gms | German Medical Science

The aim of the present article is to raise more attention and basic understanding of the importance of physician empathy (PE) in the field of medical education research. Therefore, we’ll give a concise introduction into the

1.

definition of PE and

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its influence on patients’ health outcomes.

In the next step

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we present assessment instruments to measure PE from the subjective perspective of the patient and from medical students’ view.

The latter topic will be presented in detail as we did a pilot-study and basic psychometric analyses of two self-assessment instruments of empathy, which are mostly used in medical education and empathy research, namely the German translations of the “Jefferson Scale of Physician Empathy, Student Version” (JSPE-S) and the “Interpersonal Reactivity Index” (IRI).

“One of the most frequent tasks of every physician is the communication with patients and relatives, regardless if their field of is more in surgery, internal medicine or family medicine” [1], p.709. A central prerequisite for the development of a therapeutic physician-patient relationship is the physician’s ability to empathize with the patient [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13].

Many researchers have tried to establish a precise definition of PE [10], [11] and found that empathy is comprised of two components – an affective and a cognitive one (detailed overview, see [12]). One of the mostly used definitions of PE is that of Mercer and Reynolds [5]. They took, on the other hand, an integrative approach to defining empathy, considering it both a multidimensional and skills-based construct. They describe four components of a multidimensional conception of the empathy construct based on an extensive review of literature conducted by Morse et al. [13]. These include the following:

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„Emotive: The ability to subjectively experience and share in another’s psychological state or intrinsic feelings.

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Moral: An internal altruistic force that motivates the practice of empathy;

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Cognitive: The helper’s intellectual ability to identify and understand another person’s feelings and perspective from an objective stance;

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Behavioural: Communicative response to convey understanding of another’s perspective.” [5], p.S10

By taking this multidimensional approach, Mercer and Reynolds intentionally distance themselves from the purely emotional aspect usually associated with the term empathy. At the same time, they use Morse’s concept of empathy to delimit it from the term “sympathy”, which implies strong emotional involvement in the needs and concerns of the patient and, for this reason, is often seen as a danger by medical personnel. By contrast, Mercer and Reynolds define empathy more as a learnable, professional (communication) skill and less as a purely subjective emotional experience or an innate, unalterable personality trait (overview on the learnability of empathy, see [14]).

Greater significance has been given to the cognitive and behavioral aspects of empathy within the clinical context. Mercer and Reynolds describe these dimensions as an “entering into of the patient’s perspective, beliefs, and experiences” [5], p.S10. This “entering into” does not, however, necessarily entail exactly the way the patient feels because this could lead to an over-identification with the patient and a blurring of professional boundaries.

Mercer and Reynolds [5] believe that none of the above described four components of PE are effective unless they are expressed through an action component. In other words, the physician must demonstrate unequivocally to the patient that she/he understands what the patient is experiencing and, at the same time, check back with the patient to ensure that he has understood correctly [14]. In their opinion, physicians can only provide a patient with therapeutic treatment once they have obtained an accurate and complete informational understanding of the patient as a result of such a “feedback loop.”

Based on this conceptual background and a definition provided by Coulehan et al. [15], Mercer and Reynolds define PE as:

„… the ability

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to understand the patient’s situation, perspective and feelings (and their attached meanings),

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to communicate that understanding and check its accuracy and

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to act on that understanding with the patient in a helpful (therapeutic) way.“ [5], p. S10.

Therefore, PE is understood as physician’s understanding of the patient and verbal and non-verbal communication of the physician resulting in a helpful therapeutic action.

Studies on the outcome-relevance of empathy found a range of positive effects for the patient, although most of these studies assume different definitions and measures of PE. Beside this, empathic communicating physician may lead to:

• Patients reporting more on their symptoms and concerns [11], [15], [16], [17], [18],
• Increased diagnostic accuracy [15], [17], [19], [20],
• Patients’ receipt of more illness-specific information [14], [21], [22], [23],
• Increased patient participation and education [5], [23], [24],
• Increased patient compliance and satisfaction [25], [26], [27],
• Greater “patient enablement” (i.e., the patient’s ability to cope with prescribed treatment) [14], [28], [29], [30], [31], [32], [33],
• Reduced depression and increased quality of life [14], [22],
• In patients with the common cold, PE is a significant predictor of the duration and severity of the illness and is associated with immune system changes in immune cytokine IL-8 [34].

