**5.2 Empathy in non-US countries**

8 From Preconception to Postpartum

natural tendency for medical students or physicians to distance themselves from disease and build an emotional detachment from the patient. Therefore, positive role models need to teach others how to deal with these conflicting emotions (Rosenfield & Jones, 2004).

Empathy is a multi-dimensional trait. Sociologists and psychologists break it down into two main categories; role-playing (cognitive) empathy and vicarious (innate) empathy (Hojat et al., 2009). There is an ongoing debate whether empathy is cognitive or emotional/vicarious (Spiro, 2009). Hojat defines cognitive empathy as, "Empathy is a predominately *cognitive* (rather than emotional) attribute that involves the *understanding* (rather than feeling) of experiences, concerns and perspectives of the patient, combined with a capacity to *communicate* this understanding." (Note: The words in italics and parentheses are part of the definition proposed by Hojat et al., 2009.) Vicarious empathy is defined by Mehrabian et al. (1988) as, "An individual's vicarious emotional response to perceived emotional experiences of others." In other words, vicarious empathy arises out of our own feelings and reactions; it

happens when "you and I" becomes "I am you" or "I could be you" (Spiro, 2009).

anesthesiology, and pathology (Hojat et al., 2009).

**5.1 Vicarious/innate empathy in medical students** 

specialties.

the senior year of medical school and into the first year of residency.

Recently, a scale measuring cognitive empathy, the Jefferson Scale of Physician Empathy (JSPE), developed by Hojat and colleagues, is in wide use and shows that women have slightly higher JSPE scores than men (cf. ref. 6 in Hojat et al., 2002). The JSPE shows there are equivalent declines in cognitive empathy in male and female students as they progress through undergraduate medical school, with the largest drop occurring after completion of the first clinical year of training (Hojat et al., 2009). Specialties like FM, IM, PED and OB/GYN are "people-oriented", and students who entered these specialties had higher JSPE scores than those selecting "technology-oriented" specialties like SURG, radiology,

Hojat and colleagues (2005) compared student JSPE scores, recorded in their first clinical year of training, to the clerkship director's subjective rating of their empathic behavior after their first year of residency. The results showed that residents who had higher JSPE scores as junior medical students were rated by the clerkship directors as being more empathetic than juniors who had lower JSPE scores. This implied that empathy remained stable during

Hojat et al. (2002) also examined physician cognitive empathy which showed no significant gender differences. Psychiatrists had JSPE scores that were equivalent to PED, IM, and FM physicians. However, psychiatrists had significantly larger JSPE scores than OB/GYN, SURG, radiology, anesthesia and orthopedic physicians. For specialties with continuity of patient care, IM had the largest JSPE score, followed in rank order by PED, FM and OB/GYN. However, there were no significant differences in JSPE scores between these four

residency.

As previously described, empathy can be defined from an emotional vs. a cognitive standpoint. The Balanced Emotional Empathy Scale (BEES), developed by Dr. Albert Mehrabian (1996), was used by Newton and colleagues (2007; 2008) for a seven-year longitudinal study of undergraduate medical students at the University of Arkansas for Medical Sciences. Since the BEES is gender sensitive, the data revealed significant gender differences with women having higher BEES scores than men. Newton et al. (2007, 2008) Researchers outside of the US have used the JSPE to measure cognitive empathy. There are many similarities to the US data, but some differences are revealed. Italian physicians have lower empathy scores than US physicians and no gender differences were discovered. The JSPE scores for surgeons were no different from all other specialties, and it was suggested that all differences could be attributed to cultural differences (Di Lillo et al., 2009). In South Korea, no gender differences were found, and Korean student cognitive empathy was less than US empathy. It was proposed that the Korean empathy was lower because of the more authoritative role Korean physicians assume, combined with the less assertive nature of their patients (Roh et al., 2010). Female Japanese students had significantly larger JSPE scores than males. However, the overall mean JSPE score was significantly lower than those for US students. This difference may be cultural, since the Japanese show fewer emotions via facial expressions or gestures (Kataoka et al., 2009).

#### **5.3 Maintaining empathy**

Within the US, there are decreases in both cognitive and vicarious empathy as medical students progress through their undergraduate medical education. Various interventional measures were used to try to ameliorate empathic deterioration, but the results were variable, and if successful, empathic increases were usually short-lived. (cf. refs. in Newton

Who Selects Obstetrics and Gynecology as a Career and Why, and What Traits Do They Possess? 11

