Stability of empathy scores between first- and fourth-year medical students: A longitudinal study at a Japanese medical school

Background: In medical practice, a relationship of trust between doctors and patients is essential. An important part of building and maintaining this relationship is empathy. Prior studies have suggested that empathy in medical students declined around the fourth year. The purpose of this study is to verify the decrease of empathy and gain further insights into empathy factors. Methods: This longitudinal study of undergraduate medical students was conducted through a self-administered, 20-item survey, using a 5-point Likert scale. First (n=105) and fourth (n=62) year students at Yamagata University Faculty of Medicine, School of Medicine in Japan were assessed for empathy using the Japanese version of the Jefferson Scale of Physician Empathy (JSPE). Total empathy scores were calculated, and multivariate analysis of variance (MANOVA) was used to reveal the underlying factors of the Japanese version of JSPE. Finally, logistic regression analysis was used to investigate the presence of any relationships between attributes such as gender-related differences, age, school year, and experience as a patient. Results: In total, 234 participants were contacted, of whom 167 responded (71.3%). No decrease of mean empathy scores was shown between first-year (66.4) and fourth-year students (68.4). Factor analysis identified four factors: “building good patient-doctor relationship,” “importance of empathetic care,” “understanding patients’ view,” and “compassionate care.” A weak correlation (r = - 0.271) was observed between “understanding patients’ view” and “importance of empathetic care.” The odds ratio of females in “understanding patients’ view” and “compassionate care” was significantly higher (p<0.05) than in males. For “compassionate care,” statistically significant differences were noted for gender (p < 0.05) and age (p< 0.05) and the effect of gender being larger than age. Conclusions: This longitudinal cohort study in one medical school in Japan showed that empathy scores of first- and fourth-year students did not decrease, and the contribution of “compassionate care” was lowest of the four factors. The results imply the necessity to provide a program that enables preclinical medical students to understand the significance of emotional empathy and express it before they appear for computer-based testing (CBT)

A relationship of trust between doctors and patients is essential in medical practice [1]. Empathy, which is defined as the ability to think, feel and act from one's frame of cognition, is important to maintain a relationship of mutual trust. Therefore, empathy is a fundamental issue in education for medical students. They are aware of this point. This is shown by Hurwitz et al., [2] who surveyed firstyear students regarding the desirable qualities of future doctors and reported that empathy received the second-highest score. Meanwhile, some previous studies have indicated a decline of students' empathy during undergraduate medical education [3][4][5][6][7]. However, other studies have demonstrated that there is no tendency of decline [8][9][10][11][12]. Almost all these findings are based on a cross-sectional study design. Therefore, these differences could be influenced by the baseline differences among students in different years of medical school. To confirm the tendency, it is desirable to conduct a longitudinal study design and follow a cohort during the entirety of their medical education.
Next, these studies show that empathy has many components [13]. Therefore, when dealing with empathy in medical education, it is desirable to establish the standard. The aim of empathy in medical education is to build clinical empathy that involves the abilities to: (a) understand a patient's perspective, (b) communicate that one has understood, (c) act on that understanding, and (d) share the patients' intrinsic feelings [14]. Cognitive empathy (a) is considered to be a central component of medical education. However, it is also an essential part of a doctor's foundation training to learn the emotional dimension of empathetic ability, outlined in points (b), (c), and (d). Emotional empathy is important for doctors to rebuild or maintain relationships of trust with patients who harbor negative feelings toward doctors, and in adverse situations [15,16]. Thus, emotional empathy is also crucial.
These proficiencies are considered to be the objective of empathy education and are assimilated into each medical student during the provision of education, in a way that they appear as natural behavior during their medical practice. However, hidden curricula or student distress may become barriers to learning empathy [17,18]. In addition, there is very little data on empathy situations of lower grade medical students in Japan [8].
This study uses a longitudinal design and focuses on the estimation of decline in empathy levels as the course progresses in years. It discovers grounds for the provision of empathetic education before students appear for the computer-based test (CBT) and the objective structured clinical examination (OSCE).

