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BACKGROUND:Empathy is a fundamental humanistic component of patient care which facilitates efficient and patient-centered clinical encounters. Despite being the principal recipient of physician empathy little work on how patients perceive/report receiving empathy from their physicians has been undertaken. In the context of doctor-patient interactions, knowledge about empathy has mostly originated from physicians' perspectives and has been developed from studies using self-assessment instruments. In general, self-assessment may not correlate well with the reality observed by others. OBJECTIVES:To investigate: 1-the relationship between physicians' self-assessed empathy and patients' measures of physicians' empathy; 2 -Environmental factors that could influence patients' perceptions; and 3 -the correlation between two widely used psychometric scales to measure empathy from the perspective of patients. METHODS:This is an observational study which enrolled 945 patients and 51 physicians from radiology, clinical, and surgical specialties. The physicians completed the Jefferson Scale of Physician Empathy (JSE) and the International Reactivity Index (IRI), and patients completed the Consultation and Relational Empathy scale (CARE), and the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE). RESULTS:We did not observe any significant correlation between total self-assessed empathy and patients' perceptions. We observed a small correlation (r = 0,3, P
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Physicians’ self-assessed empathy levels do
not correlate with patients’ assessments
Monica Oliveira Bernardo
, Dario Cecı
, Patrı
´cio Costa
, Thelma A. Quince
Manuel João Costa
, Marco Antonio Carvalho-Filho
1Radiology Department–Faculty of Medicine—Catholic University of São Paulo–Sorocaba–São Paulo—
Brazil, 2Center for Educational Development Innovation and Research–University Medical Center–
University of Groningen–Groningen–The Netherlands, 3Life and Health Sciences Research Institute—
School of Health Sciences—University of Minho–Braga–Portugal, 4Department of Public Health and Primary
Care–University of Cambridge–Cambridge—United Kingdom, 5Life and Health Sciences Research Institute
—School of Health Sciences—University of Minho–Braga–Portugal, 6Emergency Department–School of
Medical Sciences–University of Campinas–Campinas–São Paulo–Brazil, 7Center for Educational
Development Innovation and Research–University Medical Center–University of Groningen–Groningen–The
Empathy is a fundamental humanistic component of patient care which facilitates efficient
and patient-centered clinical encounters. Despite being the principal recipient of physician
empathy little work on how patients perceive/report receiving empathy from their physicians
has been undertaken. In the context of doctor-patient interactions, knowledge about empa-
thy has mostly originated from physicians’ perspectives and has been developed from stud-
ies using self-assessment instruments. In general, self-assessment may not correlate well
with the reality observed by others.
To investigate: 1—the relationship between physicians’ self-assessed empathy and
patients’ measures of physicians’ empathy; 2 –Environmental factors that could influence
patients’ perceptions; and 3 –the correlation between two widely used psychometric scales
to measure empathy from the perspective of patients.
This is an observational study which enrolled 945 patients and 51 physicians from radiology,
clinical, and surgical specialties. The physicians completed the Jefferson Scale of Physician
Empathy (JSE) and the International Reactivity Index (IRI), and patients completed the Con-
sultation and Relational Empathy scale (CARE), and the Jefferson Scale of Patient’s Per-
ceptions of Physician Empathy (JSPPPE).
We did not observe any significant correlation between total self-assessed empathy and
patients’ perceptions. We observed a small correlation (r = 0,3, P<0,05) between the sub-
PLOS ONE | May 31, 2018 1 / 13
Citation: Bernardo MO, Cecı´lio-Fernandes D, Costa
P, Quince TA, Costa MJ, Carvalho-Filho MA (2018)
Physicians’ self-assessed empathy levels do not
correlate with patients’ assessments. PLoS ONE 13
(5): e0198488.
Editor: Alejandro Arrieta, Florida International
Received: February 12, 2018
Accepted: May 20, 2018
Published: May 31, 2018
Copyright: ©2018 Bernardo et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: Funding was provided by Fapesp -
Fundac¸ão de Amparo a Pesquisa do Estado de São
Paulo (2016/11908-1) to Dr Marco Antonio
Carvalho-Filho. The funder had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
dimension Perspective Taking-JSE and JSPPPE. JSPPPE and CARE had a positive and
moderate correlation (0,56; p<0,001). Physicians’ gender and sector influenced the
JSPPPE score. Sector, medical specialty and the nature of the appointment (initial versus
subsequent) influenced the CARE measure.
The lack of correlation between self-assessed empathy levels and patients’ perceptions
suggests patients be included in the process of empathy evaluation.
Practice implications
Training strategies aiming the development of empathy should include patients’ evaluations
and perspectives.
Empathy is a fundamental humanistic component of patient care [1] which facilitates efficient
and patient-centered clinical encounters [2,3]. Positive associations have been found between
physicians’ self-measured empathy and patients’ outcomes, for example in LDL control and
the incidence of metabolic complications of diabetes [4,5]. Moreover, empathetic doctors are
more satisfied with their jobs and less susceptible to burnout and depression [69]. However, a
number of problems surround the definition, components, and measurement of empathy [10].
Empathy is multidimensional, involving affective, cognitive and behavioral components
[11]. The affective component refers to one’s ability to perceive subjectively another person’s
inner experiences and natural feelings [12]. The cognitive component of empathy relates to
the capacity to understand and view the outside world from the other person’s perspective
[12]. The behavioral component includes the predisposition and competency to adequately
create a bond with the other person together with the ability to communicate these under-
standings and feelings to reassure and comfort the other [13,14].
Despite being the principal recipient of physician empathy little work on how patients per-
ceive/report receiving empathy from their physicians has been undertaken [15]. Indeed, in the
context of doctor-patient interactions, knowledge about empathy has mostly originated from
physicians’ perspectives and has been developed from studies using self-assessment instru-
ments [16,17]. Very few studies have compared standardized patients’ measures of physicians’
empathy with physicians’ or medical students’ self-assessed empathy. Those undertaken have
reported no significant correlations [18,19]. In general, self-assessment may not correlate well
with the reality observed by others [20,21]. Measuring physician empathy is also fraught by the
variety of instruments employed which research suggests may measure differing constructs
Therefore, physicians’ view of their own empathy may be at worst incorrect and at best
biased. For instance, social expectations about what is considered a desirable attitude for doc-
tors may influence the way physicians appreciate themselves [22]. It would seem crucial, there-
fore, that any evaluation of physician empathy should consider patients’ perspectives. This
would allow a more concrete understanding of physician/patient interaction [23].
However, empowering patients to measure physicians’ empathy is not simple nor easy.
There are constraints related to time, and logistics to fit patients’ assessment on routine clinical
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 2 / 13
activities [24]. Moreover, a cultural change is needed to make doctors aware of the need to
consolidate the role of the patient as a legitimate evaluator of physicians’ behaviors and atti-
tudes [25].
In addition, patients’ perspectives can also be influenced by different factors beyond the
direct interaction with their doctors. These factors include the prevailing physical ambiance,
the patient’s or physician’s gender, and the duration or context of the consultation [26,27]. A
recent Argentinean study showed that age, education level, South American ascendancy and
type of hospital influenced patients’ perceptions of physicians’ empathy [28].
