Psychometrics of the student version of the Jefferson Scale of Physician Empathy (JSPE-S) in final-year medical students in Johannesburg in 2008

Kantilal Vallabh, BSc Hons, MB BCh, MSc (Med)

Steve Biko Centre for Bioethics, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: K Vallabh (kvallabh@gpnet.net)

Empathy, while remaining an elusive concept, has recently gained a respected role in psychotherapy and medical interviewing. Empathy has been much discussed in the psychological literature of the early decades of the 20th century.1 , 2 The therapeutic relationship between doctor and patient is an integral part of healing and effective medical care.3 Empathy is intuitively an important consideration in medical practice and the care of patients. The concept of empathy, however, is elusive, theoretically and operationally. Empathy is commonly contrasted with sympathy, whereby empathy is said to refer more to a cognitive understanding of a patient’s situation and feelings, and sympathy is used to refer to a sharing and feeling of the patient’s emotions.

According to Spiro4 ‘it really doesn’t matter whether empathy is a thought or an emotion. Retaining or enhancing it in medical caregivers is worth doing and may be achieved through: (1) the selection of medical students and others who will care for the sick, (2) the training caretakers receive, and more fundamentally even, (3) reconsideration of what doctors do in a world so much changed and so diverse.’ Partly because of biotechnological developments and partly because of the changes in the healthcare system, it has been argued that in the contemporary system of medical education and patient care, insufficient attention is paid to human aspects of medical education and patient care. Given this universal trend, it is important and timely to study factors that contribute to improving interpersonal relationships in the context of medical education and patient care.

‘While there may not be an inherent conflict between technology and humanism, it does seem that the human dimension of medicine has been diminished.’5 Social changes have led to new needs that require changes to develop an ‘effective’ physician with appropriate skills including empathic capacity.6

Medical education and medical practice emphasise the scientific method to address illness and suffering. Instead of observing and touching the patient directly, scientific advances substitute technology for personal closeness. Physicians are losing their skills to talk and listen to their patients.

Medical students experience medical education and training as stressful. Their reliance on technology for diagnosis, and limited bedside interactions with patients may contribute to a decline in empathy. Empathy is critical to the development of professionalism in medical students as they progress through their training. Medical students’ personal attitudes towards various vulnerable groups of patients (e.g. the elderly, the dying, the underserved, refugees, illegal immigrants, prisoners, drug and alcohol abusers, etc.) can impact on the quality of healthcare they deliver to these patients.7 As identified by Rosenfield and Jones,8 ‘Medical students face many challenges in their training. One of these is to learn how to manage the stresses and anxiety of confronting illness and suffering in patients. They may develop maladaptive responses that lead to a decrease in their level of empathy for patients.’

Empathy is believed to be measurable and teachable and has been incorporated formally in some medical curricula.8

Research on the subject is not abundant, because of the difficulty in formulating a definition of empathy. There are as many definitions of empathy as there are people working on the topic.1 The absence of a reliable instrument to measure physician empathy in the clinical setting has also contributed to the paucity of research on empathy.14

Many instruments have been developed to measure empathy in various settings. Each instrument measures a specific aspect of empathy. Stepien and Baerntein15 and Hemmerdinger et al.16 found that instruments developed to measure empathy were measuring the affective behaviour or aspects of behaviour relevant to the specific study.

The JSPE is the most widely researched test and was specifically designed by researchers from scratch for the assessment of physician and student empathy. This scale was originally developed to measure the attitudes of medical students towards physician empathy in patient-care situations (JSPE-Student or S-version). The JSPE has been translated into 25 languages including Belgian, Brazilian, Chinese, Chilean, Dutch, French, German, Greek, Hebrew, Hungarian, Italian, Japanese, Korean, Lithuanian, Norwegian, Persian, Peruvian, Filipino, Polish, Portuguese, Romanian, Spanish, Taiwanese and Turkish.

Material and methods

This is a one-shot cross-sectional survey of final-year students in the Faculty of Health Sciences, University of the Witwatersrand Medical School, in 2008. There was no reward for participating, nor any penalty for not participating in the survey.

Of the final-year class of 244 students (101 male (41.4%) and 143 female (58.6%)), only 158 (64.7%) students voluntarily and anonymously completed and returned the JSPE-S questionnaire.

The measuring instrument

The JSPE-S is a validated 20-item self-administered questionnaire answered on a 7-point Likert scale (strongly disagree = 1… strongly agree = 7). Of the 20 items in the JSPE-S, 10 items are positively worded and linked to ‘perspective taking’ and 10 items are negatively worded. Eight of the 10 negatively worded items are concerned with ‘compassionate care’ and the remaining 2 items are concerned with ‘standing in the patient’s shoes’.22 The minimum possible score on the JSPE is 20 and the maximum possible score is 140. The higher score indicates a more empathic behavioural orientation.