These empirical findings on the therapeutic effectiveness of PE lead to the question as to what makes socio-emotional components of the patient-physician relationship, such as PE, so effective. In other words, what are the exact mechanisms of PE leading to improved patient outcomes? In the “Effect model of empathic communication in the clinical encounter” [14], the specific therapeutic effects of PE and their mutual associations are detailed to explain these therapeutic mechanisms of PE. The aim of this model [14] is to give the individual using the model in clinical practice or medical education a clear illustration of the specific positive effects that PE can have on physician actions during the clinical encounter and on patients.

This chapter presents a selection of empathy measures pertinent to the fields of patient (see Section 4.1) and medical education research (see Sections 4.2 and 4.3). For recent systematic reviews of empathy measures and their critical reflection please compare the articles by Hemmendinger et al. [35] and Pedersen [36] who also discussed the CARE, the JSPE and the IRI.

One standardized instrument for the assessment of PE by patients is the widely used “Consultation and Relational Empathy” (CARE) measure [6]. Mercer et al. developed this instrument based on their theoretical conception of PE as described Section 2 as well as on qualitative in-depth interviews with patients [37]. In recent years, a working group led by Mercer has further developed this generic, non-disease-specific, measure based on a wide range of theoretical and empirical research and has continuously improved and validated the measure through qualitative and quantitative research with patients treated in-hospital and in general practice [5], [6], [33], [37], [38]. Unique to the CARE scale is that in addition to the item statements measuring the different empathic physician activities and behaviors, it also provides synonymous and antonymous definitions for each of these statements in order to clarify them for the patients being surveyed. The scale’s ten items are answered on a 5-point Likert scale (1=poor, 2=fair, 3=good, 4=very good, 5=excellent) and are preceded by the phrase: “How was your doctor at ...” [39].

A German version of the CARE measure is also available and has been psychometrically evaluated with a sample of oncology patients [18]. One main finding of the confirmatory factor analyses was that the ten items of the CARE scale fit a unidimensional model, which confirmed the psychometric properties of the German version to be the same as those of the original English version [18]. However, a recent study based on the advanced Rasch-model indicated that only the first nine items of the CARE-measure allow for the unidimensional assessment of PE [40].

Based on these satisfying psychometric properties of German CARE version, the instrument may be regarded as an adequate measure for further use in outcome and intervention research. In medical practice, physicians or medical students can use the CARE scale as a timesaving feedback instrument for assessing the strengths and weaknesses of their own empathic behavior, as a personal behavior checklist during consultations, and/or as a checklist for determining patient preferences either before or during a consultation. For these reasons, the CARE measure has been accredited in Scotland by the Royal College of General Practitioners (RCGP) as a revalidation toolkit recommended for use and being used by general practitioners as a self-audit instrument [41].

Beyond that CARE can also be used in medical education, e.g. as a feedback tool for observers during simulation patients contact.

Due to its outcome relevance (see Section 3) PE has also long been a key element of the framework of medical professionalism [42] as well as a defined educational objective in medical training in several countries [43], [44], [45]. However, in Germany, only one study has been conducted to assess the relevance of empathy in medicine from the viewpoint of medical students. This study surveyed all pre-clinical students in their first and second semesters at the University of Regensburg (N=811) and found that medical students considered physician competence and attentiveness to patients as most important. Although empathic behavior was also considered to play an important role, it ranked lower than competence and attentiveness [46].

Due to this research gap, we conducted a cross-sectional pilot study and basic psychometric analyses of the German translations of the most frequently used self-assessment measures of PE in medical education research: the JSPE-S measure (see Section 4.2.1) which aims to assess students’ perceived relevance of empathy in patient-physician interaction and the IRI measure (see Section 4.3.1) which, in contrast to the JSPE-S, aims to assess empathic abilities.

1. The “Jefferson Scale of Physician Empathy, Student Version” measure

The following are explorative results of first pilot study comparing the perceived relevance of empathy in medical care from the point of view of German medical students and students of other disciplines. The study measured students’ perceived relevance of empathy in patient-physician interaction using the German version of the JSPE-S (for in-depth overview of the theoretical assumptions of the IRI compare e.g., [7], [47], [48], [49], [50], [51]) (for German items, see Tabelle 1 [Tab. 1]). This measure was specifically developed for the context of medical education and medical education research and comprises 20 items, each answered on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Satisfactory evidence for the psychometric quality of the JSPE-S has already been provided by many studies [7], [47], [48], [49], [50], [51].

