies and showed significant decreases in empathy level when the respondents’ progress to complete their studies.[57] However, most of the longitudinal studies found no changes in the empathy scores over time. In a recent study, empathy scores in JSPE and EQ did not change and medical students were found to maintain empathy scores.[46] Appropriate educational interventions can be designed and implemented to inculcate, maintain, and enhance empathy in undergraduate medical students.[58] The inventions included patient narrative and creative arts, writing, drama, communication skills’ training, problem-based learning, interprofessional skills’ training, patient interviews, experiential learning, and empathy-focused training.[58]

This study also found that exam grades and level of empathy of medical students were significantly different who got Grade A and Grade C (P < 0.05), i.e., those who got the highest grade are more empathetic. The finding is supported by previous studies that showed a positive correlation between academic performance and clinical competence and empathy scores.[5960] However, studies found opposite findings – students from higher grade levels had lower scores than those from the lower grade levels.[5061] This issue needs further investigation using larger sample in multicenter settings.

This was a cross-sectional study with its own inherent limitations. The research sample was collected from only one public medical school of Kuala Lumpur, Malaysia. In addition, the study participants lead a restricted and disciplined military life. Hence, the study findings should be generalized with caution. Further studies are required on a longitudinal basis to explore various aspects of involving students of multiple medical institutions.

CONCLUSION

This study concluded that EQ questionnaire is found to have good reliability index for local context. We found low EQ scores among UPNM medical students in comparison to other studies conducted with the same questionnaire. In order to inculcate, maintain, and enhance the empathy level of the UPNM medical students, appropriate educational strategies and interventions should be designed and implemented in the undergraduate medical curriculum.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.