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Empathy in the Doctor-Patient Relationship in Medical Students at a University in Cali

Diana M. Gonzalez-Santos^* Médica residente de Medicina Familiar, Pontificia Universidad Javeriana, Cali, Colombia, Colombia
¹Medica residente de Medicina Familiar, Pontificia Universidad Javeriana, Cali, Colombia
²Medica residente de Medicina Familiar, Pontificia Universidad Javeriana, Cali, Colombia
³Docente investigador, Pontificia Universidad Javeriana Cali, Cali, Colombia
⁴Medica Psiquiatra. Universidad del Valle, Cali, Colombia
^*Correspondence: Diana M. Gonzalez-Santos, Médica residente de Medicina Familiar, Pontificia Universidad Javeriana, Cali, Colombia, Colombia, Email:

Received: 03-Mar-2022, Manuscript No. Iphsj-22-12572; Editor assigned: 05-Mar-2022, Pre QC No. Preqc No. P-12572 (PQ); Reviewed: 19-Mar-2022, QC No. QC No. Q-12572; Revised: 24-Mar-2022, Manuscript No. Iphsj-22-12572(R); Published: 31-Mar-2022, DOI: 10.36648/1791-809X.16.S6.919

Introduction

Training as a doctor not only implies learning technical and scientific concepts, but also dealing with emotional aspects of one's own and those that arouse the relationship and bond with the patient [1, 2]. According to the bio psychosocial model proposed by Engels in 1977, empathy in health personnel seeks to understand and respond to the suffering of patients, being a fundamental element in the relationship [3]. Still, there is a paucity of research on physician empathy despite its mediating role in physician-patient relationships and clinical outcomes [4].

Empathy comes from the Greek empathieia, meaning “affection” or the ability to feel and understand other people's feelings as if they were one's own [4]. In a publication of the journal of the American Association of Medical Colleges, empathy is defined as “a conscious and energetic mental effort to clarify the expression of the patient's experience, it involves connecting feelings and meanings that are associated with a patient's experience, while at the same time identifying and isolating one's own reactions to that patient and their experience” [6]. Empathy has been described as a multidimensional concept that involves a cognitive and an emotional component [4, 7]. The cognitive domain involves the ability to understand other people's experiences and Received: 03-Mar-2022, Manuscript No. Iphsj-22-12572; Editor assigned: 05-Mar-2022, Preqc No. P-12572 (PQ); Reviewed: 19-Mar-2022, QC No. Q-12572; Revised: 24-Mar-2022, Manuscript No. Iphsj-22-12572 (R); Published: 31-Mar-2022, DOI: 1791-809X-16.S6-919 feelings, and the affective domain involves emotionally bonding with their experiences and feelings.

The empathy of health professionals has been measured using different scales such as the Jefferson Medical Empathy Scale and the Interpersonal Reactivity Index, which are based on intrapersonal experience to assess the different dimensions of empathy [4, 8].

In 2002, Dr. Mohammadreza Hojat at Thomas Jefferson University and in 2007, Dr. Daniel Chen at Boston University conducted several studies on medical students to assess empathy in the doctor-patient relationship using of scales, finding that during the first medical year the empathy scores were higher, however, they declined as the career progressed; likewise, they identified that women obtained higher scores in relation to men [9, 10].

For 2011, the empathy in the doctor-patient relationship and the results in the medical treatment in diabetic patients were analysed, it was concluded that the patients of doctors with higher levels of empathy presented better control in their levels of glycosylated hemoglobin (56%) in compared with those whose treating physicians had low empathy scores (40%, p < 0.001) [11]. On the other hand, the empathic relationship in the doctor-patient relationship has been associated with a better preparation of the clinical history, greater patient satisfaction, and greater adherence to medical recommendations, better clinical results and a lower risk of dissatisfaction with care [7].

Regarding the relationship between the levels of empathy in medical students and their level of training, the results are contradictory. On the one hand, some studies confirm that the empathic capacity decreases as the semesters progress, thus affecting the doctor-patient relationship. [12-14], while another study found that empathy tends to improve as training progresses. In Colombia, the University of Boyacá and the Universidad del Norte de Barranquilla evaluated empathy in medical students who showed less empathic orientation as the semesters progressed, and providing additional data regarding the influence of sex, the origin of the student and their perception of student overload in said results [15-17] as well as the influence that teachers exert on students based on their own empathic expression [15]. Medical schools have the challenge that their graduates are empathic, compassionate and provide humanized care; the educational process should encourage the recognition of emotions and the implications of the empathic medical act [18].