100% sure they want to enter a particular specialty. In those rare cases, the cons of entering a specialty do not play a significant role in their decision making process. An eighteen-year longitudinal study (1975-1992) at an eastern US medical school revealed only 19% of students who showed an initial interest in OB/GYN, actually entered an OB/GYN residency program. The students who left OB/GYN, usually went into IM (19%) or SURG (17%). In comparison to OB/GYN data, 40% of students stayed with IM, 39% for FM and 22% for PED (Forouzan & Hojat, 1993). Compton and colleagues (2008) sampled the graduating class of 2003 at fifteen US medical schools, and found that at matriculation, 40 out of 942 students indicated an interest in OB/GYN. Of those, ten students (25%) placed into an OB/GYN residency, four (10%) changed their mind after going through the OB/GYN clerkship, five (13%) switched to another primary care residency and twenty-one (53%) switched to a non-primary care residency. In contrast to the OB/GYN data, 15% stayed with PED, 17% with IM and 23% with FM. In all of these cases, those who decided

Jeffe et al. (2010) looked all US graduates from 1997 to 2006, and found that the number of students desiring a primary care residency dropped within that time frame. Those desiring OB/GYN remained the most stable, but with low student interest. The numbers of graduates entering OB/GYN dropped from 8.2% to 6.1%. IM dropped from 15.7% to 6.7%. FM dropped from 17.6% to 6.9%, and PED dropped from 10.2% to 6.6%. Of those who entered an OB/GYN residency, 22.7% were male and 77.3% were female. In the UK, from 1974 to 2002, the number of male students who entered OB/GYN dropped from 2.6 to 1.1%. Meanwhile the female percentage dropped from 4.6 to 2%. Overall the number of UK

The gender disparity among students interested in OB/GYN was examined by a number of researchers. Gerber et al. (2006) reports that whereas the number of graduates entering OB/GYN residencies remained relatively stable from 1985 to 2000 (6% to 8%), the number of females practicing OB/GYN increased from 12% in 1980 to 32% in 2000. Accordingly, the number of female residents increased from 44% to 74%. Although the number of female OB/GYNs is steadily increasing, it must be remembered that the majority of patients have no gender preference in selecting an OB/GYN, and that only 14.7% of respondents in the study by Johnson and colleagues (2005) thought female OB/GYNs were better physicians

An unexpected consequence of the gender shift is that female OB/GYNs tend to work fewer hours than their male counterparts, and are only 85% as productive as full-time OB/GYNs (Pearse et al., 2001). This led the authors to conclude that increasing numbers of female OB/GYNs will lead to an aggregate decrease in OB/GYN productivity. This is occurring at a time when there are increasing numbers of women of all ages in the US, and that a workforce shortage would occur by 2010. (At the time this chapter was written, it's too early

**6.1 How do US students select an OB/GYN residency and what attracts them?** 

Before the question posed by the section heading can be answered, we must first consider what factors medical students use to select a residency. It appears that for many students the selection of a specialty is somewhat haphazard. Allen (1999) found that UK students are

not to enter PED, IM, or FM also switched to non-primary care residencies.

who PED

graduates entering into OB/GYN dropped from 3.2 to 2.0% (Turner et al., 2006).

than their male counterparts.

to tell if the prediction has come to fruition.)

et al., 2008). Newton (2008) proposed that the loss of innate empathy makes it difficult to maintain cognitive empathy. Thus, interventions to improve empathic behavior have to be taught on a repeated basis. Given that students who enter an OB/GYN residency have the highest BEES score, i.e., they better maintain their vicarious empathy than students entering other specialties, it is possible that interventions to improve empathic behavior may have a greater impact on these students as compared to those who enter other residencies. However, this suggestion must be weighed against cognitive empathy data that show students desiring an OB/GYN residency have JSPE scores which lie midway in the values for all specialty choices. It may be more desirable for students to have OB/GYN JSPE scores ranked near the top of the specialties, since having both high vicarious and cognitive empathy scores suggests a better outcome for interventions to improve empathy.

All students and physicians, whether in OB/GYN or not, must walk a fine line between being too emotionally attached to patients or being perceived as too aloof and emotionally detached. All humans are naturally repulsed by illness and death and tend to draw away from it (Rosenfield & Jones, 2004). Yet, physicians have selected a profession that deals with what is naturally repulsive. Therefore, it seems only natural that emotional conflicts arise. It is all too easy for a student or physician to depersonalize patients and transform them into a disease, or a cold list of laboratory numbers or physical findings in a medical record (Carmel & Glick, 1996). The increasing use of ever more sophisticated technology makes the depersonalization process all the more pernicious. Depending solely on "concrete numbers and images" hinders the ability to build a meaningful doctor/patient rapport. Spiro (2009) states, "Listening can create empathy – if physicians remain open to be moved by the stories they hear."

Despite decreases in student empathy as they progress through medical school, there are a number of suggested interventions to help improve empathy and, ergo, patient satisfaction. Mindfulness-based stress reduction, self-awareness training, Balint groups, and meaningful experience and reflective practice discussions have been suggested (cf. refs. in Neumann et al., 2011). Rosenfield and Jones (2004) suggested the dilemmas that erode empathy can be broken down into four different areas, each with a given solution:


Success in maintaining empathy depends on having faculty and residents exhibiting and promoting empathic behavior so that they can be role models for the students. Without a doubt, students entering into the clerkships will take on the persona of those to whom they are exposed.
