The mean empathy score of the sample in the present study is similar to that found in Japan , China , Korea , India , and Iran  and relatively lower than the mean scores reported in some Western countries, such as Spain , America , and Germany . Thus, Asian students tend to have similar levels of empathy but lower than do Western students. The differences in empathy are possibly related to cultural and social differences. For example, in Asian countries, high school graduates are admitted directly into medical colleges by passing a highly competitive and heavily science-oriented selection system [5, 7, 10, 15]. Usually, only when students attach great importance to science subjects, such as mathematics, physics, and chemistry, can they outperform others to emerge at the top of their high school graduating class and enroll in medical colleges. Those requirements for medical students come at the expense of the arts and humanities, which may be one of the reasons for their lower levels of empathy. Furthermore, communication patterns that place less emphasis on nonverbal communication, as well as differences in medical education among Asian medical schools, may also explain why Asian medical students show lower levels of empathy than their Western counterparts .
The factor analysis resulted in a four-factor solution. Factors 1, 2, and 3 represented three dimensions of empathy: perspective taking, compassionate care, and standing in the patient’s shoes. These three factors have also emerged in previous studies, in China as well as in other countries [5, 7, 17], in which perspective taking has been described as a major dimension of empathy in patient care. The fourth factor was not found in any previous studies. According to Velicer and Fava , a minimum of three items per factor is required for a stable factor. As such, factor 4 may not be a stable factor. A sudden drop in the magnitude of the pre-rotated eigenvalues after extracting the other factors also suggests the instability of the factor. Additionally, the item “Physicians should not allow themselves to be influenced by strong personal bonds between patients and their family members” (item 18) did not load on any factor and was not endorsed. An insufficient factor loading and a low correlation for this item appeared in other Asian samples [11, 19] as well as in an Australian sample . Therefore, item 18 may not be an item that represents empathy in patient care in medical students in China.
In this study, we found that women were more empathic than men, which concurs with studies in most other countries [5, 9, 16, 21], and in particular, with a study of students studying a five-year medical training program in northern China . However, there was no gender difference in empathy in a previous study of Chinese medical students studying an eight-year program . This inconsistency may be attributable to sample selection. The eight-year program is only approved in a few top universities in China, and some of its unique features, including the extreme competitiveness and high career goals and expectations of eight-year programs, may diminish any differences in empathy between men and women. However, in the present study, we included medical students studying both five-year and eight-year programs and three medical schools. In addition, because the sample size in the present study was larger than that of the previous one, and the difference in scores approached significance in the previous study, the smaller sample size might have accounted for not finding a significant difference.
Another noteworthy finding is that students who held positions as student cadres had higher empathy scores. Firstly, student cadres need to work together to resolve problems and accomplish tasks in their daily organizational activities. Thus, teamwork is their most common form of organizational activity. They must consider their teammates’ needs for belongingness and maintain an affiliation with each other, which requires them to recognize others’ emotions and concerns [22, 23]. Considering that the student cadres in an organization usually major in different specialties in the school, such altruistic inter-professional teamwork with a common value or purpose of serving other students is beneficial to the cultivation of empathy, based on previous research . Secondly, student cadres usually spend more time engaged in community service activities, and previous research showed a trend in which the more hours students spent engaged in such activities, the higher their levels of empathy . Most of these activities are medically related. For example, some student organizations at Fudan University provide students with the chance to be a volunteer for medical guidance at cooperative hospitals. In this process, student cadres try to adopt the patient’s perspective and gain a better understanding of the patient’s situation, concerns, and feelings. Consequently, students may develop higher sensitivity toward the patients, which could increase their empathic ability . Additionally, volunteer experiences in clinical settings usually occur as soon as the student enrolls at the university, and a systematic review of the effect of early practical experience concluded that it fostered empathic attitudes toward patients . Finally, student cadres act as a bridge between the school and the students; interacting with diverse groups of people including but not limited to students, teachers, and social groups. To enable them to communicate effectively with others, communication skills training is carried out regularly. Communication skills figure strongly in interventions aimed at enhancing empathy and are now used as an educational strategy to foster empathic ability in some medical schools . Therefore, training in communication skills likely enhances empathy in student cadres. This finding is particularly informative because few teaching plans on empathy development have been established in Chinese medical schools, and it suggests that educators should consider student organizations as a potential modality through which empathy can be cultivated in medical students.