Data management and analysis

The data were collected by means of the JSPE-S questionnaire. The JSPE-S responses were captured on an Excel spreadsheet and imported into STATA version 9.0 statistics package, from StataCorp LP. The data were treated with strict confidentiality.

Descriptive statistics were calculated by gender, age, and prior degree/s and no prior degree/s. Statistical significance was set at the 95% confidence level (p<0.05). Cronbach’s coefficient alpha was calculated to assess the internal consistency aspect of reliability of the instrument. Further, empathy scores for male and female students were compared by using a t-test. Correlation between each item and the total score (item-score correlation) was calculated. The factorial structure of the JSPE-S was evaluated with rotated principal component factor analysis in Stata version 9. A number of factors were selected after examining the eigenvalues.

Results

Out of the class of 244 final-year students, 164 responded (67% of the class) and voluntarily returned the completed self-administered questionnaire (63 males and 95 females, 6 surveys were incomplete). Of the 164 completed surveys 6 were discarded because of missing demographic information. A mean score was calculated for each of the 20 statements. Five surveys with less than 4 missing responses were allocated a mean score for each of the statements that had missing responses. Sixty-one students indicated that they had a previous degree.

The mean class age was 25.3 years (n=158). The mean empathy score for the class was 107.0 (SD 10.9). The difference in the mean empathy scores between female students 109 (SD 9.8) and male students 104 (SD 12.1) is statistically significant (t=2.51; p<0.013).

Descriptive statistics by gender, age, prior degree and no prior degree are reported in Table I.

Psychometrics of the JSPE-S

The mean item score responses ranged from a low of 3.5 for item 18 (reverse-scored) to a high of 6.4 for item 2.

These findings indicate that the students’ responses tend to be skewed towards the upper end of the scale although they used the full range of possible responses on most items.

The inter-item score correlation was positive and statistically significant with a mean inter-item score correlation of 0.411 (SD 0.23).

Item-score correlation ranged from a low of 0.20 for two items – item 19 ‘I do not enjoy reading non-medical literature’ (reverse-scored) and item 18 ‘Physicians should not allow themselves to be influenced by strong personal bonds between their patients and their family members’ – to a high of 0.61 for two items – item 16 ‘Physicians’ understanding of the emotional status of their patients, as well as that of their families is one important component of the physician-patient relationship,’ and item 20 ‘I believe that empathy is an important therapeutic factor in medical treatment’.

Inter-item reliability of the JSPE-S (Cronbach’s coefficient alpha) was 0.79. Table II indicates the range of student responses to the statements as per the Likert scale and item-score correlation.

Factor analysis of the data was conducted to examine the underlying components (factors) of the JSPE-S. Principal component factor analysis with orthogonal rotation was used to obtain a simpler factor structure. Six factors of eigenvalue of >1 were produced (viz. 4.83, 1.74, 1.40, 1.25, 1.15, and 1.10). These six factors accounted for 54% of the total variance.

The three factors with the largest eigenvalues were retained for orthogonal rotation. These three factors accounted for 40% of the total variance. The first factor accounted for 16 %, the second factor 15%, and the third factor 9% of the total variance. Based on the contents of the statements in the JSPE-S, three grand factors were identified: perspective taking, compassionate care and standing in the patient’s shoes.14

Factor 1 loaded seven items with a factor coefficient of greater than 0.35 for statements related to understanding from physician’s perspective (perspective taking) and the one item of standing in patient’s shoes.

Factor 2 loaded eight items with a factor coefficient of greater than 0.35 for statements reverse-scored and related to emotion and feelings (compassionate care).

Factor 3 loaded two items with a factor coefficient of greater than 0.35 related to standing in the patient’s shoes.

Items 19, 10 and 18 did not load a factor coefficient greater than 0.35. These three items are related to reading non-medical literature, patients’ perception of physician’s understanding their feelings and physicians being influenced by the family bonds of patients.

Factor coefficients greater than 0.35 are highlighted, for the 10 positively worded and 10 negatively worded items, after reverse-scoring (R) and are reported in Fig. 1.

Discussion

Evidence in support of the psychometrics (e.g. construct validity, criterion-related validity, test-retest reliability and coefficient alpha reliability) of the JSPE-S scale among medical students, registrars and physicians has been reported.17 The mean empathy score of 107 in this study is comparable to the average empathy scores of 109 - 114 reported by Chen et al. 25 Garza et al. 21 and Mangione et al. 26 among medical and pharmacy students. Roh et al. 17 and Kataoka et al. 18 however report a lower mean empathy score of 103 in Korean and Japanese medical students, respectively.

