Download Measurement of Changes in Empathy During Dental School

Critical Issues in Dental Education
Measurement of Changes in Empathy
During Dental School
Jeffrey J. Sherman, Ph.D.; Adam Cramer, B.S.
Abstract: Empathy in the health care setting is the ability to understand a patient’s experiences and feelings and the capability to
communicate this understanding. Although empathy has been shown to play an important role in the dentist-patient relationship
and is a core competence for dentists, no measure of empathy has been validated in the dental setting. Further, little is known
about changes in empathy during dental school. We examined the psychometric properties of a measure of empathy applied to
the dental school setting and compared levels of empathy in dental students across their four years of training. One hundred and
thirty students completed a survey including the Jefferson Scale of Physician Empathy (JSPE). The JSPE was found to be both a
reliable and valid empathy measure for dental students with similar psychometric properties to those found in medical students,
residents, and physicians. Further, first-year dental students had significantly higher empathy scores than students in any
subsequent year. Consistent with the literature in medical settings, the timing of the decline in empathy levels corresponded to
increases in patient exposure. We suggest that training students in the interpersonal skills designed to enhance the dentist-patient
relationship should continue throughout dental school training.
Dr. Sherman is Assistant Professor, Department of Oral Medicine, and Mr. Cramer is a Student—both at the University of
Washington School of Dentistry. Direct correspondence and requests for reprints to Dr. Jeffrey J. Sherman, University of
Washington, Department of Oral Medicine, Box 356370, Seattle, WA 98195; 206-221-3665 phone; 206-685-8412 fax;
[email protected].
This study was supported by Grant No. T32 DE 07132 from the National Institute of Dental and Craniofacial Research (USA).
Key words: empathy, communication, patient-centered health care, measurement
Submitted for publication 11/18/04; accepted 1/12/05
T
he role of communication and understanding
between health care practitioner and patient
is receiving increasing attention in general
dentistry1,2 and in dental specialties.3-5 A key component to effective communication and understanding
is the ability to demonstrate clinical empathy. In a
general context, demonstrations of empathy involve
attempts to understand another person’s experiences
and feelings and the ability to reflect back this understanding in ways that help others solve their own
problems.1,6 Empathy in the health care setting can
best be viewed as a cognitive and behavioral attribute
that involves the ability to understand how a patient’s
experiences and feelings influence and are influenced
by their symptoms and illness and the capability to
communicate this understanding to the patient.7,8 It
has been referred to as objective compassion and is
distinguished from sympathy, a more affective response to a patient’s misfortune that could interfere
with objectivity in diagnosis and care.
Empathy has been shown to play several important roles in the physician-patient relationship.7,9
338
For example, physicians high in empathy are more
competent in history-taking and physical exams,10
have higher physician and patient satisfaction,11 and
experience lower malpractice litigation than physicians low in empathy.12-15 Additionally, empathy is
described as being a significant factor in motivating
patients to actively take part in treatment and is a
key element in successful treatment outcome.16
The role of empathy in the dentist-patient relationship has received less attention.17 Some evidence
suggests that pediatric dentists using an empathetic
listening and communication style have greater treatment success.4,18 The probability that children exhibit
disruptive behaviors during the dental exam is decreased when the dentist uses empathetic reactions,
directions, and reinforcement.18 Demonstrations of
caring interpersonal skills and empathy can decrease
dental fears,19 improve treatment outcome in patients
with myofascial pain,20 increase adherence to orthodontic treatment,21 and increase patient satisfaction
with emergency dental care,17 orthodontic treatment,21 and extractions, restorations, and endodontic treatments.22
Journal of Dental Education ■ Volume 69, Number 3
The appreciation of the role of empathy and
interpersonal skills in the medical and dental setting
has led to curriculum changes in medical and dental
training. Presently, the Association of American
Medical Colleges (AAMC) has recommended that
medical schools educate students to be compassionate and empathetic in caring for patients, demonstrate
understanding of the patient’s perspective, understand
the meaning of patients’ stories in the context of their
families and cultures, and avoid being judgmental
even when patient beliefs and values conflict with
their own.23 Further, examinees taking the United
States Medical Licensing Examination (USMLE) are
now tested on verbal and nonverbal communication
skills demonstrative of empathy and active listening
using standardized patients and behavioral observation.