So far, the JSPE-S has been translated into a total of 25 languages [52]. Translation of the measure into German was carried out according to established guidelines for translating and adapting foreign instruments [53], [54], [55]. First, the JSPE scale was translated into German by three separate individuals (MN, CS, DT) with the aim to obtain a translation that remained as close to the original English version as possible. The three German versions were then back translated into English by a professional native English-speaking translator. Finally, German items closest to the original English items were selected for use in the instrument. This version was tested with three medical students and three test subjects from the regular population using qualitative psychometric pretests such as the think-aloud and probing techniques [56], [57]. The final German version was translated back into English and authorized by M. Hojat.

2. Data collection and data analysis

Data collection took place under the direction of the first author during the summer of 2009 as part of the one-week seminar called “Medical Sociology Research Practices”. The 14 seminar participants conducted a total of N=107 face-to-face standardized interviews with N=44 medical students from the University Clinic Cologne and N=63 student of other disciplines at a total of four relevant university campus locations.

PASW Statistics Version 18 was used to conduct statistical analysis. We conducted means, standard deviations, and item discriminabilities (coefficient indicating how well a single item represents the result of the whole test [58]) for basic item analysis (compare Table 1 [Tab. 1] and 2 [Tab. 2]). Moreover, Cronbach’s alpha were conducted for the basic psychometric analysis and t-test for comparing JSPE-S and IRI mean values of medical and non-medical students.

3. Sample

The average age of the medical students was 22.8 years, and the average age of the students of other disciplines was 23.8. On average, medical students had completed 4.7 semesters; for the other students, the average was 5.4 semesters. Whereas N=20 of the medical students were female and N=24 were male, N=38 of the students from other disciplines were female and N=25 were male. Students from other disciplines were N=19 from pedagogy, N=22 from economics, N=14 from natural sciences, N=8 from law.

4. Results: Basic psychometrics of the German version of the JSPE-S

The item scores on the JSPE-S of the two student groups are listed in separate columns in Table 1. As can be observed, the medical students had significantly higher scores for three of the items (marked in bold **). A comparison via t-test of the total JSPE-scores also revealed a tendential, but not significant difference between the two student groups (p=0.075). Other studies have also found significant differences in the total JSPE scores of the study population with regards to gender [e.g., 52, 58]. However, this study indicated no significant gender differences.

The psychometric quality of the German version of the JSPE-S is comparable to the original American version. Cronbach’s alphas for the medical students and students of other disciplines ranged between 0.803 and 0.805, respectively [7], [47], [48], [49], [50], [51], [52], [59]. Interestingly, however, removal of Item 7 (see Tabelle 1 [Tab. 1]) would increase the Cronbach’s alpha to 0.838 for both sample groups. The same is true for Items 5, 6 and 18, although the increase would not be as great.

Due to the small sample size in this explorative study, a factor analysis was not conducted.

Another possible means of measuring empathy involves assessing one’s own empathic abilities. Of the many self-assessment instruments available [35], [36], three scales are most commonly used in international education research. These include the “Interpersonal Reactivity Index” (IRI) [10], [58], [60], the “Hogan Empathy Scale” [61] and the “Balanced Emotional Empathy Scale” (BEES) [62]. In recent years, studies have frequently used the IRI scale for self-assessments of empathy [for in-depth overview of the theoretical assumptions of the IRI compare [10], [58], [60] among medical students and have found that

(a)self-assessed empathy is greater among medical students than students of other disciplines [63], [64], [65];

(b)there is a significant decrease in self-assessed empathy over the course of students’ medical education and training among both medical students and residents with patient-remote specialties and, in particular, among those in the clinical practice phase [66];

(c)medical students’/ residents’ distress in its various forms has a significant negative impact on self-assessed empathy [66].

So far, no studies investigating the self-assessed empathy of medical students or physicians have been conducted in Germany. To ensure consistency with the international research discussed above, Davis’ IRI measure [10], [58], [60] was translated into German according to the procedures detailed in Subsection 4.2.1.1. As with the JSPE-S, the final German version of the IRI was back translated into English and authorized by M. Davis.

The IRI Scale contains 28 items (see Table 2 [Tab. 2]) measuring both the cognitive and emotional dimensions of empathy. The items are answered on a Likert scale ranging from A (does not describe me at all, numerically coded as “1”) to E (describes me very well, numerically coded as “5”). The IRI is made up of the following four subscales:

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The perspective-taking scale assesses the personal tendency to see a situation through the eyes of others and not only through one’s own (Table 2 [Tab. 2]; items 3, 8, 11, 15, 21, 25, 28).