It is known that cross-cultural differences in norms, ethnicity, religious beliefs, and sex stereotyping can influence empathic engagement during clinical encounters. Morling and Lamoreaux27 have reported that Asians have more collectivistic and less individualistic social cultures than Westerners. South Africa having gone through various phases of Dutch and British colonisation has a predominantly Western social culture although some Asian and African influence is also present among our ‘rainbow nation’.

The gender distribution in the Johannesburg final-year class was 58.6% female; this compares with 60% reported by Looi28 for the USA medical schools. The difference in the mean empathy scores between female students (109, SD 9.8) and male students (104, SD 12.1) is statistically significant (t=2.51, p<0.013). This is consistent with the findings of other researchers6 , 18 , 25 , 29 Women have been reported to have greater empathy than men, are more receptive to emotional signals and offer more emotional support and patient-orientated care, possibly because they tend to value interpersonal relationships highly and have more competent understanding of emotions and caring attitude.23 , 25 , 32 , 33 However, one study in Italy has not indicated a significant difference in empathy scores between genders. Further research is needed to determine whether this may be due to cultural peculiarities, translation of the scale or sampling.34

Factor analysis does not reveal a value greater than 0.35 for any of the three factors for items 19, 10 and 18 (Table II). The study among Korean and Japanese medical students also revealed a factor loading of less than 0.35 for item 19.18 , 19 Looi28 argues that instruments assessing empathy may be impacted by value judgments, cultural considerations and cognitive styles. Commenting on the JSPE-HP version he cites item 19 on reading non-medical literature and enjoying the arts as enhancing the ability to render care and not necessarily empathy. He asks whether it measures what we mean by empathy or are we assessing the perception of empathy by physicians, patients and the public?

The literature in social and developmental psychology indicates that compassion, altruism and empathy are related and are relatively stable personality traits and are not easily amenable to change.35 Other researchers report that empathy is a state (like mood) and is amenable to change during and after training.26 , 32 , 36 Studies to date are not consistent regarding changes in empathy by intervention. Further research on this subject is required.

Conclusion

There is a need for systematic training of humanistic qualities in medical education. Emphatic skills are not automatically acquired during clinical training and the development of empathy may be impeded by hurried fragmented patient care and emphasis on clinical detachment or affective distance or equanimity.

The measurement of empathy should be pursued during pre-clinical and clinical years of training.

This study has some limitations. First, the possibility of cohort effects cannot be dismissed in this study. Given that the findings are based on a single cross-sectional design in which baseline differences could not be controlled, a longitudinal cohort study should be conducted in the future to examine whether such differences exist and to confirm the validity of the results. Second, although the JSPE was reported to be well correlated with observer ratings,21 there is a possibility that self-reports may be subjected to unwitting biases and discrepancies between self-reflection and actual behaviour may exist. Third, the survey was conducted in only 1 year at a single medical school in South Africa. This potentially limits the generalisation of the findings to South African medical students. This is the first study that examines the ‘empathy dimension’ among a group of South African medical students. However, more research is needed for better characterisation of the effect of medical education on medical students’ empathic skills. Additional studies are needed to elucidate the role of cultures in our ‘rainbow nation’ and the impact of medical education curriculum on empathy.

Acknowledgment. I wish to thank Dr M Hojat for permission to use the Jefferson Scale of Physician Empathy - Student version (JSPE-S) and for valuable advice during the study.

Ethical clearance to conduct the study was obtained from the Human Research Ethics Committee of the University of the Witwatersrand (Certificate number M080604).

This study is based on a research report submitted to the University of the Witwatersrand in partial fulfilment towards an MSc degree in Bioethics and Health Law in 2008.

References

1. De Vignemont F, Singer T. The empathic brain: how, when and why? Trends in Cognitive Sciences 2006;10(10):435-441.

2. Brothers L. A biological perspective on empathy. Am J Psychiatry 1989;146:10-19.

3. Larson EB, Yao X. Clinical empathy as emotional labor in patient-physician relationship. JAMA 2005;293(9):1100-1106.

4. Spiro H. Commentary: the practice of empathy. Acad Med 2009;84(9):1177-1179.

5. Pembroke NF. Empathy, emotion, and ekstatis in the patient-physician relationship. Journal of Religion and Health 2007;46(2):287-298.

6. Fernández-Olano C, Montoya-Fernández J, Salinas-Sánchez AS. Impact of clinical interview training on the empathy level of medical students and medical residents. Med Teach 2008;30(3):322-324.

7. Crandall SJS, Reboussin BA, Michielutte R, et al. Medical students’ attitudes toward underserved patients: a longitudinal comparison of problem-based and traditional medical curricula. Advances in Health Science Education 2006;12:71-86.

8. Rosenfield PJ, Jones L. Striking a balance: training medical students to provide empathetic care. Med Educ 2004;38:927-933.

