This study aimed to assess patient-centered attitudes among dental students in Korea and identify the association between the students’ characteristics and empathy, communication skill attitude and patient-centered attitude. Our results have shown that students tend to be more doctor-centered in “sharing” (i.e., sharing responsibilities and power in decision-making with patients) than in “caring” (i.e., understanding patient’s perspectives). Being male and having a longer academic period in the field of dentistry were related to a doctor-centered attitude. Empathy and attitudes on learning communication skills were related to a patient-centered attitude. Among the influencing factors, empathic concern had the highest and significant impact on patient-centered attitude. The current study supports that education programs should focus on enhancing empathy, emphasizing positive attitudes on learning communication skills, and on conducting follow-up education sessions to prevent students from becoming less patient-centered with an increase in their academic period.
Our results indicate that our sample of Korean dental students was moderately oriented toward the caring aspect of patient-centeredness and slightly less oriented toward the sharing aspect. Compared to that in previous studies, the overall PPOS score (4.09) was higher (more patient centered) than the mean reported among Indian dental students (3.38) [24] and Korean (3.90) [44] and Greek (3.81) [45] medical students; however, it was lower than that in dental students (4.37) [46] and medical students in the USA (4.57) [16] and medical students in Japan (4.56) [47] and Brazil (4.66) [48]. However, unfortunately, we could not compare with multiple studies conducted on dental students owing to the availability of limited trials. Moreover, scores from our study and those that have been cited from previous studies should be interpreted with caution because the internal consistency was either inadequate or not reported in the publications. Nevertheless, these results indicate that education is needed to improve patient-centered attitudes among dental students.
Previous studies [15, 22-24] have consistently reported that female students generally had a more patient-centered attitude than male students. The influence of sex was more evident for the sharing component than the caring component. A previous meta-analysis of observational studies on physician communication indicated that female physicians engaged in more communication that could be considered patient-centered, such as addressing the patient’s psychosocial issues, using emotion talk and positive talk, and more actively incorporating patient input [25]. This result suggests that patient-centered attitudes of medical students were maintained after graduation and influence the patient-centeredness of the practicing style in clinical settings. Therefore, it is important to emphasize patient-centered attitudes during pre-medical education. Further studies targeting gender differences with specific interventions are needed, such as formal curriculum, professional development programs, and patient simulations.
The study duration has been identified as a significant factor that lowers the patient-centered attitudes. Previous studies have showed that the attitudes of students in the later years of medical school are more doctor-centered or paternalistic than those in students in earlier years [15, 16, 47]. Although the design of this study is a cross-sectional study, these results provide evidence that patient-centered erosion occurs among students of dentistry. These results suggest that it will be very challenging to develop an effective curriculum that improves the patient-centered attitude of Korean dental students and maintains them after graduation.
In this study, empathy was a key contributor of the patient-centered attitude of dentistry students, in line with earlier studies [46, 49]. Compared to previous studies that have used the Jefferson Scale of Physician Empathy (JSPE), this study measured students' empathy using the IRI. The JSPE is a measure of empathy that was designed to measure empathy in medical and health professionals [50], while IRI describes a general empathic attitude that is not specifically related to encounters with patients [51]. Although both the measures are broadly applied to evaluate the empathy disposition of medical or dental student studies, IRIs have strengths in that they examine the relationship between four individual aspects of empathy and social function, self-esteem, emotions, and sensitivity measures for others [51-53]. Therefore, we could examine the effect of each of the four individual aspects on patient-centered attitude.
Empathy was the most important predictor of patient-centered attitudes in terms of both sharing and caring because it explained 4.8% and the 18.1% of the sharing and caring variance, respectively. In other words, our results showed that dental students who experienced pity or were touched by others and were soft-hearted were associated with both the components of sharing information and decision-making with the patient, and caring about patient’s expectations, preferences, and emotions. In particular, among the aspects of empathy, empathic concern was the most important predictor of patient-centered attitudes and the only aspect that significantly affected the “sharing” subscale of patient-centered attitude. According to Hojat and his colleagues, empathic concern is a cognitive component of empathy that assesses “other-oriented” feeling of sympathy and concern for unfortunate others [54] and is more relevant to patient care situations than other aspects [50, 53]. The ability to assess the patients’ feelings and concerns can help medical students agree with the idea of sharing aspects of patient-centered attitude, that patients should be treated as partners with the doctor with equal power and status, and that doctors should share information and try to share responsibility in decision-making. Empathic concern is not only measurable, but also teachable [55]; therefore, it can be provided as an important educational content to improve patient-centered attitude of medical and dental students.
When it comes to the caring aspect of patient-centered attitude, not only “empathic concern,” but also “fantasy” and “personal distress” aspects of empathy were positively associated with it significantly. “Fantasy” refers to the extent to which the respondents transpose themselves imaginatively into the feelings and actions of others [54], which are likely to appraise affective component of empathy. This result suggests that the ability to imagine and engage a patient’s feelings is related to being open and warm and fostering therapeutic relationships with the patients. Interestingly, “personal distress” has shown a negative impact on caring for a patient-centered attitude. The personal distress aspect of empathy refers to the extent of an individual’s feelings of anxiety and discomfort owing to a negative experience [51]. The emotional aspect of this empathy may relate to the student's preference for more instrumental interactions rather than psychosocial interactions with patients as well as physician-centered roles in patient-physician relationships. This is consistent with previous studies showing that medical students with high scores in personal distress prefer limited exposure to affectively charged situations and less contact or interaction with patients [51, 56, 57]. Moreover, too much personal distress type of empathy can sometimes produce higher levels of burn-out, terms “compassion fatigue” [58, 59].
Our study suggests that the type of empathy that students manifest contributes to the PPOS score in terms of the role they prefer in patient-physician relationships in both sharing and caring. In this study, empathic concern and fantasy type of empathy tended to be associated with more patient-centered attitudes, while personal distress type of empathy was associated with more doctor-centered attitude. This may have implications on the developmental support provided for the medical and dental students. For example, the present findings suggest that students with low empathic concern and fantasy and high personal distress type of empathy may be at a higher risk of employing physician-centered practicing style and may need more intensive training support. Several studies have shown the effectiveness of various educational interventions in developing medical student empathy [42, 60]. Therefore, curricula targeted to increase empathic concern and fantasy type of empathy and decrease personal distress type of empathy can be effective in enhancing the patient-centered attitudes of medical and dental students.
Moreover, attitudes on learning communication skills were a significant factor that affected the students’ patient-centered attitude; negative attitudes were related to doctor-centered attitude and positive attitudes were related to patient-centered attitude. Therefore, teaching and emphasizing the importance of communicating with patients can help students develop a more patient-centered attitude toward caring and sharing. For example, efforts to make students believe that learning communication skills can help enhance their practice and provide enough time to learn communication skills can be a practical and efficient way to enhance the patient-centeredness of the student’s attitude on provider-patient relationships.
This study has certain limitations. The first limitation is related to the use of the IRI as a measure of empathy. Although the IRI is a widely used measure of empathy in research in the field of education of health professions and can assess both, the cognitive and emotional attributes of empathy, it describes a general empathic attitude that is not specifically related to encounters with patients. Second, the participants of our study were from only one Korean dental school; therefore, the generalization ability of the present results is limited. A possible suggestion for future studies is the use of a multi-centric research design.