**5. Empathy in the doctor/patient relationship**

Numerous studies have shown empathic physicians are better at maintaining a good doctor/patient relationship. This makes the patients more relaxed, confident in their physician, compliant, and less likely to sue for malpractice (cf. refs. cited in Newton et al., 2008). Accordingly, the American Association of Medical Colleges and the Accreditation Committee for Graduate Medical Education have emphasized the importance of promoting empathy and professionalism in the curriculum. Displaying empathy is counter to the

Who Selects Obstetrics and Gynecology as a Career and Why, and What Traits Do They Possess? 9

separated the data into males and females who desired to enter "core" specialties which have continuity of patient care, i.e., IM, FM, OB/GYN, PED, and psychiatry or "non-core" specialties without continuity of patient care, e.g., radiology, pathology, emergency medicine, anesthesiology and SURG. Significant drops in vicarious empathy occurred in both sexes after the completion of the first and third years of undergraduate medical school. Those students who selected core specialties had a smaller drop in BEES scores compared to those whom selected non-core specialties. Females that selected core specialties had the smallest overall drop in BEES scores, while females selecting non-core specialties had the greatest overall decrease, with their BEES scores approaching the naturally lower BEES scores of males. These data suggest that females who desire to enter male-dominated specialties may be taking on the persona of the less empathic males (Newton et al, 2008).

When the BEES data from the final year of medical school were analyzed with respect to residency choice, students who entered core residencies had significantly higher BEES scores than students who entered non-core residencies (Newton et al., 2007). The average BEES score for the general population is 45. The top four residency BEES scores were OB/GYN (52.21), psychiatry (47.68), PED (46.30) and FM (39.00). The other core specialty, IM, had a BEES score of 33.02, and was ranked 9th out of 16 specialties. (All specialties with an n 8 students were considered as providing valid data.) In relation to the general population, the top four specialties had "average" vicarious empathy, while IM was "slightly low". Surgery had "moderately low" vicarious empathy (19.95), while plastic surgery (12.00) and neurosurgery (7.25) had "very low" empathy. However, the lowest two specialties did not have eight or more students entering the residencies over a seven-year period, so interpretive caution must be used since the aggregate BEES score may not be a true reflection of the vicarious empathy shown by this low number of medical students.

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

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

**5.2 Empathy in non-US countries** 

**5.3 Maintaining empathy** 

via facial expressions or gestures (Kataoka et al., 2009).

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).

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

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

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 specialties.

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

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) separated the data into males and females who desired to enter "core" specialties which have continuity of patient care, i.e., IM, FM, OB/GYN, PED, and psychiatry or "non-core" specialties without continuity of patient care, e.g., radiology, pathology, emergency medicine, anesthesiology and SURG. Significant drops in vicarious empathy occurred in both sexes after the completion of the first and third years of undergraduate medical school. Those students who selected core specialties had a smaller drop in BEES scores compared to those whom selected non-core specialties. Females that selected core specialties had the smallest overall drop in BEES scores, while females selecting non-core specialties had the greatest overall decrease, with their BEES scores approaching the naturally lower BEES scores of males. These data suggest that females who desire to enter male-dominated specialties may be taking on the persona of the less empathic males (Newton et al, 2008).

When the BEES data from the final year of medical school were analyzed with respect to residency choice, students who entered core residencies had significantly higher BEES scores than students who entered non-core residencies (Newton et al., 2007). The average BEES score for the general population is 45. The top four residency BEES scores were OB/GYN (52.21), psychiatry (47.68), PED (46.30) and FM (39.00). The other core specialty, IM, had a BEES score of 33.02, and was ranked 9th out of 16 specialties. (All specialties with an n 8 students were considered as providing valid data.) In relation to the general population, the top four specialties had "average" vicarious empathy, while IM was "slightly low". Surgery had "moderately low" vicarious empathy (19.95), while plastic surgery (12.00) and neurosurgery (7.25) had "very low" empathy. However, the lowest two specialties did not have eight or more students entering the residencies over a seven-year period, so interpretive caution must be used since the aggregate BEES score may not be a true reflection of the vicarious empathy shown by this low number of medical students.
