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      Revisiting the trajectory of medical students’ empathy, and impact of gender, specialty preferences and nationality: a systematic review


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          Empathy allows a physician to understand the patient’s situation and feelings and respond appropriately. Consequently, empathy gives rise to better diagnostics and clinical outcomes. This systematic review investigates the level of empathy among medical students across the number of educational years and how this level relates to gender, specialty preferences, and nationality.


          In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors conducted a systematic search of studies published between February 2010 and March 2019 investigating the level of empathy among medical students. The databases PubMed, EMBASE, and PsycINFO were searched. Studies employing quantitative methodologies and published in English or Scandinavian language and examining medical students exclusively were included.


          Thirty studies were included of which 24 had a cross-sectional and 6 a longitudinal study design. In 14 studies, significantly lower levels of empathy were reported by increase in the number of educational years. The remaining 16 studies identified both higher, mixed and unchanged levels. In 18 out of 27 studies it was reported that females had higher empathy scores than males. Only three out of nine studies found an association between empathy scores and specialty preferences. Nine out of 30 studies reported a propensity towards lower mean empathy scores in non-Western compared to Western countries.


          The results revealed equivocal findings concerning how the empathy level among medical students develops among medical students across numbers of educational years and how empathy levels are associated with gender, specialty preferences, and nationality. Future research might benefit from focusing on how students’ empathy is displayed in clinical settings, e.g. in clinical encounters with patients, peers and other health professionals.

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          Most cited references48

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          Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

          The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.
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            Clinical empathy as emotional labor in the patient-physician relationship.

            Empathy should characterize all health care professions. Despite advancement in medical technology, the healing relationship between physicians and patients remains essential to quality care. We propose that physicians consider empathy as emotional labor (ie, management of experienced and displayed emotions to present a certain image). Since the publication of Hochschild's The Managed Heart in 1983, researchers in management and organization behavior have been studying emotional labor by service workers, such as flight attendants and bill collectors. In this article, we focus on physicians as professionals who are expected to be empathic caregivers. They engage in such emotional labor through deep acting (ie, generating empathy-consistent emotional and cognitive reactions before and during empathic interactions with the patient, similar to the method-acting tradition used by some stage and screen actors), surface acting (ie, forging empathic behaviors toward the patient, absent of consistent emotional and cognitive reactions), or both. Although deep acting is preferred, physicians may rely on surface acting when immediate emotional and cognitive understanding of patients is impossible. Overall, we contend that physicians are more effective healers--and enjoy more professional satisfaction--when they engage in the process of empathy. We urge physicians first to recognize that their work has an element of emotional labor and, second, to consciously practice deep and surface acting to empathize with their patients. Medical students and residents can benefit from long-term regular training that includes conscious efforts to develop their empathic abilities. This will be valuable for both physicians and patients facing the increasingly fragmented and technological world of modern medicine.
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              The QCAE: a Questionnaire of Cognitive and Affective Empathy.

              Empathy has been inconsistently defined and inadequately measured. This research aimed to produce a new and rigorously developed questionnaire. Exploratory (n₁ = 640) and confirmatory (n₂ = 318) factor analyses were employed to develop the Questionnaire of Cognitive and Affective Empathy (QCAE). Principal components analysis revealed 5 factors (31 items). Confirmatory factor analysis confirmed this structure in an independent sample. The hypothesized 2-factor structure (cognitive and affective empathy) was tested and provided the best and most parsimonious fit to the data. Gender differences, convergent validity, and construct validity were examined. The QCAE is a valid tool for assessing cognitive and affective empathy.

                Author and article information

                BMC Med Educ
                BMC Med Educ
                BMC Medical Education
                BioMed Central (London )
                17 February 2020
                17 February 2020
                : 20
                [1 ]ISNI 0000 0001 0728 0170, GRID grid.10825.3e, University of Southern Denmark, ; Campusvej 55, 5230 Odense M, Denmark
                [2 ]ISNI 0000 0001 0728 0170, GRID grid.10825.3e, Research Unit of General Practice, Department of Public Health, , University of Southern Denmark, ; J.B. Winsløws Vej 9A, 5000 Odense C, Denmark
                [3 ]ISNI 0000 0001 0728 0170, GRID grid.10825.3e, Department of Psychology, , University of Southern Denmark, ; Campusvej 55, 5230 Odense M, Denmark
                [4 ]ISNI 0000 0001 0728 0170, GRID grid.10825.3e, Department for the Study of Culture, , University of Southern Denmark, ; Campusvej 55, 5230 Odense M, Denmark
                © The Author(s). 2020

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Research Article
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                © The Author(s) 2020

                empathy,medical students,systematic review
                empathy, medical students, systematic review


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