Despite the importance of their views, to the authors’ knowledge, only three studies directly
compared physicians’ perceptions of their own empathy and patients’ perceptions of physicians’
empathy, using validated psychometric scales. [2931]. Two studies reported no significant cor-
relation, but both studies had small samples of physicians (n = 27 and n = 29), and the number
of patients was not reported [29,30]. A third study found a positive and significant correlation,
but the samples of physicians and patients were small (36 physicians and 90 patients) [31]. Since
medical training at both graduate and post-graduate levels relies heavily on self-assessed mea-
sures of physicians’ empathy, more studies are needed to understand in what extent self-
assessed empathy matches with patients’ perspectives. This understanding would be particularly
relevant to guide feedback and further professional development of doctors.
Our study set out to investigate the relationship between physicians’ self-assessed empathy
levels and patients’ measures of physicians’ empathy. We also investigated whether patients’
assessments could be influenced by patient socio-demographics and consultation contextual
factors in the physician-patient interaction. These factors included gender, medical specialty,
and aspects of the consultation, such as location and whether this was an initial or subsequent
consultation. This work was undertaken in public and private hospital settings in Brazil.
Based on the assumption that self-assessment is frequently not accurate [20], we hypothe-
sized that self-assessed empathy levels would be poorly correlated with patients’ perceptions.
Empathy has several dimensions which may not be fully covered by one instrument. There-
fore, we used two instruments that capture different constructs of empathy [22] to measure
self-assessed physician empathy and two instruments to measure patients’ perspectives of phy-
sicians’ empathy.
For physicians’ self-assessment we used the Jefferson Scale of Empathy (JSE) and the Inter-
personal Reactivity Index (IRI). These instruments were developed with different perspectives
[32]. The JSE was specifically designed to measure empathy in the healthcare context and
focuses on the cognitive aspects of physician empathy [29]. IRI was developed to measure
empathy in the general population and assesses both the affective and cognitive components of
empathy [27]. An international study demonstrated that these two instruments capture differ-
ent constructs of empathy [22].
The instruments to evaluate patients’ perspectives of physician empathy were the Jefferson
Scale of Patient’s Perceptions of Physician Empathy (JSPPPE) and the Consultation and Rela-
tional Empathy Scale (CARE). The JSPPPE was developed assuming empathy to be a “predom-
inantly cognitive attribute” [33].
The CARE measure was developed to capture patients’ expectations of clinical encounters
[34,35]. Both instruments were based on extensive literature reviews, and the latter was also
based on in-depth interviews with a group of ambulatory patients. We hypothesized that
JSPPPE and CARE could also reflect patients’ views of the different components of empathy.
To explore the relationship between patients’ and physicians’ assessments of physician
empathy we asked the following research questions:
1. How do scores on patient scales (JSPPPE and CARE) relate to each other?
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 3 / 13
2. Do the patients’ scores vary according to contextual aspects of the consultation (gender,
location, specialty or initial versus subsequent consultations) beyond the specific doctor/
patient interaction?
3. Do self-assessed physicians’ scores on the IRI and the JSPE scales correlate with patients’
scores obtained with the JSPPPE and CARE scales?
Physicians. All physicians in two clinics (one private, one public) located in the same
multi-specialty medical center in Sorocaba, São Paulo, Brazil (n = 60) were invited to partici-
pate, and 51 agreed to do so. Those who declined to participate mentioned time constraints
(n = 6) and not feeling comfortable taking part (n = 3). All participants were experienced phy-
sicians with an average of 18,8 years (±11,7/range 3–43) years of practice and comprised inter-
nists (n = 24), surgeons (n = 10) and radiologists (n = 17). Table 1 present physician’s
demographic information, local of work, their specialties, and self-assessed empathy levels
(Table 1).
Patients. Adult patients (n = 1100) under the supervision of the participating physicians
were randomly invited to join the study and 1050 decided to participate. Fig 1 gives the patient
flow chart: 50 patients declined because time constraints and feeling uncomfortable comment-
ing on their doctors. A further 105 were excluded because they were under 18 years-old, not
able to complete the instrument, or illiterate. The total number of patients was 945, of whom
639 were females (average age 50,5 years-old ±14,1/range 19–84) and 306 males (average age
50,4 years-old ±14,8/range 18–94). Between 18 and 25 patients of each of the participating
doctors took part in the study. (The primary objective was to have 25 patients per doctor.)
Administration procedures
Paper questionnaires were used and patients were approached by an independent researcher,
with no responsibility or connection to their care. The patients were instructed to fill the scales
and to hand them back to the researcher in a closed envelope. All forms were anonymized.
Patients and physicians had access only to their own aggregate results at the end of the study.
The questionnaires were returned directly to the researchers in closed envelopes and the
results were inserted into a data system by a designated person, who did not have access to
patients’ names.
Table 1. Descriptive and comparative statistics for physicians’ characteristics.
Physicians’ characteristics N (%) JSE IRI
Gender Male 35 (69%) 116,3 ±16,5 57 ±10,1
Female 16 (31%) 123,3 ±9,0 61,6 ±9,1
Sector Private 39 (76%) 119,2 ±12,7 58,3 ±9,6
Public 12 (24%) 116,2 ±20,9 58,9 ±11,5
Specialty Internal Medicine 24 (47%) 120,4 ±11,8 58 ±10,9
Surgery 10 (20%) 117,4 ±23,2 57,3 ±10,2
Radiology 17 (33%) 116,4 ±13,3 59,7 ±8,8
Total 51 118,5 ±14,9 58,4 ±9,9
JSE = Jefferson Scale of Physician Empathy; IRI = Interpersonal Relative Index.
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 4 / 13
Physicians. We used the Portuguese versions of the Jefferson Scale of Empathy (JSE) and
the Interpersonal Reactivity Index (IRI assess physicians’ self-assessment of their empathy.
Both self-assessment instruments have a mixture of positive and negative items and both ask
respondents to rate the extent to which they agree or disagree with statements. JSE has 20
items each rated on a 7-point Likert scale and comprises three subdimensions, Perspective
Taking, Compassionate Care and Standing on the Patients’ shoes [36]. The IRI has 28 items
each rated on a 5-point Likert scale and comprises four distinct dimensions: Perspective Tak-
ing, Empathic Concern, Personal distress and Fantasy [37].
Patients. We used the Jefferson Scale of Patient’s Perceptions of Physician Empathy
(JSPPPE) and the Consultation and Relational Empathy scale (CARE) to measure physicians’
Fig 1. Patient´s flowchart.
