The physician-patient relationship is one important factor that could support adherence to treatment recommendations, increase continuing care, and promote patient satisfaction with health care.1,2 Empathy is the most effective component of a good relationship between patients and physicians, which has a very important role in the patient’s treatment process. It is also one of the important indicators of professionalism of physicians.3 Indeed, empathy provides a quick way to connect with patients, and, in addition, improves the quality of the relationship. Empathic understanding constitutes the core of interaction between the medical team and the patients. Empathy with the patient means being able to understand the patient’s conditions and feelings for providing effective and quality care.4 Although it is very difficult to define empathy, one of the commonly accepted definitions is “empathy: a cognitive feature capable of understanding patient experiences and insights.”5 Empathy provokes this feeling in the patient that the physician is able to understand the patient’s mental world in line with his or her emotions, while the patient does not lose their independence.4

The results of a randomized study revealed that clinicians who use warm, friendly, and calm methods of treatment have more effective clinical outcomes than physicians who fully advise and do not reassure patients.6 Empathy is an important part of the therapeutic alliance with the patient, which contributes to better diagnosis and treatment, as well as patient satisfaction.7–9 In addition, interpersonal empathy can reduce racial bias, so it may have a protective role against treatment inequalities.8

Two systematic reviews support medical schools in promoting teaching physician-patient empathy as a valid part of medical curricula. While both studies concluded that it is possible to sustain and further enhance empathy during medical school years,10,11 some research suggests that empathy in medical students diminishes with increasing academic years. There is little research about why some medical students benefit from empathy educational programs in medal school teaching while others do not.12 Previous studies have demonstrated that medical student characteristics strongly affect the learning of empathy in medical training.13–16 Therefore, student characteristics could influence the manner in which they react to educational programs. Evidence supports that students might disobey the educational programs if their characteristics are inconsistent with educational programs.14 However, few studies have assessed the factors that predict empathy in medical student’s relationship with patients. Characteristics such as the tendency to elitism, desire for egalitarianism, and medical authoritarianism are factors that can independently predict attitudes of medical students toward empathy in the relationship with patients.8

Although medical views and dispositions may influence the responses to perspectives toward empathy in physician-patient relationship,14–16 there is little knowledge on the psychological predictive factors of empathic perspective in physician-patient relationship among medical students. A better understanding of the incoming medical students’ characteristics that predict perspectives toward the value of physician-patient empathy in clinical settings may be a first step in improving the understanding of differences in students’ response to teaching during medical school. The aim of this study was to examine whether psychological well-being, dispositional perspective, and spiritual well-being could predict the empathic perspective of medical students in the physician-patient relationship.

Methods

We conducted a cross-sectional study on medical students of at Babol University of Medical Sciences from June to October 2018. This study was approved by the Ethics Committee of Babol University of Medical Sciences (IR.MUBABOL.HRI.REC.1397.111).

All medical students of Babol University of Medical Sciences in 2018 going through the academic years one to seven were invited to the study. The medical curriculum at Babol University of Medical Sciences consists of four major phases. The first two and a half years are basic sciences, one year for ‘preclinical medicine’ including physiopathology courses, two years for clinical exposure, named as ‘clerkship’, and finally 18 months, known as ‘internship’.

A total of 500 medical students studying in the four phases were invited to participate in the study. A sample size of 350 was acceptable based on Morgan’s table and a 30% drop-out rate. One of the research team members visited the medical school and explained the aims of the study and invited the students to attend the research. If the student was willing to participate in the study, the research team member delivered the printed questionnaires to her/him with an unnamed envelope. The envelope contained questions about demographic characteristics (age, sex, and grade of the study), Jefferson Scale of Physician Empathy - student (JSE-S) version, and three psychological questionnaires including Brief Ryff psychological well-being, Individual Disposition, and Spiritual Well-Being. A staff member outside the research team was responsible for collecting the completed questionnaires. After one week, the staff asked the students if they had completed the questionnaires via an SMS message. If the questionnaires were completed, the staff delivered the completed questionnaires in a sealed envelope to the research team. Of 500 medical students invited, 350 students completed and returned all of the questionnaires.