Even though China’s medical reform is entering a new period, tense patient-physician relationships have not been alleviated . Some medical students are considering working in industries outside of the clinical setting as well as choosing careers totally unrelated to medicine . Our findings showed that students who preferred not to become doctors had the lowest empathy scores, which were also lower than those of students who preferred other career options. This result is in accordance with that of the previously mentioned study of the eight-year medical program . It is possible that poorly covered empathy cultivation in teaching plans, the prioritization of acquiring medical expertise over humanistic knowledge, and a conflict between students’ career goal and what is actually fulfilling to them in their training might lead to a decline in empathy and may account for this difference in empathy among the students.
Results from studies on the effect of parents’ education level on empathy in medical students are inconsistent. While some studies have found no significant relationship [30, 31], one study revealed that the mother’s education status affected medical students’ levels of empathy . Conversely, we found the father’s education status to be associated with levels of empathy; students whose fathers’ education was high school or below were higher in empathy than those students whose fathers had attained a more advanced education.
This finding might be due to cultural and social differences. Following the reform and the open-door policy in China in the late 1970s, there have been enormous social and economic changes. These changes have, in turn, caused fundamental changes in a person’s position in the social hierarchy, which is basically determined according to occupation, education, capital, and income level . Higher education generally leads to better occupations and a higher income; thus, physicians, lawyers, teachers, engineers, managers, administrators, and accountants have climbed the hierarchy , becoming the middle or upper class. Those with lower levels of education, such as employees in the service sector, workers, peasants, and the unemployed are more likely to receive a lower income and have shifted into the lower class. The burgeoning middle- and upper-class view education as a reliable means to achieve high social status, and therefore parents place great importance on their children’s academic achievements . Ignoring humanistic values and promoting scientific ones is not likely to be conducive to the development of empathy in children.
Another possible explanation is related to the psychology of social class. Studies investigating the relationship between social class and emotion showed that people from lower socioeconomic classes were more empathic than those of a higher socioeconomic status [35, 36]. Additionally, the association between social class and empathic accuracy was investigated [36, 37], and people of lower-class status demonstrated greater empathic accuracy than people of the upper class. In light of these findings, using the father’s level of education as a proxy for socioeconomic status might explain the differences in participants’ levels of empathy.
Another consideration as to why the father’s education status may be related to empathy in medical students is the one-child policy in China. Parents, especially those who attained higher education, tend to have only one child. A significant correlation between the father’s higher education and having only one child was found in the present study (r = -0.450, data not shown). There is evidence that the one-child policy has affected parenting [38, 39], such as inflicting increased pressure on the child to succeed in school . Currently, in the Chinese society, people are often judged by what academic degrees they hold and from which universities. As they have only one child, parents tend to have a high degree of anxiety over their child having an advantage when competing for academic and job positions . Pressure and anxiety exist both in the education system and in the family, which ultimately is passed on to the student. In a study including 2400 Chinese students of different ages in six cities and provinces, 76.4% of the students reported being in a bad mood because of pressure and high parental expectations, and some of them even reported feelings of despair . Academic stress not only affects psychological health but extends to social relationships with peers and attitudes toward society at large. As a result of intense academic competition, feelings of jealousy, distrust, and animosity have been found to be common in peer relationships . Such negative emotional states can impede the development of empathy [15, 42].
There are several limitations to this study. First, the three medical schools are all in Shanghai and therefore may not be representative of the national experience. Future research should include other university populations. Second, selection bias may have affected the findings. It is possible that students with higher empathy were more likely to complete the questionnaire online, and therefore we are unable to know the characteristics of non-responders. Finally, the JSE-S is a self-report instrument and susceptible to socially desirable responses, which can lead to response bias. Although a prior study showed that the social desirability response bias did not distort the validity of the scores , future studies are needed using instruments such as observer ratings and patient assessments to obtain more comprehensive and objective results.