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 5 / 13
empathy as perceived by their patients. Both instruments ask patients to rate the extent they
agree or with statements and both are administered at the end of the clinical consultation. The
JSPPPE has 5-items rated on a 7-point Likert scale [29,30]. As no Portuguese version was avail-
able it was translated into Portuguese by four bilingual physicians and checked for accuracy by
a professional translator. The developers of the original English version supervised the process
[38,39]. Researchers interviewed voluntary patients (n = 100) to verify whether the final ver-
sion was understandable. The CARE instrument has 10 items which address different compo-
nents of empathy (affective, cognitive and behavioral). Each item is measured on a 6-point
Likert scale. We used the Portuguese version of CARE scale, which was translated by Scarpel-
lini in 2014 [40]. We performed an analysis of the structure of the scale, as this has not done
Empathy scores. The total score of JSPPPE and CARE is the sum of all item scores and all
the items must be answered to be included. The overall score for the JSE is the sum of all items
scores, but the negative items are transformed into positive ones for analyses; the higher the
total score, the higher the levels of empathy. Similarly, negative items on the IRI were trans-
formed into positive scores. We used the subscale scores for both the JSE and IRI. In accor-
dance with other studies of physician empathy we used the total score for the JSE. For the
purposes of consistency in the analysis we also used the total score for the IRI.
Statistical analyses
We investigated the psychometric properties of the JSPPPE and CARE instruments. The abso-
lute values of skewness and kurtosis for all items were within the acceptable range of the nor-
mal distribution (between -2 and 2) for both JSPPPE and CARE scales, with the exception of
item number 5 of the JSPPPE scale. Subsequent analyses demonstrated that there was no dif-
ference when using the raw and transformed data in the outcome of the analysis. Therefore,
we only present the outcomes of parametric analyses using the raw data. Cross-validation of
the JSPPPE and CARE was assessed using a holdout method with Principal Component Anal-
ysis and Confirmatory Factor Analysis, applied to two sub-samples (A and B), obtained from
randomization of the full sample. An exploratory principal component analysis with Principal
Axis Factoring was applied to sub-sample A (n = 474). A confirmatory factor analysis with
Maximum Likelihood estimation was applied to sub-sample B (n = 471). To assess the best
confirmatory factor model, we used the following goodness of fit: Chi-square statistics, Com-
parative Fit Index (CFI), Tucker-Lewis Index (TLI) and Root Mean Square Error of Approxi-
mation (RMSEA). The Chi-square statistics was used to assess the overall fit and discrepancy
between the sample and the model. Both CFI and TLI were considered optimal with values
above 0,90. Optimal RMSEA is close to zero. Reliability was calculated using Cronbach Alpha.
We used Pearson correlation to investigate the relation between physicians’ self-report
empathy and the empathy perceived by their patients. Since the Jefferson Scale of Empathy
(JSE) and the Jefferson Scale of Patient’s Perceptions of Physician Empathy (JSPPPE) were
developed by the same researchers using similar words in many questions, we also have ana-
lyzed the intra-class correlation between the items of the JSPPPE and JSP. We have analyzed
the four from the JSPPPE with items 2 and 10 from JSE; the item 3 from the JSPPPE with item
16 from JSE; and the item 1 from JSPPPE with items 3, 6 and 9 from JSE. We compared
patients’ assessments in respect of their gender and sector (public vs. private) using t-tests and
we investigated differences between medical specialty by means of an analysis of variance
Data were analyzed using IBM-SPSS 21.0 and AMOS 18. The latter was only used for the
confirmatory factor analysis.
Patients’ assessment of physicians’ empathy
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Ethical approval
We obtained ethical approval for this study from the Research Ethics Committee of the Faculty
of Medical Sciences–São Paulo Catholic University in June 2015 (CAAE = 46056115.0.0000.
5373). All participants gave written informed consent before data collection began.
Cross-validation of instruments
There are no validation studies in the respective contexts of the instruments used in this study
to assess physician empathy as perceived by the patient participants. Therefore, we included a
validation step.
The necessary assumption of Principal Component Analysis (PCA) was met with a
KMO = 0,781, and Bartlett’s Test of Sphericity was significant (p <0,001). The PCA demon-
strated a unidimensional factorial structure with an eigenvalue of 3,42, explaining 68,9% of the
variance; factor coefficients ranged from 0,84 to 0,87.
Confirmatory Factor Analysis (CFA) revealed that the base model (model A) for the
JSPPPE demonstrated poor fit index values, based on the χ2/df ratio, the Comparative Fit
Index (CFI) and Root Mean Square Error of Approximation (RMSEA). When the correlation
between the items’ errors was added (model B), the model achieved a satisfactory level of
model fit (Table 2).
Cronbach’s Alpha for the total sample was 0,88, indicating that the instrument is reliable.
The necessary assumptions of PCA were meet with a KMO = 0,849, and Bartlett’s Test of Sphe-
ricity was significant (p <0,001). The Principal Component Analysis demonstrated a unidi-
mensional factorial structure with an eigenvalue of 7,66, explaining 76,7% of the variance;
factor coefficients ranged from 0,77 to 0,91.
Confirmatory Factor Analysis (CFA) revealed that the base model for the CARE scale
(model A) displayed poor fit index values, based on the χ2/df ratio, the Comparative Fit Index
(CFI) and Root Mean Square Error of Approximation (RMSEA). When the correlation
between the items’ errors was added (model B), the model achieved a satisfactory level of
model fit (Table 3).
Table 3. Fit indices for the CARE scale.
(df) Sig. Ratio χ
Model A χ
(35) = 307; p<0,001 8,771 0,940 0,954 0,129 (0,142)
Model B χ
(30) = 126; p<0,001 4,200 0,975 0,984 0,083 (0,098)
Table 2. Fit indices for the JSPPE.
(df) Sig. Ratio χ
Model A χ
(5) = 61,38; p<0,001 12,276 0,932 0,966 0,155 (0,191)
Model B χ
(3) = 5,66;
p = 0,129
1,888 0,995 0,998 0,043 (0,098)
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 7 / 13
Cronbach’s Alpha for the total sample was 0,97, indicating that the instrument is reliable.
Concurrent validity
The correlation between the JSPPPE and CARE latent variables was moderate (0,56) and sig-
nificant (p<0,001), indicating that both scales share 32% of the same measurement.
Contextual elements influencing patients’ perspectives (Table 4)
Patients’ gender did not affect their assessments on either the CARE or the JSPPPE scales.
However, patients’ assessments of female physicians were higher on the JSPPPE scale but not
on the CARE scale.
Patients in the private sector perceived their physicians’ empathy to be significantly higher
than those in the public sector on both scales.
There was a significant difference regarding medical specialty for the CARE measure (F
(2,942) = 7,426 –p<0,005), but not for the JSPPPE (F (2,942) = 2,904 –P>0,05).
Subsequent consultations resulted in a higher score for empathy on the CARE measure, but
no difference was observed with the JSPPPE scale when compared to initial consultations.
Associations between the patients’ and the physician self-assessed empathy
As the number of patients per doctor differed we averaged the patients’ responses to their par-
ticular physician before conducting the Pearson correlation analysis. All correlations between
patients’ and physicians’ perspectives were not significant, with one exception (Table 5). The
score of the JSPPPE positively and significantly correlated with the sub-score of the Perspective
Taking dimension of the JSE. Also, the outcomes regarding the intra-class analyses showed a
low agreement between the empathy perception of the physician and the patient (ranging
from 0,151 to 0,197). The exception was item 1 from JSPPPE with items 3, 6 and 9 from JSE in
which the analyses did not have enough variance.