Motivated by the relevance of empathy in the doctor-patient relationship, the need to know its levels in medical students at a private university in Cali, and the interest in expanding current knowledge of possible factors associated with the results of levels obtained, the objective of this study was to determine the level of empathy and its associated factors in medical students at a private university in Cali in 2020. We hope that the knowledge generated from the results obtained motivates actions in the scientific community, educational institutions and government entities, for the development of strategies during the training of doctors to strengthen empathy in health professionals

Methodology

Type of study

An observational and cross-sectional study was carried out in medical students from a private university, in the city of Cali, Colombia.

Study design and population

The study was approved by the Ethics Committee of the Pontificia Universidad Javeriana Cali. The population consisted of students from the fifth to the twelfth semester enrolled in July 2020. The University in which the study was applied is private; It has an 11-year-old medicine program that serves students from all socioeconomic strata, most of whom come from Cali; It has scholarships for students from indigenous and Afro-descendant communities, from the "ser pilo pays" program; and encourages students with low socioeconomic status, those who stand out academically and international mobility.

Inclusion and exclusion criteria

All students over 18 years of age with enrolment in July 2020 (which was verified through the control sheet provided by the academic direction of the faculty), from the fifth to the twelfth semester and with the desire to participate in the study were included. Study by signing the informed consent. And those students who were doing internships, exchanges and trainees from another university were excluded.

Instrument

The measurement instrument was the Jefferson Medical Empathy Scale (EEMJ) Student S version, translated into Spanish [4, 19] and validated, in Mexican medical students, with good internal consistency; it has a Cronbach's alpha coefficient of 0.90. It consists of 20 Likert-type questions of 7 points each, with 1 = strongly disagree and 7 = strongly agree. The maximum score of the scale was obtained by the sum of the questions (maximum 140 points is considered more empathetic, minimum 20 points) where it was considered that a higher score is correlated with a higher degree of empathy. The EEMJ defines empathy according to three factors: 1) perspective taking, 2) compassionate care, and 3) ability to "put yourself in the patient's shoes" [4, 19].A pilot test was carried out with students from the Pontificia Universidad Javeriana, to verify the understanding of the questions of the Jefferson Empathy Scale.

Variables and data collection

The level of empathy was considered as a dependent variable, it is a continuous quantitative variable. As independent variables, gender, age, social stratum, religion, place of birth, marital status, type of family were taken into account; taken from the structural classification; such as family homes (nuclear, large, families without a nucleus) and non-nuclear (one-person, nonfamily without a nucleus) [20] and the performance of physical activities, leisure activities and volunteering, among others

To collect the information, a web questionnaire was designed in Google Forms, which had restrictions and was mandatory to ensure the complete completion of the survey. The survey was sent to 483 medical students through whatsapp messages and email. Participation was voluntary and anonymous, without financial remuneration. The survey was active between October 21, 2020 and March 8, 2021. Informed consent was obtained electronically using a check box before responding to the form

Statistic analysis

The data was exported to the SPSS version 26.0 program for information analysis. Each of the variables was taken, their behavior was observed, looking for extreme values, missing values and it was rectified that the values obtained corresponded to what was expected.First, the normal distribution of the response variable "empathy score" and the scores of each domain were explored using the Kolmogorov-Smirnov test. The assumption of normality was rejected, so these variables were summarized with median and interquartile range, although the mean and standard deviation (SD) were also reported.

To explore the factors associated with empathy; a bivariate analysis was performed that consisted of comparing the empathy scores according to the factors under study using the non-parametric Mann-Whitney U test (two groups) and KruskalWallis (plus of two groups). Spearman's Correlation Coefficient (Rs) was used to explore the relationship between empathy scores and age.

A multivariate analysis was performed using a multiple linear regression model where the response variable was the "empathy score" and the independent variables were Sociodemographic and family factors. The regression analysis was conducted in two phases. In the first phase, the response variable was correlated with each of the independent variables using a simple linear regression model, where the variables that showed a significance of less than 0.20 were considered for the following phase two. In phase two, a multiple linear regression model was used with all the relevant variables from phase one. The backward selection method and the Likelihood Ratio Test were used to compare the models. In these analyses, the results were considered statistically significant if p < 0.05.