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The fantasy scale assesses a person’s tendency to identify with the situation and feelings of characters in novels, movies or plays (items 1, 5, 7, 12, 16, 23, 26).

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The empathic concern scale measures a person’s tendency to care about the feelings and needs of others (items 2, 4, 9, 14, 18, 20, 22).

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The personal distress scale measures the personal tendency to experience distress and discomfort in difficult social situations (items 6, 10, 13, 17, 19, 24, 27).

The data collection procedures and sample characteristics are the same as in Subsections 4.2.1.2 and 4.2.1.3 respectively.

Item scores obtained for the medical students and students of other disciplines for the German version of the IRI are presented in separate columns in Table 2. Contrary to our assumption [67], neither the individual items of the IRI scale nor the four subscales indicated in t-tests any differences in the degree of self-assessed empathy when comparing the two groups of students (perspective-taking: p=0.883; fantasy: p=0.104; empathic concern: p=0.727; personal distress: p=0.358). However, as hypothesized [67], gender-specific differences in the overall sample were found for two of the four IRI subscales. In a t-test we found that female students assessed their level of empathy to be higher in the dimensions of fantasy (p=0.000) and personal distress (p=0.002) and a little bit higher, but not significantly, in the empathic concern dimension (p=0.091).

The basic psychometric quality of the Germany version of the IRI is comparable to the original American version [10], [58], [60]. Cronbach’s alpha for the four IRI subscales were 0.736 (fantasy), 0.693 (empathic concern), 0.752 (perspective taking) and 0.702 (personal distress) for the medical students and 0.779 (fantasy), 0.616 (empathic concern), 0.759 (perspective taking) and 0.703 (personal distress) for the students of other disciplines. What is striking is that removal of Item 13 would considerably improve the Cronbach’s alpha for the personal distress scale (medical students= 0.810; other disciplines= 0.754).

Due to the small sample size in this first explorative study, a factor analysis was not conducted.

Future studies have to verify and enhance these first very basic and descriptive psychometric analyses of the German versions of the JSPE-S and IRI by using larger samples from various medical faculties and other disciplines. This should be done through exploratory, confirmatory factor analyses [18] and with the Rasch-model [40] in a more in-depth study of the instruments’ divergent, convergent and criterion validities. Furthermore, the construct validity of the JSPE-S and the IRI has to be verified as well, e.g. their correlation with personality measures, gender. Particularly important for the JSPE-S is to verify in future studies if students are aware of the construct empathy and its meaning, because it this seems to be a prerequisite to be able responding to this measure. Moreover, also the relatively low values [68] of Cronbach’s alpha and partly too low item discriminabilities [68] of the JSPE-S and IRI reveal further in-depth and critical psychometric analyses in the future with larger samples.

Nevertheless, the measurement of medical students’ empathy via self-assessment requires methodological awareness on its limited validity. Future medical education research should therefore explore e.g. diagnostic tests or other methods of assessment (overview [69]) as considerable proxies for the self-assessment of empathy.

This literature overview and pilot study demonstrates that PE as an outcome-relevant element in the patient-physician relationship requires more consideration in the education of medical students and, thus, in medical education research. The German versions of the JSPE-S and IRI measures seem to be promising means to evaluate these education aims and to conduct medical education research on empathy in the future.

We are grateful to the Software AG Foundation, the Mahle Foundation and the Cultura Foundation for their financial support of Melanie Neumann, Christian Scheffer, Gabriele Lutz, Diethard Tauschel and Friedrich Edelhaeuser.

We would also like to thank Gudrun Lamprecht for her tireless support in providing literature. We are grateful to Fawn Zarkov for her qualified support concerning our use of English.

Parts of this study can be found in a book chapter in German language under the following reference: Neumann M, Edelhaeuser F, Tauschel D, Scheffer C (2010). Ärztliche Empathie: Definition, therapeutische Wirksamkeit und Messung. In: Witt C.(Hrsg.), Der gute Arzt aus interdisziplinärer Sicht. Ergebnisse eines Expertentreffens. Essen, KVC Verlag, S. 157-186. We thank the KVC Verlag for the permission to publish this excerpt in English language.

The authors declare that they have no competing interests.