There were no significant correlations between the total scores and the sub-scores of IRI
and JSE.
Table 4. Descriptive and comparative statistics for patient’s characteristics and measurements.
Patient’s Gender . Male 306 32% 30,1 ±5,8 p = 0,064 43,1 ±7,5 p = 0,302
. Female 639 68% 30,8 ±5,4 42,6 ±7,8
Physician’s Gender . Male 692 73% 30,2 ±5,7 p<0,001 42,5 ±7,7 p = 0,124
. Female 253 27% 31,6 ±5,2 43,4 ±7,8
Sector . Private 810 86% 31,0 ±5,1 p<0,001 43,5 ±7,3 p<0,001
. Public 135 14% 28,2 ±7,4 38,2 ±8,5
Specialty . Internal Medicine 437 31,1 ±5,3 p = 0,055 43,8 ±7,5 p<0,001
. Surgery 177 30,0 ±6,0 42,3 ±7,8
. Radiology 331 30,1 ±5,7 41,5 ±7,8
Appointment . Initial 543 57% 30,4 ±5,5 p = 0,266 42,3 ±7,6 p = 0,031
. Subsequent 402 43% 30,8 ±5,7 43,4 ±7,8
Total 945 100% 30,6 ±5,6 42,8 ±7,7
JSSPPE = Jefferson Scale of Patients Perceptions of Physician Empathy; CARE = Consultation and Relational Empathy Scale.
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 8 / 13
Discussion and conclusion
The present study was developed with the underlying premise that patient involvement is vital
to evaluate physician’s empathy. Our study indicates that the JSPPPE and CARE scales may
capture different aspects of how patients perceive their physician’s empathy but that they share
a common element. Both are validated measures which should be more widely employed.
Our study also revealed that contextual factors influenced patients’ perspectives of the
empathy they received. We found a small but significant difference in CARE measures among
different medical specialties, which was not found with the JSPPPE. CARE was also able to
capture differences between empathy measurements from initial and subsequent consulta-
tions. It suggests that the CARE measure can capture more subtle nuances of patients’ interac-
tions with their doctors, confirming its value to address relational components of empathy.
Another interesting aspect of our results is the influence the sector (public vs private) had on
patients’ scores. In Brazil, the Health System is divided into a public sector, supported by the
government, and a private sector, maintained by private profit-driven Health Insurance Com-
panies. Our results show that patients in the private sector tend to give higher empathy scores
to their doctors. Two interpretations are possible: the doctors are consciously or unconsciously
modulating their behavior, or there are other elements influencing patients scores beyond the
direct interaction with their doctors. Regarding the first possible interpretation, a study with
German doctors showed a positive impact of financial incentives on patients’ perceptions of
physicians’ empathy measured by the CARE scale, which is aligned with our findings [26].
Considering the second possibility, a similar survey in Argentina showed opposite results, with
patients scoring higher physicians from the public sector. The authors of this second study
hypothesized that patients were expecting less from the doctors working in the public sector
[28]. It could suggest that different cultural expectations regarding the public or private health
systems can interfere in patient’s perceptions.
This study involved patients and doctors exclusively from one institution and nationality.
Extrapolations of findings to other cultures need to be cautious, as patient definitions and clas-
sifications of empathy are culturally sensitive. Indeed, patients from different cultures can have
disparate expectations regarding an empathetic doctor and doctors themselves can vary their
understandings about how to demonstrate empathic concern or shared understanding [41]. In
Table 5. Pearson correlations between empathy measurements: Physicians’ and patients’ perspectives.
Physicians’ Perceptions (n = 51) Patients’ Perceptions’ (n = 945)
JSE Perspective Taking 0,3010,04
Compassionate care 0,07 0,03
Standing in the Patient’s Shoes 0,10 -0,07
Jefferson Total 0,23 0,01
IRI Perspective Taking 0,14 -0,09
Empathic concern 0,06 0,14
Personal Distress -0,02 -0,04
Fantasy 0,08 0,04
IRI Total 0,12 0,02
p<0.05. Note: Perspective Taking and Empathic concern are other-oriented dimensions of IRI, while Personal
Distress and Fantasy are self-oriented.
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 9 / 13
addition, the interpretation of the instrument items may have cultural nuances that the study
did not expose, as that went beyond the predetermined goals. For instance, the item “How was
the doctor showing care or compassion” (CARE scale) can be differently understood by a
European, South American or Asian patient. Subsequent research should clarify the influence
of cultural specificities in our findings.
An important objective of our study was to evaluate associations between widely used phy-
sician self-assessed empathy measures (JSE and IRI) and patient measures (JSPPPE and
CARE) collected from the respective patients. The main finding was that there were no corre-
lations between physician and patient measures. Overall, this study confirmed that self-
assessed physician measures: JSE and the IRI, did not accord with the perceptions of their
patients about their empathy as collected with the CARE and the JSPPPE. The main implica-
tion of this study is the confirmation that inferences about physician empathy based on self-
assessment measures should not be taken as representative of patient perceptions.
The correlation of JSPPPE with the Perspective Taking dimension of JSE is in accordance
with its development, which aimed the cognitive aspect of empathy [33]. Both instruments
were developed by Hojat et al and use similar wording [29]. On the other hand, the CARE
items were developed based on in-depth interviews with patients and further refined through
interviews with patients, physicians and experts [34,35]. The CARE items aim to capture the
internal atmosphere of the consultation; valuing empathy in the context of listening, reassur-
ing and planning, from a patient perspective [34]. The lack of correlation of CARE and self-
assessed measures of empathy gives insight into how inefficient self-assessment could be in
capturing patients’ subjective experiences.
Patients’ assessment of physicians’ empathy must be valued in empathy research and also in
clinical care evaluation. More research is needed to investigate better how the different compo-
nents of empathy and the various elements of the clinical encounter influence patient care and
satisfaction. Physicians’ self-assessment of their own empathy is insufficient to evaluate the
complexity of the interaction between doctors and patients. Insights from the empowerment
of patients can give opportunities to develop training strategies to physicians willing to
improve their clinical interactions with patients. Health care providers can also use this data to
bring the multi-professional team together to discuss how to implement changes in patient
care that could foster a patient-centered approach. Future research should explore what
patients demand for their physicians’ behaviors and attitudes to acknowledge them as
empathic doctors.
Practice implications
Our data corroborate the understanding that empathy is a complex construct that should be
evaluated through different lenses, depending on the goal of the evaluation process. If the
intention is to create awareness among clinical doctors or medical students about the clinical
value of empathy, self-assessment may represent a good strategy, providing there is awareness
of the advantages and disadvantages of the instruments used. If, however, the purpose is to
improve clinical care, then education and other interventions based on self-assessment instru-
ments may not be enough because self-assessment cannot capture the reality as perceived by
patients. As such, the curricular design for teaching and learning empathy and the interna-
tional studies about medical students’ empathy development should be revisited, and there are
implications for curricula and for teaching and learning empathy, of international studies
about the development of undergraduate medical students’ empathy [42] and of studies
Patients’ assessment of physicians’ empathy
PLOS ONE | May 31, 2018 10 / 13
evaluating the impact of programs to enhance empathy [43] should be revisited. Not only is
selecting and applying the appropriate instrument to the research or practical question under
investigation important but also, where ever possible, including patients is crucial.