Similarly, the American Dental Education Association (ADEA) lists providing empathic care for
all patients as its second clinical competency for dental training.24 In turn, most dental schools acknowledge the importance of interpersonal skills and include some training in empathy, active listening, and
verbal and nonverbal communications, but measurement of the acquisition of these skills remains a challenge. The gold standard for assessment of empathy
and interpersonal skills is behavioral observation by
trained observers to ascertain use of skills. However,
this can be costly and time-consuming. The dearth
of research on the topic has been attributed to the
absence of adequate self-report measures.25-27 While
several self-report measures of empathy have been
developed for use in the general population, only one
has been developed for use in the health care setting.
The Jefferson Scale of Physician Empathy (JSPE)7,27
has been validated in a variety of health care settings, but its psychometric properties have not yet
been established in the dental setting. Further, little
is known about changes in empathy during formal
dental education. This study had two primary aims.
First, we examined the psychometric properties of
the JSPE7 in order to assess the reliability and validity of the measure as applied to dental students. Second, we examined changes in empathy across dental
school training using a cross sectional survey design.
Methods
The study sample consisted of 130 dental students (eighty-five men, forty-five women) at the
University of Washington School of Dentistry. This
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represents 61 percent of the total student body at the
time the survey was administered, a response rate
considered “good” for mail survey research.28 A comparison of our sample to that of the student population suggests that our sample had similar demographic features to the population. Of the 130
respondents, forty-three were first-year dental students, twenty-nine were second-year, twenty-seven
were third-year, and thirty-one were fourth-year dental students. The mean age of all participants was
26.4 years of age (SD=3.8). Sixty-five percent of our
sample was male, a proportion that remains similar
throughout each of the classes. Eighty-one percent
of our sample reported their race as white, with 18
percent as Asian or other; 1 percent did not respond.
Fifty-five percent were never married, 40 percent
were married or living as married, and the remainder were divorced. We were unable, however, to collect any information from nonresponders.
All 214 students of the University of Washington School of Dentistry received the survey at the
end of their spring quarter with a self-addressed,
postage-paid envelope. Electronic mail was used for
notification and for two reminders requesting return
of the survey. A cover page to the survey explained
that completing and returning the survey would be
implied consent indicating their willingness to participate in the study and their understanding of their
rights as a research participant, including the option
to refuse any portion of the study. All procedures
were approved by the University of Washington Institutional Review Board. All students were informed
of a possible monetary incentive to completing and
returning the survey. Of those who completed and
returned the survey, four subjects were selected at
random and received a $40 gift certificate to the university bookstore.
The Jefferson Scale of Physician EmpathyHealth Professionals Version (JSPE-HP)7,27,29 was
used to measure empathy in our subjects. There are
two versions of the scale to measure empathy in
medical students27 and health professionals.29 Among
other differences between the measures, wording of
items in the HP version reflect actual caregiver behavior rather than attitudes or orientations about practice in general.29 As dental students typically start
delivering care in their second year, we chose the
HP version. The JSPE was constructed on the basis
of an extensive review of the literature, followed by
pilot studies with groups of practicing physicians,
medical students, and medical residents.27,29 After
several iterations and refinements, the JSPE includes
339
twenty items answered on a 7-point Likert scale
(1=strongly disagree through 7=strongly agree).
Construct validity of the scale has been confirmed
among medical students, medical residents, and physicians using factor analytic methods.25,26,28 Internal
consistency (coefficient alpha) of the items was .89,
.87, and .81 among medical students, residents, and
physicians, respectively. Three- to four-month testretest reliability was .65 among physicians.29
Based on previous work by Shugars et al.,30
we developed a scale to assess current attitudes toward twenty-six published clinical competencies at
the University of Washington School of Dentistry.31
These competencies include technical skills (examining a patient using contemporary diagnostic methods, prescribing and administering pharmacological
agents, performing uncomplicated oral surgical procedures) and behavioral and communication skills
(applying the principles of behavioral science that
pertain to patient-centered care, having the interpersonal and communication skills to function successfully in a multicultural work environment, providing
patient education in prevention). Students were asked
to rate the importance of training in each clinical competency on a 7-point scale (1=not important through
7=very important). Our purpose in assessing these
ratings was to provide an external criterion by which
to evaluate the JSPE.