The JSE-S version is a self-administered inventory, well-accepted, and reliable instrument to assess the student’s perspective regarding clinical empathy in the relationship with patients. It contains 20 items where the students mark 1 of the 7 options provided on a Likert scale in response to each item (1 = strongly disagree, 7 = strongly agree). The scores range within 1–140, with higher scores signifying a more positive and consistent view of students with empathy in the relationship with patients. This scale has three subscales: perspective taking, compassionate care, and standing in the patient’s shoes.17 The average alpha coefficient for JSE-S is reported as 0.78. This study employed the Iranian version of JSE-S version.18

We used the Brief Ryff Well-Being questionnaire (18 questions) to assess the psychological well-being of the participants. This questionnaire contains six subscales: environmental mastery (sense of controlling), self-acceptance (positive attitude toward self), positive relations with others (sense of satisfaction and intimacy with people), purposeful life (having a purpose in life), personal growth (sense of steady growth), and autonomy (sense of independence). Scoring is based on the six-point Likert scale (1 = strongly disagree to 6 = strongly agree).19 The correlation of three subscales with test-retest reliability is reported 0.70 to 0.89.18 We used the valid Persian version of the questionnaire, which has been used in many Iranian studies.20,21

The Individual Disposition questionnaire assesses the individual tendency of medical students. This scale consists of 14 items with seven-point rating (1 = strongly disagree to 7 = strongly agree). Each subscale includes cognitive empathy, discomfort with uncertainty, tendency to elitism, tendency to egalitarianism, medical authoritarianism, locus of control, self-esteem, and self-awareness. Each subscale consists of two questions with higher scores revealing a better agreement with the view. The alpha coefficient for six subscales is reported 0.63 to 0.89.22,23

The Spiritual Well-Being scale was first developed by Paloutzian and Ellison in 1982.24 The questionnaire consists of 20 items with two subscales: religious well-being and existential well-being. The total scores of the scale range from 20 to 120. The higher scores represent greater spiritual well-being.24 The Cronbach’s alpha coefficients for subscales were overall score of spiritual well-being 0.95, for religious well-being 0.94, and religious well-being 0.84.25 We used the valid Persian version of the spiritual well-being scale.26

The descriptive statistics reported included means and frequencies. Student’s t-tests were used to compare the mean scores of empathy, spiritual well-being, spiritual well-being, and dispositional perspectives between male and female medical students Pearson’s correlation coefficient was applied to test possible significant relationships between empathy and spiritual well-being, as well as between spiritual well-being and dispositional perspectives.

The total JSE score, as main outcome and the dependent variable, was not normally distributed. We created square rooted the total JSE-S score. We repeated the analyses using square rooted variables, but all analyses were no differences between two patterns of variables. Thus, the original, non-transformed total JSE was retained in the final analyses.

Finally, stepwise multivariate analysis regression was used to find the predictors of medical students’ perspectives regarding empathy. The variables included in the model were those showing a significant correlation with empathy scores in previous bivariate associations. Age was considered an adjusted variable. Also, we repeated the analysis using recoded total score of empathy to dichotomize in to high and low scores (median as a cut-point). Then, we repeated the analysis using logistic regression. As there were no differences between two patterns of the results, we presented the results of linear regression.

Data analysis was carried out using SPSS Statistics (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). The level of significance in all analyses was considered as p < 0.050.

Results

Our response rate was 70.0%, with 42.0% of respondents male and 58.0% female. The average age of the participants was 22.5±2.3 years. One-hundred students (28.6%) were at basic sciences level, 50 (14.3%) preclinical medicine, 100 (28.6%) clerkship, and 100 (28.6%) internship [Table 1].

Table 2 compares the mean of individual differences of medical schools regarding academic level. The results of analysis of variance and the comparison of Tukey’s comparison mean tests revealed that the internship students had lower mean scores of cognitive empathic tendencies compared to clerkship students. Regarding the discomfort of uncertainty, the mean scores of basic science students were significantly higher than those of clerkship and preclinical medicine students. Further, the mean scores of discomfort of instability were significantly higher in clerkships than in internships. Therefore, the discomfort of instability seems to significantly decrease with the increase in the academic year. Regarding the tendency toward elitism, the basic science scores were higher than both preclinical medicine and clerkship scores. Medical authoritarianism was significantly higher in internship than in basic sciences. Also, the mean scores of spiritual well-being were significantly higher in students of basic sciences compared to their preclinical medicine and clerkship counterparts. In addition, basic sciences students had significantly higher scores of spiritual well-being than the other three groups of preclinical medicine, clerkship, and internships. The mean total scores of psychological well-being in students of internships were lower than those of basic sciences. Also, clerkships had higher scores of psychological well-being than the other three groups of students.