Our contribution to the field is to show that the patient scales JSPPPE and CARE could be
measuring different components of empathy and that other elements of the clinical encounter
affects patients’ perceptions of their physicians’ empathy.
Unfortunately, our study was not designed to identify and to discriminate all the possible ele-
ments that could interfere with patients’ perceptions. However, we could hypothesize that
time spent on consultation, time waiting for consultation, the general comfort of the environ-
ment, interactions with other health care professionals, the sense of the dignity of the process
of care, and also heuristic bias related to the act of paying for the consultations are all possible
factors. Further research is necessary to clarify these relations and how they can affect patients’
perceptions of physicians’ empathy, so allowing a more meaningful interpretation of data orig-
inated from these measurements. Also, our data were collected in a single center which can
prevent generalization of the results. Although the number of interviewed patients was ade-
quate, the number of doctors participating was small.
Supporting information
S1 Data.
The authors would like to thank all the patients and physicians who contributed to this work.
Author Contributions
Conceptualization: Monica Oliveira Bernardo, Manuel João Costa, Marco Antonio Carvalho-
Formal analysis: Dario Cecı
´lio-Fernandes, Patrı
´cio Costa, Manuel João Costa.
Investigation: Monica Oliveira Bernardo, Marco Antonio Carvalho-Filho.
Methodology: Monica Oliveira Bernardo, Dario Cecı
´lio-Fernandes, Patrı
´cio Costa, Manuel
João Costa, Marco Antonio Carvalho-Filho.
Project administration: Monica Oliveira Bernardo, Marco Antonio Carvalho-Filho.
Supervision: Thelma A. Quince, Manuel João Costa, Marco Antonio Carvalho-Filho.
Validation: Monica Oliveira Bernardo, Thelma A. Quince, Marco Antonio Carvalho-Filho.
Writing – original draft: Marco Antonio Carvalho-Filho.
Writing – review & editing: Monica Oliveira Bernardo, Dario Cecı
´lio-Fernandes, Thelma A.
Quince, Manuel João Costa, Marco Antonio Carvalho-Filho.
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... 37 We evaluated construct validity, taking into account previous studies, by means of confirmatory factor analysis (CFA). 24,38,39 We performed CFA with Stata 12.1. using structural equation modeling (SEM) on a polychoric correlation matrix, as well as with the estimation method considered to provide maximum likelihood thanks to its adequacy for ordinal data. ...
... The mean Sp-JSPPPE score was similar to the original scale's results 30,44,45 and to the mean obtained with other translations. 38 Nevertheless, other versions have reported lower scores. 46,47 Other empathy scales (CARE) also had lower values in Asian countries. ...
... Other studies also had a high ceiling effect, 39 while articles that make no reference to this effect presented high mean scores. 30,38 These results can be explained by the fact that Spanish (Spain) patients usually hold a positive view of their PCPs' work. In fact, the community of Navarre, where the Sp-JSPPPE Measure was validated, attained the second highest score in a study involving satisfaction with the Spanish health care system. ...
Background and objectives: Empathy is considered a prerequisite for a successful physician-patient relationship. The Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) is a regularly-used, patient-rated measure of physician empathy. The aim of this study is to translate and analyze the reliability and validity of the JSPPPE Spanish (Spain) version (Sp-JSPPPE) in primary care in order to use it with medical trainees. Methods: After translation and back translation of the JSPPPE, 369 patients from 21 primary care physicians in Pamplona (Navarre, Spain) completed the Sp-JSPPPE, a sociodemographic questionnaire, the Spanish (Spain) Consultation and Relational Empathy Measure (Sp-CARE), and a question about overall satisfaction. We studied internal reliability (Cronbach's α and ordinal α), homogeneity (corrected item-total correlations), construct validity (confirmatory factor analysis [CFA]) and concurrent validity (Spearman's correlation) of Sp-JSPPPE. Results: Cronbach's α and ordinal α were 0.870 and 0.919, respectively, for the Sp-JSPPPE, and all corrected item-total correlations exceeded the accepted cutoff of 0.30, demonstrating high internal reliability and homogeneity. CFA corroborated the one-factor structure proposed in the original version. The total score for the Sp-JSPPPE was significantly correlated with sp-CARE (Spearman's ϱ 0.651, P<.001) and with overall patient satisfaction (Spearman's ϱ 0.504, P<.001). Conclusions: The results support the reliability and validity of the Sp-JSPPPE in primary care. Sp-JSPPPE could be useful in empathy assessment of medical trainees, both graduate and postgraduate, in the Spanish context.
... During the pandemic, they must deal not only with the prejudice and social stigma associated with working with COVID-19 patients but also with the potential risk of contamination (24,25). Compared to other physicians, empathic physicians have a high degree of satisfaction and are less prone to weariness and sadness (26). It is highly beneficial to investigate the characteristics of further empathetic medical students and support the development of empathy throughout medical education (27). ...
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Background: The COVID-19 pandemic has induced fear and mental health problems in the community and among healthcare workers. Empathy with patients may be difficult in such situations due to urgent conditions. Objectives: We aimed to evaluate medical students’ empathy and fear toward COVID-19 patients during the pandemic. Methods: This cross-sectional study recruited 107 medical students from Shiraz Medical School in 2021. A Persian version of the Jefferson Scale of Physician Empathy (JSPE) was used to assess the participants’ empathy toward COVID-19 patients. The internal validity of the Persian version of JSPE was 0.78, and its test-retest reliability after 14 days was 0.92 in a previous study. The participants were requested to fill out a fear of COVID-19 scale (FCV-19S) previously developed to assess their fear of affliction with COVID-19. Since the normality of data distribution was not approved, we used nonparametric tests, namely, the Mann-Whitney U test and the Spearman correlation coefficient. Results: The mean empathy score based on the Persian version JSPE was 71.94 ± 12.83 out of 140, which was higher in male students and those who resided in dormitories. The mean fear score was 24.93 ± 6.16 out of 35. Participants living out of dormitories feared COVID-19 to a greater extent. No statistically significant association was found between the age of the participants and these two parameters. The Spearman correlation coefficient test showed that students with a history of COVID-19 had less fear and more empathy because of their experience with COVID-19 (r = -0.249, P-value = 0.02). Conclusions: This study highlights the impact of the pandemic on the interaction between medical students as healthcare professionals and patients by affecting medical students’ fear and empathy. The study indicates ways to improve readiness for future pandemics. Our study showed that living far away from families in dormitories may influence students’ fear and empathy. Moreover, empathy, unlike fear, was affected by gender. A reverse correlation existed between fear and empathy in students with a history of COVID-19, indicating that the more they had empathy, the less they experienced fear.