Internal consistency was analyzed using coefficient alpha for internal reliability and a SpearmanBrown for split half reliability. The JSPE consists of
ten positively worded and ten negatively worded
statements. For the split half coefficient, the scale
was split into two halves, each containing five positive and five negatively worded statements. Criterion-related validity was examined by correlating
total scores of the JSPE with attitudes toward clinical competencies using Pearson correlations. It was
expected that significant correlations would be found
for the more behavioral and communication-oriented
competencies, demonstrating convergent validity,
and that nonsignificant correlations would be found
for the more technical competencies, demonstrating
discriminant validity of the measure. Construct validity was analyzed by conducting an exploratory
factor analysis to investigate the underlying structure of the JSPE. Data were subjected to factor analysis using a principal component factoring method and
an orthogonal varimax rotation with Kaiser Normalization.32 Analysis of variance procedures were used
to compare group means among demographic vari-
340
ables. A one-way analysis of variance was conducted
to evaluate the relationship between empathy and
year in dental school, followed by post hoc contrasts
using Tukey’s HSD tests. The independent variable,
school year, included four levels.
Results
Cronbach’s coefficient alpha for the JSPE was
.90, and the split half coefficient was .87, indicating
that the JSPE as applied to dental students was internally consistent. To examine criterion-related validity, scores on the JSPE were correlated with ratings
for all twenty-six of the attitudes towards clinical
competencies. There were significant positive correlations for eighteen of the twenty-six clinical competencies. The strongest correlations were observed
for “apply the principles of behavioral science that
pertain to patient-centered oral health care”; “evaluate different models of oral health care management
and delivery”; “manage medical emergencies in dental practice by providing basic life support”; and
“practice dentistry within the ethical standards of the
dental profession and the law”—with correlations of
.523, .374, .345, and .321 (p’s<.001), respectively.
Other significant and positive correlations included
attitudes towards competencies such as “recognize
the role of lifelong learning and self-assessment in
maintaining competency” and “manage a diverse
patient population and have the interpersonal and
communication skills to function successfully in a
multicultural work environment.” Lowest correlations were observed for “ diagnose and manage hard
and soft tissue lesions and diseases of the orofacial
complex”; “prescribe and administer pharmacological agents for patient care”; “manage acute and
chronic orofacial and dental pain”; and “utilize business and management skills to conduct an efficient
and effective clinical practice”—with correlations of
.097, .124, .132, and .135 (p’s>.05), respectively.
To investigate the construct validity of the JSPE
as applied to dental students, we conducted a factor
analysis using a principal component factoring
method with an orthogonal varimax rotation of factors and an eigenvalue cutoff set at 1.32 Similar to
previous findings for this measure,27 the resulting
principal components analysis yielded a four factor
solution explaining a total of 57.8 percent of the item
variance. The magnitude of the eigenvalues was 7.52,
1.66, 1.29, and 1.09. These factors explained 22.36
Journal of Dental Education ■ Volume 69, Number 3
percent, 13.22 percent, 11.89 percent, and 10.35 percent of the item variance, respectively. Factor loadings >.40 were applied as the criterion for including
an item in a particular factor; the rotated factor matrix is shown in Table 1. This strategy has been used
in prior validation research on this measure.27,29 The
principal factor corresponds to the belief that taking
the patient’s perspective will improve health outcomes. With some item redundancy, factors two and
three correspond to understanding the patient’s ex-
periences and feelings, and factor four corresponds
to efforts to ignore emotions in patient care.
The mean empathy score for all participants
was 117.71 (Table 2). Consistent with other findings,7
the mean empathy score for females was significantly
higher than for males (p<.01). There were no significant differences in empathy scores by race, marital
status, or age. The ANOVA comparing mean levels
of empathy by year in dental school was significant,
F=6.57, (p<0.01; df=3). Follow-up contrasts using
Table 1. Rotated factor loadings for the JSPE-HP version among dental students (n=130)*
Item
Factor 1
Factor 2
Factor 3
Factor 4
My understanding of how my patients and their families feel does not
influence medical or surgical treatment.
.762
.261
-.035
.366
I believe that emotion has no place in the treatment of medical illness.
.737
-.008
.071
.235
My patients value my understanding of their feelings, which is therapeutic
in its own right.
.706
.147
.183
.013
Empathy is a therapeutic skill without which success in treatment is limited.
.670
.168
.291
.012
I believe that empathy is an important therapeutic factor in medical or
surgical treatment.
.659
.305
.287
.030
My patients feel better when I understand their feelings.
.625
.216
.072
.204
Patients’ illnesses can be cured only by medical or surgical treatment;
therefore, emotional ties to my patients do not have a significant influence
on medical or surgical outcomes.
.596
.151
-.116
.509
An important component of the relationship with my patients is my
understanding of their emotional status, as well as that of their families.