Regarding the total score of students’ perspective to clinical empathy, the mean empathy score of all students was 106.1±29.8 (range: 20–140). The minimum scores were seen for internship students while the maximum belonged to the basic sciences students. The mean scores of basic sciences students were significantly higher than those of preclinical medicine, clerkships, and internships students. On the other hand, the scores of preclinical medicine were higher than clerkships, and clerkships were higher than internships. Therefore, it seems that with an increase in the academic year, the score of students’ perspective to clinical empathy is significantly reduced. Also, all of the three subscales of student’s perspective to clinical empathy including compassionate care and standing in the patient’s shoes decreased significantly with further academic years of the medical students.

Table 3 shows that female students had significantly higher mean scores of medical authoritarianism and self-awareness, self-acceptance, positive relationship with others, personal growth, and total score of psychological well-being compared to males. Also, total scores of female students’ perspective to clinical empathy and three subscales of empathic perspective, compassionate care, and standing in the patient’s shoes were higher than in male medical students.

Table 4 revealed a strong positive significant relationship between students’ perspective to clinical empathy and spiritual well-being (r = 0.56), cognitive empathy (r = 0.51), and psychological well-being (r = 0.43). Also, there was a significant relationship between the students’ perspective to clinical empathy and discomfort with uncertainty, tendency to egalitarianism, medical authoritarianism, existential well-being, total score of psychological well-being, self-esteem, self-awareness, environmental mastery, self-acceptance, positive relations with others, purposeful life, personal growth, autonomy, empathic perspective, compassionate care, and standing in the patient’s shoes. On the other hand, there was no significant relationship between student’s perspective to locus of control and self-awareness.

Table 5 provides the results of multivariate stepwise regression tests between students’ perspective to clinical empathy and psychological well-being, dispositional perspective, and spiritual well-being. The final analysis revealed that cognitive empathy (β = 0.300), self-esteem (β = 0.133), and spiritual well-being (β = 0.388) positively predicted student’s perspective to clinical empathy regarding the physician-patient relationship.

Discussion

Our study investigated the role of psychological well-being, dispositional views, and spiritual well-being in predicting empathic prospective of medical students about the physician-patient relationship. In this study, the mean empathy scores of all students were high. The mean scores of empathy of medical students in Mirani et al.’s report were lower than in this study (98.11±12.31).26 The findings of the study revealed that students’ perspective to clinical empathy and all of the three subscales of the JSE including compassionate care, and standing in the patient’s shoes decreased significantly with increasing academic years of the medical students. In line with these results, van Ryn et al,8 found a significant difference in terms of perspective between students in their early years of study and those studying at higher levels. Indeed, students studying at higher levels of education are less likely to value doctors’ empathy. However, our study had methodological difference with that van Ryn et al,8 In a longitudinal design, van Ryn and colleagues compared empathic prospective of first year of medical students about the physician-patient relationship with their scores at the end of the last medical academic year. In this regard, Farahaninia et al,27 reported that with increasing years of education, the empathy scores of medical students were reduced. Another study showed that students in clinical training (sixth/seventh years) had lower empathy than students studying in the first to fifth years.28

Here, female students had higher scores of student’s perspective to clinical empathy and its three subscales (perspective empathic taking, compassionate care, standing in the patient’s shoes) compared to their male counterparts, which was in accordance with previous studies.26,29 A study found a significant correlation between the empathy and students’ gender (p = 0.010) where women had higher empathy scores than their male counterparts.29 Another study also concluded that female medical students had higher scores of empathy compared to males.26 However, elsewhere there was no difference between empathy scores of females and males among Chinese medical students.28 The different findings regarding the correlation of gender and empathy score of medical students can be attributed to different countries and communities.