Participants
The survey was administered to 126 first-year students at Yamagata University Faculty of Medicine, School of Medicine in June 2010, and again three years later in 2013 to 108 students from the same sample in their fourth year, before the CBT and the OSCE. Eighteen students could not progress from the first-year to fourth-year, and were not included in the second survey. year: Learning practical abilities for physicians, and performing common achievement tests (CBT and OSCE); and (5) Fifth and six years: Acquiring abilities for clinical examinations, medical interviews, and differential diagnoses. The course starts in April. First, effective communication for building relationships of trust with patients is taught in 3.6 hours of the curriculum related to medical mediation. This medical mediation is intended to foster effective empathetic communication in the context of patient safety and quality [15]. After that, the students experience early medical exposure that includes on-site training in emergency medicine by riding in an ambulance. Of the 956 hours of education provided to first-year students, 660 are allocated to general education. The rest of the time is assigned to the study of basic medical sciences. Second-year students receive 1,162 hours of education, which only includes specialized medical sciences. Third-year students receive 1,246 hours of education in specialized medical sciences. Fourth-year students receive 902 hours of education in specialized medical sciences before the common achievement tests, CBT and OSCE, which are conducted September onward. Prior to the tests, students in this school year receive a second round of medical mediation program of 1.6 hours.
The medical mediation program mentioned above teaches a conflict management method for dispute resolution. It attempts to minimize emotionally hostile conflicts and improve less-satisfactory resolutions, for example, in litigations in which issues are narrowly limited and the important need for sincere emotional responses are ignored. Students participating in these sessions learn the concept through lectures, role-plays, and group discussions [15,19]. The program consists of behavioral and recognition skills, acceptance of negative feelings, disclosure of information with expressions of the doctor's sincere attitude, and sharing of information between the doctor and patients and their families.

Instruments
Empathy was investigated using the Japanese version (Abe) of the Jefferson Scale of Physician Empathy (JSPE). The Japanese instrument consists of a 20-item self-administered questionnaire answered on a 5-point Likert scale that ranges from 1 -"Don't agree at all," to 5 -"Completely agree," and total scores were 20 to 100. The validity and reliability of the instrument was verified earlier by Abe, K et al. [20]. Respondent attributes surveyed were gender, age, school year and presence/absence of experience as a patient (outpatient and inpatient treatment). The final item, experience as a patient, was newly added to the attribute items as it was considered a possible factor related to understanding patient emotion.

Statistical analysis
The mean total scores of empathies were shown as mean ± standard deviation, 95% confidence intervals [CI] of the means. The median total empathy scores of the two grades were statistically tested using Mann-Whitney U-test. The following static examinations were analyzed on an ordinal scale. We conducted a factor analysis of the scores of all the respondents by generalized least squares, rotating axes by the direct oblivion method. The numbers of factors were decided in accordance with the scree plot criterion (eigenvalues: 1 or higher). Next, logistic regression analysis was performed for factors 1 through 4 derived from the factor analysis. The four dependent variables were gender, age, school year, and experience as a patient (outpatient and inpatient treatment). The analysis was done with the dependent variable set to (1) if the factor score for each factor was positive and (0) if it was negative. The level of statistical significance was set at p < 0.05.

Results
Participants and mean empathy score Of a total of 234 students, 167 participated in the survey. Respondent attributes are shown in Table 1.
The mean empathy score by school year and gender is shown in Table 2. Mean empathy sores increased from 66.4 in the first year to 68.8 in the fourth year (not significant), and mean empathy scores of females were higher than that of males. Median empathy scores increased from 67.0 to 69.0 (not significant).

Factor analysis and correlation among factors)
The Kaiser-Gattman and scree plot criteria were shown to be valid. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.914 and Bartlett's test was p < 0.01, confirming the validity of this factor analysis. Four factors were identified (Table 3). Factor 1 was composed of eight items (10, 13, 7, 15, 8, 18, 20, 9 and 4) and, because it was related to interpersonal relations between doctors and patients, it was called "building good patient-doctor relationship." Factor 2 comprised four items (16, 11, 12, and 17) and, because responding to patients' emotional needs is also an important aspect of medicine, it was called "emphasizing empathy therapeutically." Factor 3 was composed of two items (1 and 5) and, because it was related to disregarding patients' point of view in practicing medical therapy, it was called "not emphasizing patients' view therapeutically." Empathetic patient understanding was called "understanding patients' view." Factor 4 was composed of five items (6, 19, 14, 3, and 2) and, because responding to patients' emotional needs is also an important aspect of medicine, it was called "compassionate care." The cumulative contribution ratio was 38.58% for factor 1, 42.74% for factor 2, 45.87% for factor 3, and 49.22% for factor 4.
An inverse weak relationship of correlation between factors 2 and 3 was revealed (Table 4).
Logistic regression analysis Table 5 shows the results of logistic regression analysis for each factor with gender, age, school year and experience as a patient. Odds ratio of females is significantly higher than males in factor 2, "importance of empathic care" (p<0.05). For factor 4, "compassionate care," statistically significant differences were noted for gender (p < 0.05) and age (p< 0.05), and the effect of gender differences was larger compared to age.