... En una revisión sistemática se recomienda utilizar un informe que sea respondido por el médico y otro por el paciente (Lelorain et al., 2012), lo cual haría posible comparar ambas medidas y hallar inconsistencias. En un estudio en el que se efectuó dicha comparación se encontró que la evaluación de la empatía autorreportada por el médico ("resonancia") y la calificación del paciente ("recepción") no estaban correlacionadas (Bernardo et al., 2018), y en otro se encontraron resultados similares, siendo las calificaciones de los pacientes más elevadas (Hermans, Hartman y Dielissen, 2018). Por tal motivo, deben tomarse en cuenta que cuando los médicos responden cuestionarios que involucran variables psicosociales, tienden a hacerlo de manera deshonesta o poco genuina debido a los diversos estigmas a los que se enfrentan en el contexto sanitario (Gold, Sen y Schwenk, 2013). ...
Diversos autores han postulado que la variable empatía, esto es, la que manifiesta el médico durante el contacto con sus pacientes, beneficia al usuario y al mismo profesional de la salud, para lo cual se suele citar la literatura internacional, lo que plantea dificultades para la generalización en virtud de que se ha señalado que el comportamiento empático se ve afectado por la nacionalidad del médico y del paciente. Por otra parte, no todos los autores consideran que la relevancia de la empatía sea sobresaliente en el contexto sanitario, o que su importancia sea una cuestión resuelta por la falta de consenso sobre cómo medir y operacionalizar esta variable. Por lo anterior, este trabajo tuvo como objetivo analizar y reportar los resultados de una revisión de la literatura nacional e internacional de artículos en los que se ha encontrado un efecto benéfico de la empatía y la relación de esta con un resultado positivo hacia el paciente o los manifestados en el mismo profesional empático; igualmente, reportar los instrumentos que se han utilizado para evaluar el constructo cuando los autores indican el hallazgo de sus beneficios. La búsqueda se limitó a los años 2014-2020, siendo las fuentes de información Pubmed, Cochrane, Scielo, Latindex y RedALyC. Se encontraron 420 artículos en total, pero solo nueve satisficieron los requisitos de búsqueda; además, se halló la referencia de siete instrumentos de medición. Por un lado, en este documento se discuten algunas implicaciones sobre la evaluación de la empatía con base en la investigación actual; por otro, se provee información relevante para aquellos profesionales interesados en los beneficios de la empatía en el contexto sanitario, así como en la evaluación del fenómeno en el personal médico.
... Furthermore, communication skills have been related to competence in providing person-centered care (Park & Choi, 2020 Ozdemir & Sendir, 2020). Empathy has also been correlated to humanistic and individual caregiving abilities (Bernardo et al., 2018;Ward, 2016). Empathy is other-oriented and grounded in concern for the other's well-being. ...
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Purpose: The aim of the study was to investigate the empathy level and caring behaviors perceptions of nursing students. Method: This cross-sectional and correlational study was conducted with 276 nursing students. Results: The mean Empathic Tendency Scale score was 62.71 ± 5.10 (min. 20 to max. 100), indicating a low level of empathy. The mean of the Caring Assessment Questionnaire was 5.42 ± 0.80 (min. 1 to max. 7), showing a good perception of caring behaviors. There was a positive, low, and significant relationship between empathy and caring behaviors (r = 0.286, p < 0.001). Conclusion: This study revealed that nursing students have low-level empathy and high-level caring behaviors. Practice implications: Throughout the educational process, the students' caring competencies, which include empathy and caring behaviors, developed. It is suggested that humanistic and value-oriented pedagogical approaches be incorporated into nursing curricula.
Introduction: Since the patient-doctor relationship (PDR) plays a crucial role in patient primary health care and management, the evaluation of the PDR from both, the patients' and primary care physicians', perspectives is an important approach to improve the quality of primary care. However, although there are a variety of questionnaires surveying the patients' view of the PDR, only few consider the physicians' perspective. The purpose of this study was to develop a questionnaire that adds the physicians' perspective to an existing PDR instrument and thus enables a mutual assessment of the relationship. Methods: This study was embedded in a German project aiming at enhancing the adherence in patients with hypertension. Patients and primary care physicians were asked to complete a questionnaire concerning their PDR. The Patient-Doctor Relationship Questionnaire (PDRQ-9) was used to assess the patients' perspective. For the physicians, the PDRQ-9 items were adapted to the physicians' perspective resulting in the GP-Patient Relationship Questionnaire (GPPR). The Helping Alliance Questionnaire (HAQ) was used for external validation. Results: A total of 60 physician questionnaires and 50 matched pairs of questionnaires from physicians and patients were included in the analyses. Within the analysis, notable deviations were found for one Item, nevertheless the calculated Cronbach's α of 0.89 showed a high internal consistency of the 9-item questionnaire. External validation showed a high correlation of the GPPR with the HAQ, confirming the good psychometric properties demonstrated for the overall instrument. Discussion: Overall, this initial validation study revealed good psychometric properties of the GPPR. A retest will be performed in the course of the overall project to confirm the reliability of the newly developed questionnaire. Conclusion: A new questionnaire to assess the physicians' perspectives on the PDR was successfully developed to improve adherence depending processes of quality improving in primary care.
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Background Empathic care is considered extremely important by patients and providers alike but there is still an ample need for assessing empathy among healthcare students and professionals and identifying appropriate educational interventions to improve it. This study aims to assess empathy levels and associated factors among students at different healthcare colleges at the University of Iowa. Methods An online survey was delivered to healthcare students, including nursing, pharmacy, dental, and medical colleges (IRB ID #202,003,636). The cross-sectional survey included background questions, probing questions, college-specific questions, and the Jefferson Scale of Empathy-Health Professionals Student version (JSPE-HPS). To examine bivariate associations, Kruskal Wallis and Wilcoxon rank sum tests were used. A linear model with no transformation was used in the multivariable analysis. Results Three hundred students responded to the survey. Overall JSPE-HPS score was 116 (± 11.7), consistent with other healthcare professional samples. There was no significant difference in JSPE-HPS score among the different colleges (P = 0.532). Conclusion Controlling for other variables in the linear model, healthcare students’ view of their faculty’s empathy toward patients and students’ self-reported empathy levels were significantly associated with students’ JSPE-HPS scores.
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Background: Empathetic communication improves the physician-patient relationship and enhances patient and physician satisfaction. This study aims to evaluate the impact of empathic communication skills training on physicians’ self-perceived performance and patient satisfaction regarding the empathetic quality of their relationship with their physicians. Methods: In this single-group before-after experimental study, we recruited 50 internal medicine residents at a large teaching hospital. We assessed the residents’ empathy using the Jefferson Scale of Empathy before and 3 weeks after an 8-hour workshop on empathic communication skills. We also recruited 50 of their patients before and another 50 patients 3 weeks after the training to assess the patient’s perceptions of their physician’s empathy using the Consultation and Relational Empathy scale. Physicians’ and patients’ mean scores on empathetic care at the beginning of the study were then compared using paired t-tests with their scores after the workshop. Results: The residents’ mean score on Jefferson Empathy Scale increased from 81.1 (95%CI:78.8-83.3) at baseline to 96.8 (95%CI:93.6-100) following the workshop (p < 0.001). Before the empathetic communication skills training, patients assessed their doctors' empathy at 68.3 (95%CI:63.5-73.2). After the intervention, this improved to 84.9 (95%CI:82.2-87.5) (p < 0.001). Conclusion: In this study, both the residents and their patients stated that the residents' empathy skills had significantly improved after an empathetic communication workshop for internal medicine residents.