.566
.239
.419
-.027
I do not allow myself to be influenced by strong personal bonds between
my patients and their family members.
.463
.117
.343
.103
Attentiveness to my patients’ personal experiences does not influence
treatment outcome.
.431
.474
-.058
.276
I try to think like my patients in order to render better care.
.407
.519
.423
.115
I consider understanding my patients’ body language as important as
verbal communication in caregiver-patient relationships.
.111
.816
.127
.075
I try to understand what is going on in my patients’ minds by paying
attention to their nonverbal cues and body language.
.119
.758
.364
.096
I try to imagine myself in my patients’ shoes when providing care to them.
.339
.483
.500
.168
I try not to pay attention to my patients’ emotions in history taking or in
asking about their physical health.
.309
.461
.015
.205
It is difficult for me to view things from my patients’ perspectives.
.136
.191
.719
.278
I have a good sense of humor, which I think contributes to a better
clinical outcome.
.114
.092
.648
-.019
Because people are different, it is difficult for me to see things from my
patients’ perspectives.
.038
-.004
.461
.642
Asking patients about what is happening in their personal lives is not
helpful in understanding their physical complaints.
.211
.208
.353
.720
I do not enjoy reading nonmedical literature and the arts.
.139
.155
-.049
.620
*Items are listed by the order of magnitude of the factor structure coefficients within each factor. Values greater than .4 are in
bold.
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Journal of Dental Education
341
Tukey’s HSD Test show that empathy scores for firstyear students were significantly higher than for any
of the subsequent years of dental school (p<.01).
There were no significant differences between the
subsequent classes (Figure 1).
Analysis of Results
Our findings suggest that the Jefferson Scale
of Physician Empathy can reliably and validly assess levels of empathy in a dental student population. Internal consistency of the measure was quite
high. The measure demonstrated good convergent
validity by correlating with self-reported attitudes
consistent with more biopsychosocial orientations
toward the practice of health care and demonstrated
good discriminant validity by not correlating with
attitudes toward more technical skills of dentistry.
Further, the four-factor solution of the measure
was similar to that found in medical students, residents, and physicians and demonstrated good construct validity of the measure.
Although the items administered in this survey corresponded to the JSPE-HP version and are
slightly different from the student version of the
JSPE, the resulting factor structure in this study is
similar to that found for the student version of this
measure. Hojat et al.27 found a four-factor solution
with similar items loading on the factors. While we
too found that a four-factor solution best represents
the measure using the Kaiser criterion of factor se-
Table 2. Baseline demographic characteristics by
empathy levels
Groups
Mean
SD
Empathy levels for all
participants (n=130)**
117.71
14.06
Gender
Men (n=85)
Women (n=45)
115.28
122.29
14.17
12.76
Race
White (n=105)
Asian (n=20)
Other (n=3)
116.65
121.50
126.33
14.21
11.50
18.72
Marital Status
Married (n=52)
Single (n=71)
Divorced (n=5)
117.35
117.15
124.60
13.18
14.33
20.51
P-value*
<0.01
<.20
<.66
* t-tests or analysis of variance procedures
** Range of empathy scores: 0 to 140
JSPE
empathy
score
130
*
125
120
115
110
105
First
Second
Third
Fourth
Figure 1. Mean empathy levels ±SE by year of dental school training
*Indicates significant difference between first year and all other years of training (p<.001)
342
Journal of Dental Education ■ Volume 69, Number 3
lection,32 it is important to note that an alternative
method to choosing the number of factors is to observe the scree test.33 In this method, eigenvalues are
examined and retained until there is a large drop in
eigenvalue, that is, until the values seem to plateau.
Using this alternative method, the items in this measure may best be represented by a single factor corresponding to the health care professional’s efforts
to understand patients’ perspectives and emotional
status.
Conclusion
As in other health care settings, the relationship between dentist and patient has a considerable
impact on successful treatment and on patient and
provider satisfaction. Empathy, the understanding of
patients’ inner experiences and perspectives, combined with the ability to communicate this understanding7,8 is integral to establishing and maintaining that relationship. This study demonstrated that
empathy in dental students can be operationally defined and reliably and validly measured using a selfreport instrument originally developed for the measurement of empathy in medical students.
