The current study detected that mean empathy score among medical residents in Aga Khan University was 103±13 on JSPE scale. This value was relatively lower than the empathy scores observed among the residents in the Western countries, such as USA and Italy [12], [14]. However, the mean empathy score of this study was higher than Korean physicians and even comparable with Japanese and Iranian physicians, thus supporting Hojat’s hypothesis of socio cultural differences existing between Western and Asian countries [22].
The present study could not detect any significant difference in the mean empathy scores among the residents of two different specialties as opposed to the previous findings [23], [24].One of the possible explanations for this might be that both these specialties are more ‘people- oriented’ rather than ‘technology oriented’ and thus the residents in these specialties are assumed to have direct patient interaction and might have better communication skill than their counterparts in other technology based specialties and thus have higher empathy scores [22].
The mean empathy scores among junior and senior residents of both specialties did not show significant variation. The same results were seen in a fairly recent study involving Singaporean residents where empathy levels were stable throughout the training period.[25]
This study found a higher empathy level among the female residents compared to males in both specialties. This finding was in accordance with many other studies [11], [22], [26]. Probable explanation for this finding could be the association between activation of right cerebral hemisphere and empathy level in women. Another possible reason could be higher emotional receptivity in women than men, which might provide more emotional support, greater care, and also development of more interpersonal relationships. In contrast, a study by Mathew (2016) showed a higher empathy level in men and till date only one study had reported no gender based difference in empathy level [27].
The internal consistency of the PCI (Cronbach’s α of 0.65) was less than the standard value. However, dividing the items into professional and unprofessional constructs, led to an improvement of the Cronbach’s α to 0.8 for the professional construct, while for unprofessional behaviors it remained 0.57, proposing a probable shortcoming of this instrument for the sample used in this study. Moreover, use of negative words for ‘unprofessionalism’ items might have caused some problems in interpretation. Similar problem was confronted by Spiwak, who performed exploratory analysis to identify these professional versus unprofessional behaviors [28]. This would occur due to differences in population and probably there is a need for a different instrument to measure this important construct.
The most obvious finding of this study was the climate of professionalism existing in the institution. No significant difference was detected by the residents in the mean observed unprofessionalism behaviors among three groups i.e., medical students, residents and faculty, but a higher professionalism was detected among the residents. The finding was in accordance to the study by Quaintance on American medical learners showing a significant difference between preclinical and clinical trainee’s observations of professionalism among students, residents, and faculties [20]. Spiwak reported that residents rated the faculty to be the poorest in terms of observed professional behaviors [28].The finding of this study can be explained as the medical residents might rate the peer group more favorably since they had social similarity in behaviors and characteristics [28]. Moreover, the residents spent more time in training, had increased opportunity to interact with the faculties, who act as a role model for the trainees and they learnt professionalism and unprofessionalism behaviors by observing the faculty [29], [30]. [19]
The current study could not identify any correlation between empathy score and professionalism climate. This was in opposition to the study by Brazeau who found a direct correlation between empathy score and PCI score among medical students in the learning environment [18]. The probable reason for this finding could be the problem of self-reporting of empathy level by the residents and also low reliability of PCI instrument. Also Brazeau’s study included medical students only and the current study included residents directly providing patient care, with long working hours and sleep deprivation, probable causes of lower level of empathy in the clinical training. [15]
Limitations
There were some limitations of this study. Firstly, the use of self-reported questionnaires for detection of empathy level might not reveal the actual empathetic behavior of the residents during medical practice; rather it would indicate residents’ orientation towards empathy. Secondly, the external validity or generalization of the findings was limited due to convenient sampling that included residents of a single institution of a particular geographical area. Thirdly, the sample size was small with only residents of two specialties leading to inadequate statistical power. Fourthly, since it was not a longitudinal study, it was difficult to ascertain empathy decline among the residents. Last, but not the least, PCI instrument despite being a validated tool for measuring professionalism climate, might be unable to capture participants’ evaluation of others’ behavior properly in this study.