Doctors and patients rely on verbal and nonverbal resources to co-construct clinical empathy. In language-discordant consultations, interpreters’ communicative actions might compromise this process. We aim to explore doctors, patients, and professional interpreters’ perspectives on their own and others’ actions during their empathic interaction in interpreter-mediated consultations (IMCs). We analyzed 20 video stimulated recall interviews with doctors, patients, and interpreters using qualitative content analysis. Doctors and patients found ways to connect with each other on the level of empathic communication (EC) that is not limited by interpreters’ alterations or disengaged demeanor. Some aspects of doctors and interpreters’ professional practices might jeopardize the co-construction of EC in IMCs. The co-construction of EC in IMCs is not only subject to participants’ communicative (inter)actions, but also to organizational and subjective factors. These results provide evidence of the transactional process between the behavioral, cognitive, and affective components of clinical empathy in the context of IMCs.
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Empathy is an important factor in developing a positive patient–provider relationship. It has been shown to lead to improved patient outcomes, well-being, and satisfaction. This study examines the relationship between first-year physical therapy students’ self-reported empathy levels and a patient's perceptions of caregiver empathy during a standardized patient interview via telehealth. Forty-five students completed a self-reported empathy survey before the standardized patient encounter using telehealth. Following the experience, standardized patients rated the perceived empathy demonstrated by the students during that patient–provider encounter using 2 validated measures. The mean student self-reported empathy using the Jefferson Scale of Empathy-Health Care Provider Student (JSE-HPS) version was 123.93 (range 95-135 SD 7.328). The standardized Jefferson Scale of Patient Perception of Provider Empathy (JSPPPE) scores showed a mean of 23.8 (range 11-32 SD 3.951) and a mean of 3.16 (range 1-5 SD.85) on the Global Rating of Empathy (GRE). There was no significant correlation found between the JSE-HPS and the JSPPPE, r = −.47, P = .760, or the GRE r = −.166, P = .276. The artificial nature of a standardized patient interaction using the telehealth format for this encounter may have contributed to the students’ inability to communicate empathy to the patient and may explain this discrepancy.
Recent advances in computational behavioral modeling can help rigorously quantify differences in how individuals learn behaviors that affect both themselves and others. But social learning remains understudied in the context of understanding individual variation in social phenomena like aggression, which is defined by persistent engagement in behaviors that harm others. We adapted a go/no-go reinforcement learning task across social and non-social contexts such that monetary gains and losses explicitly impacted the subject, a study partner, or no one. We then quantified participants' (n = 61) sensitivity to others' rewards, sensitivity to others' losses, and the Pavlovian influence of expected outcomes on approach and avoidance behavior. Results showed that subjects learned in response to punishments and rewards that affected their partner in a way that was computationally similar to how they learned for themselves, consistent with the possibility that social learning engages empathic processes. Further supporting this interpretation, an individualized model parameter that indexed sensitivity to others' punishments was inversely associated with trait antisociality. Modeled sensitivity to others' losses also mapped onto post-task motivation ratings, but was not associated with self-reported trait empathy. This work is the first to apply a social reinforcement learning task that spans affect and action requirement (go/no-go) to measure multiple facets of empathic sensitivity. Supplementary information: The online version contains supplementary material available at 10.1007/s42761-022-00119-4.
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Background: The aim of this study was to evaluate the validity of a modified Spanish version of the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE) in Argentine patients and to explore how local demographic characteristics influence patients' perceptions of their physicians' empathy. Methods: A survey was conducted in March 2013 among 400 Spanish-speaking outpatients attending three different public or private hospitals of Buenos Aires. A principal component analysis (PCA) was used to identify the JSPPPE factor structure, and a confirmatory factor analysis (CFA) was employed to evaluate its construct validity. Demographic variables including age, gender, geographic origin, education, health coverage, regular physician-established and patient-perceived health status were used to find what factors may influence empathy rating. Results: The PCA yielded a one-factor model that accounted for 77.5% of the variance, and an adequate model fit was observed with CFA indices. Male and elderly patients, South American descendants, less educated people, and public hospital attendants were associated with a higher JSPPPE score. Patients perceived a lower interest of physicians in their daily problems and a poorer capacity "to stand in their shoes." Discussion: The JSPPPE provides a valid score to measure patients' perceptions of physician empathy in Argentina. These findings afford insight into Argentine patients' awareness of their doctors' empathic concern; however, JSPPPE scores may be alternatively interpreted in terms of patients' satisfaction or likeability.
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The prominence of reciprocal understanding in patient–doctor empathic engagement implies that patient perception of clinician’s empathy has an important role in the assessment of the patient–clinician relationship. In response to a need for an assessment tool to measure patient’s views of clinician empathy, we developed a brief (5-item) instrument, the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE). This review article reports evidence in support of the validity and reliability of the JSPPPE.
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Context: The use of standardized patients (SPs) promotes and enhances interpersonal skill sets of medical students and provides a critical opportunity for students to display their relational competence during simulated patient encounters. Objective: To investigate whether SPs' ratings of osteopathic medical students' empathy and interpersonal skills correlate with students' self-rated empathy. Methods: The study used a cross-sectional quantitative design. After SP encounters, first-, second-, and third-year osteopathic medical students self-rated empathy using the Jefferson Scale of Empathy medical student version. Standardized patients also assessed students' empathy using the Jefferson Scale of Patient Perceptions of Physician Empathy and interpersonal skills using the Professionalism Assessment Ratings Scale. Results: Of 780 first-, second-, and third-year students, 717 students returned the survey (91.9%). In total, 383 students were women (53.4%) and 334 were men (46.6%). Of 717 SP encounters, SPs returned surveys for 648 encounters (90.3%). Ratings from SPs regarding their perceptions of osteopathic medical students' empathetic abilities and interpersonal skills did not correlate with students' self-rated empathy scores. Second- and third-year students were perceived by SPs as having better-developed empathetic and interpersonal skill sets when compared with first-year students. Results of SPs' ratings indicated that the higher the interpersonal skills, the higher the SP-perceived empathy for students across all years (r=0.66; P<.001). Conclusion: Students' self-rated empathy did not correlate with SP-perceived empathy. However, the findings validated that students' core relational competencies increase as they progress through medical school.