Mean empathy levels for all dental students
closely corresponded to norms for medical students
and medical residents.27 However, results demonstrated that empathy levels during the first year of
dental school are quite high and comparable to those
reported in medical specialties such as psychiatry,
but that empathy levels drop sometime during the
second year of dental training and remain at this lower
level throughout dental school. Of potential clinical
and theoretical relevance, this is the same year that
dental students begin to treat patients. It has been
previously reported34,35 that decreases in empathy
follow clinical experiences in medical students. For
example, Hojat et al.35 observed a statistically significant drop in empathy levels in medical students
from the beginning to the end of their third year of
medical school. In medical school, students encounter patients on a regular basis during their third-year
clinical clerkships. These clerkships typically consist of six- to eight-week focused rotations in the disciplines of family and internal medicine, obstetrics
and gynecology, pediatrics, psychiatry, and surgery.35
Similar declines in empathy have also been observed
during medical residency.36,37
This paradoxical relationship can be explained
several ways. At the most simplistic level, it may be
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Journal of Dental Education
that increased technical demands during intensive
clinical training exhaust student resources and less
essential skills and behaviors are sacrificed. This
decrease may also occur as students approach graduation and place greater importance on their own
needs, in this case credits based on completion of
procedures, than on the needs of their patients. The
requirement-driven environment of many dental
schools may encourage students to be procedurally
focused rather than patient-centered. Others have
suggested that development of a sense of belonging
to an elite and privileged group, such as being a doctor, contributes to declines in empathy.38 Declines in
empathy may also be a defense that accompanies fear
and insecurity when novice health care practitioners
must first interact with patients.
An alternative explanation focuses on the impact of education to promote empathy and improve
communication skills. A large body of evidence suggests that empathy and communication skills can
improve from targeted training in both medical39-41
and dental professionals.42-44 The first-year winter
quarter of the UW Dental School curriculum has
considerable emphasis on behavioral science with
courses in communication skills, cultural competence, and history taking. These classes emphasize
the use of nonverbal behaviors (e.g., nodding consent, eye contact, body posture) and verbal behaviors such as reflection, validation, support, partnership, and respect that are demonstrative of empathetic
communication. In the second and third years, this
emphasis is reduced because of the relative importance and predominance of courses emphasizing the
technical skills of dentistry. Thus, when students
begin working with patients, they may come to realize that patients are not always willing to change their
high-risk behaviors in the face of adverse health outcomes. This noncompliance may make it more difficult to feel empathy toward patients who do not or
will not implement the student’s well-meaning, and
often necessary, advice.
Although not statistically significant, it is interesting to note a slight increase in empathy levels
in the last year of dental school. During their last
year, students receive training in ethics, practice
management, and management and treatment of fearful patients. It is possible and hopeful to consider
that a gradual increase in empathy follows this final
year of dental school training and continues beyond
into practice or graduate education. In any case, these
data suggest that education in behavioral science may
be effective in increasing self-reported empathy and
343
that further training may be necessary in order to
maintain high levels.
Consistent with previous findings7 on physicians and medical students, females in our sample
scored significantly higher on the JSPE than males.
This finding suggests that female students might render a different type of dental care based on a greater
ability to empathize with the patient’s experiences
and feelings. Physicians higher in empathy may
spend more time on history taking or rapport building. Further research in the dental profession might
focus on differences in aspects of treatment related
to empathy.
This study has several limitations. First, it relies solely on self-reported measurement of empathy. Although the JSPE has been shown to be a reliable and valid indicator of the construct of empathy,
it is limited to reflecting students’ orientation to empathy and not actual behaviors. Behavioral observation of activities during a practitioner and patient
interaction as an adjunct to self-report would be a
valuable addition to future research in the area. Second, the nature of the study was cross-sectional, and
it is possible that cohort effects could account for
the observed differences across dental school classes.
Although the classes were similar on other variables,
they may be dissimilar in empathy levels. A longitudinal study tracking changes in a single cohort
through dental school and potentially beyond might
offer considerably more insight into the stability of
characteristics such as empathy in practice. Third,
as our data are limited to one dental school, our findings may not generalize to all dental students. Future research may focus on multiple sites and larger
samples.
The dentist-patient relationship can have a profound positive influence on a number of health behaviors and outcomes.17,22 Although empathy is an
integral component to the relationship, there has been
relatively little research on the topic. One possible
reason is the absence of a psychometrically valid
measure of the construct for the dental setting. Results from this study suggest that the JSPE provides
a reliable and valid measure of empathy and that,
based on that measure, empathy levels decrease during dental school. We suggest that students enter
dental school with enormous capacity and intent to
provide compassionate, patient-centered care and that
training in the skills to do so should continue throughout dental school training and perhaps beyond.
344
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