Discussion
Previous studies conducted in the United States of America and other countries have suggested that empathy scores may reduce during the span of the educational course at medical schools [3][4][5][6][7].
However, no decrease in students' empathy scores between first-and fourth-years medical students was shown, and the mean empathy score increased slightly in fourth-year students (Table 2). This tendency was also reported by some researchers [8][9][10][11][12]. Kataoka et al. reported that the mean empathy score of first-year students was 98.5 and that of fourth-year students was 102.8 (rated on a 7-point Likert scale) [8].
Other researchers reported different results, witnessing that empathy scores declined in third-or fourth-years students whose curriculum was shifting toward patient-care activities [3][4][5][6][7]. In particular, the empathy score of Chein's study (rated on 7-point Likert scale) [3] was 115.5 in the incoming class, which corresponded to third-year students in Japan, and 118.2 in second-year students, which matched fourth-year scholars in Japan. In this viewpoint, no decrease of empathy scores was found in these grades. This means that when comparing changes in empathic scores, it is necessary to consider differences in educational courses. To confirm the tendency of decreasing empathy scores in Japan, further longitudinal studies of fifth-and sixth-year students are needed.
Possible explanations of stability of empathy scores are as follows. First, fourth-year medical students do not opt for such subjects as technology-oriented specialties or people-oriented specialties [3,4].
Second, medical students might not be losing empathy during the course of their medical education.
It might be that they receive insufficient empathic training, and the instrument estimates empathic thinking of medical students in clinical empathy. It has been seen that the intervention of empathic education increases cognitive empathy [21][22][23][24]. Compared to these previous studies, which does not specify their stage of education, the approximately 5 hours curriculum of medical mediation in our study might be very short to defend the decline of empathy. The contents are, however, somewhat meaningful. This program focuses on conflict resolution of negative feelings toward doctors, whereas they intend to enhance empathetic competence of students. The third explanation is the differences in admission processes, curricula, and cultural factors. Further study is needed to identify which program may foster the growth of cognitive empathy in medical students.
In the factor analysis, factor 3 was identified negatively (not emphasizing patients' view therapeutically) and showed weak negative correlation with factor 2. If students fully understand the meaning of empathy, which contains not only an emotional aspect but also a cognitive one, factor 3 should be identified positively and show moderate or strong correlation with factor 2. Therefore, this result implies that many of the students confuse empathy with sympathy.
As the results in Table 3 show, in the opinion of medical students, factor 1, with regard to empathy, is "building good patient-doctor relationship," which means the factor of "perspective taking" (factor 3).
However, what was chosen as factor 4 (compassionate care) in this study was placed in second position (factor 2) in other studies [5,8,12] that were conducted on first-to sixth-year medical students. This difference may indicate that there is little recognition of the importance of emotional empathy in fourth-year students before starting clinical clerkship. They do not understand that "compassionate care" is an important, necessary communication skill for doctors. Therefore, between the time students are in their first and fourth years, it is necessary to create an awareness of empathetic emotion, and strengthen the understanding that others' individual emotional perspectives are equally important [21].
For the independent variables, gender and age of factor 2 (importance of empathetic care) and factor 4 (compassionate care) displayed significant difference of odds ratios (Table 5). Female medical students were shown to have higher recognition of emotional sympathy than male students. This result is consistent with previous findings [6,8]. The variable of age showed weaker affect compared to gender in "compassionate care." This implies that gender was the main variable in emotional empathy in this study. An awareness that one's own empathetic emotion is as necessary as another's particular emotional perspective should be strengthened between first-and fourth-year students.
The presence of a relationship between experience as a patient (outpatient and inpatient treatment) and empathy found no significant correlations with any factor (Table 4). These experiences may not influence empathy scores of lower-grade medical students. To confirm this, further study is necessary.
Our longitudinal study has limitations. First, because of the small sample size and first-and fourth- year students from only one Japanese medical school, it is difficult to apply our results to students in other medical schools in Japan and other countries. Second, our study does not reveal a reason for the lack of decline of empathy score. It implies some possibility, which may be a program of conflict management resolution for first-and fourth-year students and the lowest position of the factor, "compassionate care." Further longitudinal design studies are needed within medical schools in Japan and other countries to confirm these facts.

Conclusion
The decrease of empathy scores between first-and fourth-year students was not shown at a medical school in Japan. The analysis of factors extracted that factor 1 was "building good patient-doctor relationship" and there were weak correlations between factor 2 (importance of empathic care) and factor 3 (understanding patients' view). Gender differences significantly affected factor 2 and factor 4 (compassionate care). These results demonstrate that there was confusion of empathy with sympathy, and little awareness of the importance of the emotional dimension of empathy. They imply the necessity of an educational program to illuminate the importance of clinical empathy before the CBT and the OSCE in Japan. The students were told that their participation in the survey and/or their answers would not affect their grades or other assessment, and data were de-identified, further ensuring that participant identities would not be revealed. Students who agreed to participate were requested to fill out the survey using their own judgment.

Consent for publication
Not applicable.

Availability of data and material
All data generated or analyzed during this study are included in this published article.

Competing interests
The authors declare that they have no competing interests.

Funding
This study was not funded.
Authors' contributions TN was involved in conception and design, data acquisition, data interpretation and drafting the article and revised the manuscript. HI was involved in statistical analysis and evaluation of the data.
All authors were involved in the writing of the manuscript and have approved the final version.  Tables   Table 1 Characteristics