9. Satterfield JM, Huges E. Emotion skills training for medical students: a systematic review. Med Educ 2007;41:935-941.

10. Kanter SL, Wimmers PF, Levine AS. In-depth learning: one school’s initiatives to foster integration of ethics, values, and the human dimensions of medicine. Acad Med 2007;82(4):405-409.

11. Stephenson AE., Adshead LE, Higgs RH. The teaching of professional attitudes within UK medical schools: reported difficulties and good practice. Med Educ 2006;40:1072-1080.

12. Dereboy C, Harlak H, Gürel S, et al. Teaching empathy in medical Education. Turkish Journal of Psychiatry 2005;16(2):1-6.

13. Shapiro J, Morrison EH, Boker JR. Teaching empathy to first year medical students: evaluation of an elective literature and medicine course. Evaluation for Health 2004;17(1):73-84.

14. Hojat M, Gonella JS, Mangione S, et al. (2003). Physician empathy in medical education and practice: experience with the Jefferson Scale of Physician Empathy. Seminars in Integrative Medicine 2003;1(1):25-41.

15. Stepien KA, Baernstein A. Educating for empathy: a review. J Gen Intern Med 2006;5:524-530.

16. Hemmerdinger JM, Stoddart SDR, Lilford RJ. A systemic review of tests in empathy in medicine. BMC Medical Education 2007;7(24):1-8.

17. Roh MS, Hahm BJ, Lee DH, Suh DH. Evaluation of empathy among Korean medical students: a cross-sectional study using the Korean version of the Jefferson Scale of Physician Empathy. Teach Learn Med 2010;22(3):167-171.

18. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. Measurement of empathy among Japanese medical students: psychometrics and score differences by gender and level of medical education. Acad Med 2009;84(9):1192-1197.

19. Kane GC, Gotto JL, Mangione S, et al. Jefferson Scale of Patient’s Perception of Physician Empathy: preliminary psychometric data. Croatian Medical Journal, 2007;48:81-86.

20. Glaser KM, Markham FW, Adler HM, et al. Relationships between scores on the Jefferson Scale of Physician empathy, patient perceptions of physician empathy, and humanistic approaches to patient care: a validity study. Med Sci Monit 2007;13(7):CR291-294.

21. Garza AA, Guuerrero JFG, Herrera SE, et al. Validaciόn de la Escala de Empatίa Médica de Jefferson en Estudiantes de Medicina Mexicanos. Salud Mental 2005;28(5):57-63.

22. Hojat M, Gonella JS, Nasca TJ, et al. Empathy scores in medical school and ratings of empathic behavior in residency training 3 years later. The Journal of Social Psychology 2005;145(6):663-672.

23. Hojat M, Gonella JS, Nasca TJ, et al. Physician empathy: definitions, components, measurements, and relationship to gender and specialty. Am J Psychiatry 2002;159:1563-1569.

24. Hojat M, Gonella JS, Nasca TJ, et al. The Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item level. Acad Med 2002;77(10):s58-s60.

25. Chen D, Lew R, Hershman W, et al. A cross-sectional measurement of medical student empathy. J Gen Intern Med 2007;22(10):1434-1438.

26. Mangione S, Kane GC, Caruso JW, et al. Assessment of empathy in different years of internal medicine training. Med Teach 2002;24(4):370-373.

27. Morling B, Lamoreaux M. Measuring culture outside the head: a meta-analysis of individualism-collectivism in cultural products. Personality and Social Psychology Review 2008;12:199-221.

28. Looi JCL. Empathy and competence. Med J Aust 2008;188(7):414-416.

29. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ 2004;38:934-941.

30. Sherman JJ, Cramer A. Measurement of changes in empathy during dental school. Journal of Dental Education, 2005;69(3):338-345.

31. Kliszcz J, Nowicka-Sauer K, Trzecial B, et al. Empathy in health care providers-validation study of the Polish version of the Jefferson Scale of Empathy. Advances in Medical Science 2006;51:219-225.

32. Austin EJ, Evans P, Magnus B, et al. A preliminary study of empathy, emotional intelligence and examination performance in MBChB students. Med Educ 2007;41:684-689.

33. Newton BW, Barber L, Clardy J, et al. (2008). Is there hardening of the heart during medical school? Acad Med 2008;83(3):244-249.

34. Di Lillo M, Cicchetti A, Lo Scalzo A, Taroni F, Hojat M. The Jefferson Scale of Physician Empathy: preliminary psychometrics and group comparisons in Italian physicians. Acad Med 2009;84(9): 1198-1202.

35. Carmel S, Glick SM. Compassionate-empathic physicians: personality traits and social organizational factors that enhance or inhibit this behavior pattern. Social Science and Medicine, 1996;43(8):1253-1261.

36. Hojat M. Empathy in Patient Care. New York, NY: Springer, 2006: 181.