In our cross-sectional study, empathy appears to increase during the first year of medical school, but falls after the third year (first clinical year) and remains down through the final year of medical school. JSPE-S scores differ by as great as 11.9 points between the first- and fourth-year classes after adjusting for gender, age, financial indebtedness, and career preferences.
Our results, although cross-sectional, are consistent with previous studies, suggesting that empathy decreases after clinical training in medical school. Using the JSPE-S, one cohort of medical students had a decline in empathy during the third year of medical school.15
This group of 125 third-year medical students exhibited a postclerkship decline in empathy of 2.5 points (123.1 to 120.6). The authors found no significant associations between changes in empathy scores and gender, age, or academic performance on step 1 of the USMLE.15
Another group measured empathy in a cohort of medical students at the beginning of medical school and just before graduation and found lower empathy scores in the graduating class.16
Among another group of health care professionals, dental students, empathy scores also decreased after patient care responsibilities began.20
The only other cross-sectional study of multiple medical school classes that we could find did not demonstrate differences in empathy across classes, but this study used an outcome measure, which was not specifically designed for health professionals.22
Studies of medical resident empathy have noted similar declines. A cross-sectional study in an internal medicine program observed that first-year residents scored 4 points higher on the JSPE–Physician Version than third-year residents (117.5 vs 113.5, P
Whereas these studies lack an assessment of behavior, one recent report showed a positive association between the individuals’ scores on the JSPE-S in medical school and ratings of their empathic behavior made by their residency program director 3 years later.23
This study suggests a long-term predictive validity of the self-report empathy scale.
Various stressful aspects of medical education and training, such as long work-hours and sleep deprivation, as well as dependence on technology for diagnoses, shorter patient hospitalizations, and limited bedside interactions may contribute to decreases in empathy.14,24–27
In response, some programs now include clinical narrative or critical incident writing; classes on medically themed creative writing, literature and art; journal writing; and use of standardized patients in the medical education curriculum to maintain or increase empathy.28–34
Studies offer conflicting results with respect to their impact on empathy. One group preliminarily measured an increase in empathy in students who participated in role-playing and simulated patient scenarios.35
In contrast, an entire medical school class taking a 4-month patient-interviewing course designed to teach communication and emphasize empathy did not show an improvement in the latter.16
A recent review suggests that empathy may be amenable to a range of interventional strategies.36
Qualitative data from independent observations and unvalidated surveys note that these interventions improve student communication skills and empathy. Lastly, student course evaluations and feedback suggest that students respond positively to these educational interventions and perceive themselves to be more sensitive and empathic toward their patients from such activities despite a lack of more objective outcomes.26,28,31–34,36,37
Another possible explanation for the observed decrease in empathy may be an acculturation phenomenon. Student doctors experience a wide range of emotions and stresses and may struggle to maintain their empathy.14,38
This would suggest that to remain effective for patients, students and trainees become less empathic as they face emotionally challenging and draining situations. Outcome measures to assess such a hypothesis should be included in future research.
We found that medical students expressing a preference for people-oriented specialties had higher empathy scores than those expressing a preference for technology-oriented specialties. These data are consistent with another study, which found that students likely choosing family medicine, internal medicine, psychiatry, pediatrics, and obstetrics and gynecology had higher empathy scores than all other specialties, when controlled for gender effects.22
Previous studies have demonstrated a difference in empathy among practicing physicians of different specialties. Physicians in people-oriented specialties, such as primary care specialties (family medicine, internal medicine, and pediatrics), obstetrics and gynecology, emergency medicine, psychiatry, and medical subspecialties, had higher average empathy scores than physicians in technology-oriented specialties—anesthesiology, radiology, pathology, surgery, and surgical subspecialties (see Table ).2,17
Psychiatrists had the highest mean JSPE–Physician Version score (127.0), primary care specialists scored from 120–122, and the lowest values were noted in orthopedic surgeons and anesthesiologists (approx. 116).18
Students may possibly be prestratified in career preferences before coming to medical school, with those students who are naturally endowed with more empathy attracted to people-oriented specialties. Although we categorized medical students as preferring either people-oriented or technology-oriented specialties, the vast majority of incoming and first- through third-year medical students had small mean differences ranging from 0.46 to 0.62 when comparing their average Likert score for the people-oriented and technology-oriented specialty groups. This suggests that they may not be definitive in their career preference early in medical school and raises the possibility of changing career preferences with different experiences in medical school. Future studies should determine whether fostering empathy skills impacts student career preferences. With fewer graduating medical students selecting careers in primary care (people oriented) specialties,39–41
if enhancement in empathy can be achieved and be shown to modify career preference, potential policy implications regarding medical curricula and resource allocation could be possibly driven by societal or regional needs for primary care clinicians.
There are several limitations of our study. First, our measurement of empathy, the JSPE-S, is self-reported. It measures medical students’ orientation to empathy and is not correlated with behavior. A recently demonstrated correlation between individuals’ empathy scores at the beginning of third year of medical school and ratings of their empathic behavior at the end of their first year of postgraduate training does suggest predictive validity of the JSPE-S.23
Studies of practicing physicians have noted that JSPE score difference is as great as 11 between practicing psychiatrists and anesthesiologists,18
a range difference seen in some of our comparisons.
A second limitation of our study is the possibility of cohort effects. We recognize this as a limitation of all cross-sectional studies. However, except for our new finding of differences seen in the preclinical years, our data are consistent with other studies of medical student empathy, which suggest a decline during medical school.15,16
Unexpectedly, we found that there is an increase in empathy scores from beginning to end of first-year among the medical students. As the JSPE-S questions were designed to assess the empathy of health care providers in patient-provider situations, it is possible that a complete lack of clinical exposure impacts how the JSPE-S is completed by incoming students and hence the instrument may be invalid in this group. Whereas there is limited patient contact in the first 2 years of our medical school, students do interact with patients when shadowing practicing physicians and participating in their clinical skills training courses. Patient contact in the context of the first 2 years of medical school possibly alters the perception of students so that the subjective anchors on JSPE-S questions and Likert-scale anchors are interpreted differently. Alternatively, the limited clinical exposure during the first 2 years of medical school may positively influence medical students’ empathy by reinforcing their desire to help people through medicine. A third hypothesis is that this represents a cohort effect. The robustness of our observation could be tested by sequentially tracking these medical student cohorts.
Lastly, we acknowledge that attendance, survey participation, and possibly response (e.g., level of empathy) may be influenced by the situations or events during which we obtained the data.
Although our study is limited to one medical school, we feel that our results can be generalized to medical schools that have a traditional structure similar to ours. In particular, we are struck by the consistency of the decline in score after a full year of clinical exposure.