Comparing the overall results between the two Faculties of Medicine, significantly higher levels of empathy were found in FCS-UBI students for the total score of JSPE and for the “Perspective taking” component and for 3rd year students of each university still with higher scores in FCS-UBI.
These results are in line with those obtained in the only study we found also comparing the levels of empathy in two universities with different curricular models27. Such Pakistan study, showed higher levels of empathy among university students with an integrated modular system (with formal teaching in the various domains of empathy) compared to university students with a “traditional” teaching system. Another multi-institutional study revealed that the type of course influences the levels of medical students empathy but did not specify the curricular model of each of the studied institutions28.
Some reasons can explain higher levels of empathy in FCS-UBI students. In a national survey evaluating pedagogical conditions, the student-tutor ratio and student satisfaction in the various Medicine Faculties of Portugal, found that FMUC had a student-tutor ratio of 18.5 (the largest in the country and more than twice the national average, which is 7.53), contrasting with a 3.1 ratio in FCS-UBI, the second lowest in Portugal29. By students opinions, FMUC is the national medicine faculties with the worst levels of overall satisfaction and with clinical teaching and study conditions, whereas FCS-UBI has the highest levels of satisfaction in regard to these parameters29. Highest student-tutor ratio at FMUC contributed to lower satisfaction with the teaching, less clinical contact and less opportunities to develop empathic relationships with patients19,29.
Analysing the curricula of both faculties several differences can contribute to the inequality in the levels of empathy17,18. FCS-UBI integrates a larger number of curricular units relating to the area of humanistic sciences, with emphasis on the development of interaction and communication skills. Early contact with clinical practice is encouraged (through internships in hospitals and primary health care centres since the 1st year of MIM) and is integrated in the syllabus the curricular unit of Primary Health Care (which contemplates empathy as one of the learning objectives) in the 2nd, 4th and 5th years of MIM. In addition, role-playing activities are conducted regularly with discussion and specific assessment of students’ communicative and empathic abilities 8,22,23. FMUC lacks subjects related to the humanistic sciences and has a more superficial and limited approach to clinical practice (started in the 4th year of MIM). The curricular unit of General Practice/Family Medicine, which includes the discussion of topics such as empathy and communication and the performance of role-playing activities, is taught in the 5th year of the MIM. These multiple differences may explain the higher levels of empathy in FCS-UBI. The same reasons may support statistically significantly differences in overall levels of empathy that occur in the 3rd year of MIM. By the 3rd year, FCS-UBI students already have had contact with clinical practice, whereas FMUC students have not17,18.
Another possible reason is suggested in several studies that show that empathy is positively influenced by quality of life and negatively by stress, fatigue, and burnout29–31. Studies carried out in both the universities that partook in this study showed that, compared to FMUC students, FCS-UBI students have a better quality of life and are less vulnerable to stress and fatigue, which may justify higher levels of empathy in this institution32,33.
There are also differences in the profiles of the students that initiate MIM in the two Medicine Faculties and contributing to the present results. FMUC is chosen by about half of those students entering each year as the first choice, due to very high in a 20 grade marks, while at the FCS-UBI that ratio is of about 7%34,36,37. Further studies are needed to evaluate the intrinsic characteristics of the students at each medicine faculties, such as the family economic environment and place of residence, versus the characteristics of teaching and also different characteristics of the placement of both Universities38.
The characteristics of the tutors influence the levels of student’s developed levels of empathy 15,22,39. Thus, the differences between the two universities can also be so explained, and that deserves future study, and Faculty’s intervention in their tutors upgrading them.
Significant differences are only found in feminine gender and only in the total JSPE score and in the “Perspective taking” component, with a higher scores in FSC-UBI. It seemed that female students of FCS-UBI have higher levels of empathy than male ones even though it is suggested that female students are more susceptible to stress and fatigue and have a worse perception of their quality of life than male students30,40,41. Combining these data with the information that FCS-UBI students present higher quality of life and less vulnerability to stress and fatigue theses were reasonable results to expect32,33.
The existence of differences in empathy between the two universities supports the need to consider the impact of the curriculum model and other MIM characteristics on the development of the empathic capacities of medical students. So several changes can be considered in order to increase the levels of empathy in medical students, in the long term, in order to improve and maintain the levels of empathy in medical students:
Educational interventions focused on empowering empathic capacities by role-playing, video-watching and real consultations with patients with analysis and discussion of medical communication23. Also lectures and practice of the importance of empathy and communication in the doctor-patient relationship and early integration of more contents of the human sciences area into the study plan, with a more reduced student-tutor ratio, preferably a one to one even if for shorter period of time 8,9.
Tutors must also be integrated in training programs aimed at promoting empathy so making an example to followed.
As stress negatively influences student’s levels of empathy, it is important to provide “tools” that help students deal with such promoting extra-curricular activities8,9,42.
It is advisable that research is continued in this area, including comparisons with more national and international medical Faculties, all years of MIM and more variables (such as, grade and order of application, university region, socioeconomic class and personality traits of the students and the characteristics of the tutors).
In spite of the attempts to minimize bias, there may have been distraction in reading the questionnaires. Attempts were made to close the selection bias through the random selection of the classes included in the study. The scale used evaluates the student’s self-perception of their level of empathy, which may be different from their actual empathic behaviour.