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Despite the increasing awareness of the relevance of empathy in patient care, some findings suggest that medical schools may be contributing to the deterioration of students' empathy. Therefore, it is important to clarify the magnitude and direction of changes in empathy during medical school. We employed a scoping review to elucidate trends in students' empathy changes/differences throughout medical school and examine potential bias associated with research design. The literature published in English, Spanish, Portuguese and French from 2009 to 2016 was searched. Two-hundred and nine potentially relevant citations were identified. Twenty articles met the inclusion criteria. Effect sizes of empathy scores variations were calculated to assess the practical significance of results. Our results demonstrate that scoped studies differed considerably in their design, measures used, sample sizes and results. Most studies (12 out of 20 studies) reported either positive or non-statistically significant changes/differences in empathy regardless of the measure used. The predominant trend in cross-sectional studies (ten out of 13 studies) was of significantly higher empathy scores in later years or of similar empathy scores across years, while most longitudinal studies presented either mixed-results or empathy declines. There was not a generalized international trend in changes in students' empathy throughout medical school. Although statistically significant changes/differences were detected in 13 out of 20 studies, the calculated effect sizes were small in all but two studies, suggesting little practical significance. At the present moment, the literature does not offer clear conclusions relative to changes in student empathy throughout medical school.
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Burnout is a multidimensional work-related syndrome that is characterized by emotional exhaustion, depersonalization – or cynicism – and diminution of personal accomplishment. Burnout particularly affects physicians. In medicine as well as other professions, burnout occurrence depends on personal, developmental-psychodynamic, professional and environmental factors. Recently, it has been proposed to specifically define burnout in physicians as “pathology of care relationship”. That is, burnout would arise, among the above-mentioned factors, from the specificity of the care relationship as it develops between the physician and the patient. Accordingly, experimental studies and theoretical approaches have suggested that burnout and empathy, which is one of the most important skills in physicians, are closely linked. However, the nature of the relation between burnout and empathy remains not yet understood, as reflected in the variety of theoretical and contradictory hypotheses attempting to causally relate these two phenomena. Firstly, we here question the epistemological problem concerning the modality of the burnout-empathy link. Secondly, we hypothesize that considering the multidimensional features of both burnout and empathy, on one hand, and on the other hand, the distinction between empathy and sympathy enables to overcome these contradictions and, consequently, gives a better understanding of the relationship between burnout and empathy in physicians. Thirdly, we propose that clarifying the link between burnout, empathy and sympathy would enable developing specific training in medical students and continuous professional formation in senior physicians and would potentially contribute to the prevention of burnout in medical care.
OBJECTIVE: To conduct a systematic review of studies examining how culture mediates nonverbal expressions of empathy with the aim to improve clinician cross-cultural competency. METHODS: We searched three databases for studies of nonverbal expressions of empathy and communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peer-reviewed, experimental or observational articles. Sixteen studies met inclusion criteria. RESULTS: Nonverbal expressions of empathy varied across cultural groups and impacted the quality of communication and care. Some nonverbal behaviors appeared universally desired and others, culturally specific. Findings revealed the impact of nonverbal communication on patient satisfaction, affective tone, information exchange, visit length, and expression decoding during cross-cultural clinical encounters. Racial discordance, patients’ perception of physician racism, and physician implicit bias are among factors that appear to influence information exchange in clinical encounters. CONCLUSIONS: Culture-based norms impact expectations for specific nonverbal expressions within patient-clinician dyads. Nonverbal communication plays a significant role in fostering trusting provider-patient relationships, and is critical to high quality care. PRACTICE IMPLICATIONS: Medical education should include training in interpretation of nonverbal behavior to optimize empathic cross-cultural communication and training efforts should accommodate norms of local patient populations. These efforts should reduce implicit biases in providers and perceived prejudice in patients.
Purpose: Understanding medical student empathy is important to future patient care; however, the definition and development of clinical empathy remain unclear. The authors sought to examine the underlying constructs of two of the most widely used self-report instruments-Davis's Interpersonal Reactivity Index (IRI) and the Jefferson Scale of Empathy version for medical students (JSE-S)-plus, the distinctions and associations between these instruments. Method: Between 2007 and 2014, the authors administered the IRI and JSE-S in three separate studies in five countries, (Brazil, Ireland, New Zealand, Portugal, and the United Kingdom). They collected data from 3,069 undergraduate medical students and performed exploratory factor analyses, correlation analyses, and multiple linear regression analyses. Results: Exploratory factor analysis yielded identical results in each country, confirming the subscale structures of each instrument. Results of correlation analyses indicated significant but weak correlations (r = 0.313) between the total IRI and JSE-S scores. All intercorrelations of IRI and JSE-S subscale scores were statistically significant but weak (range r = -0.040 to 0.306). Multiple linear regression models revealed that the IRI subscales were weak predictors of all JSE-S subscale and total scores. The IRI subscales explained between 9.0% and 15.3% of variance for JSE-S subscales and 19.5% for JSE-S total score. Conclusions: The IRI and JSE-S are only weakly related, suggesting that they may measure different constructs. To better understand this distinction, more studies using both instruments and involving students at different stages in their medical education, as well as more longitudinal and qualitative studies, are needed.
In their study published in this issue of Academic Medicine, Costa and colleagues confirmed the underlying constructs of the Interpersonal Reactivity Index (IRI) and the Jefferson Scale of Empathy (JSE) in medical students. The authors of this Commentary propose that in comparing two instruments that both purport to measure empathy, researchers or test users must pay close attention to the target populations, the conceptualizations of empathy, and the validity evidence in relation to pertinent criterion measures. The Commentary's authors draw attention to the fact that the IRI was developed for administration to the general population, whereas the JSE was developed specifically for administration to students and practitioners of health professions. Also, the author of the IRI conceptualized empathy as a combination of cognitive and emotional attributes, whereas the authors of the JSE defined empathy as a predominantly cognitive attribute. These differences are reflected in the content of the items, which determines the underlying constructs of the two instruments. The Commentary authors suggest that any empathy-measuring instrument in the context of health professions education and patient care requires the crucial evidence of significant relationships with indicators of clinical competence and positive patient outcomes. Such validity evidence is readily available for the JSE, and the Commentary authors recommend that researchers make efforts to provide pertinent validity support for any other instrument measuring empathy in health professionals-in-training and in-practice.
This welcome updated and expanded edition offers new findings and insights into this cornerstone of practice as well as effective tools for its clinical use. Spanning psychodynamic theory to neuroscience and evolution to medicine, the book defines empathy in the context of patient care, and both in its critical role as a human attribute and in its necessity in promoting change and healing. Theory and data link practitioner empathy with patients’ positive outcomes in areas such as provider trust, treatment adherence, clinical improvements, and quality of life. Author also provide convincing evidence in support of validity and reliability of the Jefferson Scale of Empathy for measuring the empathy of practitioners and students in the healing professions, and detail obstacles to developing and strategies for enhancing empathy among care providers. Among the topics covered: • Definition of empathy in patient care. • Conceptualization and consequences of empathy and sympathy in patient care. • An evolutionary perspective, sociophysiology, and heritability of empathy. • Measurement of empathy in the general population and in health professions-in-training, and in-practice. • Interpersonal dynamics in clinician-patient relationships. • Ten approaches to enhance empathy in Health professions education and patient care. • Exploration of neurological underpinnings of empathy. • Plus in-depth discussion of development, psychometrics, and correlates of the Jefferson Scale of Empathy. An essential text in theory and applications, Empathy in Health Professions Education and Patient Care enhances the work of health professions students, faculty, and practitioners in a variety of disciplines such as medicine, nursing, dentistry, psychology, clinical social work, and other health professions.