Another important finding was that medical students in their last years of education, especially internship grade, had many differences with other grades of medical academic education regarding empathic perspectives, disposition view, psychological well-being, and spiritual well-being. Internship students had the lowest scores in the following items: cognitive empathic tendencies, tendency to egalitarianism, and both of spiritual well-being's subscales; religious well-being and existential well-being, psychological well-being, personal growth scores, and self-acceptance. van Ryn et al,8 reported that personality factors such as self-perception, close relationship with the patient, targeted empathy, tendency to elitism, medical authorities, health, and the desire to egalitarianism could affect physicians’ attitude toward empathy in the clinical practice. The different results regarding the correlation of personality factors with empathy score of medical students can be attributed to different teaching set-ups for medical students in various countries and communities.

The results revealed a strong positive significant relationship between students’ perspective to clinical empathy and spiritual well-being, cognitive empathy, and psychological well-being. Also, cognitive empathy, self-esteem, and spiritual well-being positively predicted students’ perspective to clinical empathy regarding the physician-patient relationship. Evidence has suggested that high level of well-being can be associated with high levels of empathy in clinical setting.30 In agreement with our results, van Ryn et al,8 observed that discomfort with uncertainty, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept, and well-being predicted medical students’ attitudes toward empathy. Another study concluded that spirituality openness and religiosity were significant predictors of empathy in medical students.30 Note that spirituality openness was associated with empathy only in students without depressive symptoms.30 However, different methodological design, different included population study, and various assessment evaluations, can lead to different results regarding the relationship between students’ perspective to clinical empathy and psychosocial well-being or spiritual well-being.

The results of this study indicated that although the overall mean score of empathy was high in medical students, with further years of education, medical students’ perspective to clinical empathy dropped.

Several hypotheses are proposed to explain this finding. First, internship students had the lowest scores in cognitive empathic tendencies, tendency to egalitarianism, spiritual well-being, and psychological well-being especially personal growth scores and self-acceptance. Secondly, there was a positive association between empathy, cognitive empathic tendencies, tendency to egalitarianism, spiritual well-being, and psychological well-being. Further, cognitive empathic tendencies and spiritual well-being were predictors of students’ perspective to clinical empathy. Therefore, internship students with lower scores of empathic tendencies and spiritual well-being were more likely to have lower scores of students’ perspective to clinical empathy.

The study had several limitations possibly limiting the generalization of the results. First, the study was cross-sectional; therefore, causal direction is uncertain. Second, sampling was limited to a medical school in Iran. Therefore, the medical students of here may not be a suitable representative of the other medical students. Further, the medical students with different levels of education were compared in the study. In future, multicenter and multinational studies with large sample sizes and cohort design should be planned to test this hypothesis on how the spiritual well-being, individual disposition, and psychological well-being profiles of the medical students affect their perspective to clinical empathy with patients. Keeping these limitations in mind, our study highlighted a valuable finding in the physician-patient relationship; the individual characteristics of medical students should be taken into account in the assessment of perspectives to the relationship with patients.

Conclusion

Although the score of medical student’s perspective to clinical empathy was high, with increasing years of education, the score diminished. Females had significantly higher empathy scores compared to males. There was a strong positive relationship between student’s perspective to clinical empathy and spiritual well-being, cognitive empathy, and psychological well-being. Also, cognitive empathy and spiritual well-being positively predicted the students’ perspective to clinical empathy regarding the physician-patient relationship. The study also revealed the characteristics of empathy in medical students in four grades of academic education and provided a reliable reference for designing interventions to cultivate empathy among Iranian medical students.

The results provide useful insights into interventions in curricula of medical schools for improving empathic physician-patient relationship.Training physicians to enhance empathy in relationship with patients should be framed such that it is consistent with the previous perspectives of medical students. The results suggested that promoting empathic care in curricula of medical school may be more effective if students’ preexisting perspectives, especially cognitive, tendency to egalitarianism, and spiritual empathy are taken into account.

Disclosure

The authors declared no conflicts of interest. The study was funded by Babol University of Medical Sciences.

Acknowledgements

The study has been adapted from the results of Pouria Amiri’s dissertation at Babol University of Medical Sciences (Code:1682). The medical students are highly appreciated for their assistance in data collection. We also hereby express our gratitude to Babol University of Medical Sciences for its financial support.

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