In the final model, the assumptions of normal errors with zero mean, constant variance, absence of multicollinearity and no autocorrelation were validated.

Discussion

Motivated by the relevance of empathy in the doctor-patient relationship, the need to know its levels in medical students at a private university in Cali, and the interest in expanding current knowledge of possible factors associated with the results of levels obtained, we found that the levels of empathy remained similar between the students of both the first and last years. Also, the values of empathy tend to decrease if the student practices less than 150 minutes of exercise a week and increase if the student has some type of scholarship. It was shown that the results in the minimum and maximum empathy scores are comparable with the scores of other national [16, 17] and even international [7, 9, 21, 22] studies.

The results of the present study did not show significant differences in the levels of empathy among the medical students of the different academic years evaluated. These findings are not consistent with that reported by Hojat et al in their different studies [7, 9, 21], nor with the results of other countries such as the United States [7, 21, 23], Belgium [24], Turkey [25], Mexico [26] or India [22, 27] in which a phenomenon of empathy decline has been seen in the doctor-patient relationship with the increase in the years of training. However, it does correlate with a study conducted in Brazil, in which they observed that empathy levels remained stable over time [28 ]. This allows us to analyse that these differences in trends are not a generalized fact. It would be important to include in future studies a determination of the levels of empathy in students in their first years of training, where they study subjects related to society and community heal.

better reports of empathy among women, but this result was not statistically significant, which is consistent with what has been described in other studies [12]. Age is a variable that influences levels of empathy; in the study by Remón et al. carried out in Peru, those students with an age range between 26 and 30 years obtained a higher empathy score [29]; however, in our study no relationship was found between age and empathy score.

In the reviewed literature, no studies were found that explored the levels of empathy in relation to the family typology, however, no statistically significant difference was found in the empathic relationship of the students and the type of family to which they belong according to the results. of this study; More studies related to this factor are needed, since according to the concept and social construct of the family, from these first relationships, shared experiences are lived, necessary to promote humanism in the individual who develops empathy [30].

The influence of the practice of volunteering activities has been seen in the results of the levels of empathy of the students [ 31], which could be explained by the affinity for the development of this type of activities in more empathic individuals, or because said work promotes the improvement of empathy levels. The results obtained with the present study did not show statistical significance in this aspect.

Among the results obtained, we were able to show a positive correlation between the empathy score and the history of having studied in a public school, being a novel finding since in the review of the literature we did not find any reference to this variable, it would be important for future studies. The possible determination of the aspects related to this result. It was found that there was a statistical significance between the empathy scores and the fact that the students were benefiting from some type of scholarship for their university studies, this could be related to the perceptions that the students have of making an effort to take care of something that is important to them. , and within that is their relationship with patients.

Empathy should be considered as a fundamental aspect in the training of medical students since it has a positive impact on the doctor-patient relationship, on pharmacological and nonpharmacological therapeutic adherence, and on treatment results, being an essential ingredient for the Obtaining satisfactory results in the health-disease process. According to a recent study carried out at the Universidad del Norte, it is necessary to evaluate and improve the contents of the curriculum as well as the teaching processes in medicine programs in order to have an impact on the empathic capacity of students.

Similarly, strategies could be generated to implement from secondary education, with continuity during university life, for the promotion of activities that facilitate the development and strengthening of student empathy. The present study suggests that the practice of physical activity for more than 150 minutes per week contributes to the increase in the levels of empathy of the students, adding an additional benefit to the exercise apart from the many already known.

Study Limitations

During the conduct of the study several limitations were presented, one of these was the change in the information collection route, which went from being face-to-face to being done through email and Whatsapp due to the public health problem experienced since March. 2020 (Covid-19 Pandemic), this may have had an impact on the power of the investigation. At the level of student participation, both the pandemic and the recognition that the application of surveys electronically has a lower response rate compared to the direct interview. In addition, the moment of the pandemic meant that everything was taken to virtualization, which could have saturated the student emails and not identify the survey as a priority. However, different efforts were made to contact them, such as sending the survey once a week by email and Whatsapp, while it was active, as well as sending it by rotation groups so that it was the student himself who shared the survey with his classmates. It is possible that the change caused by the pandemic in some practice scenarios that went from face-to-face to virtual has influenced the results of the empathic capacity of the students, due to the limitation that this generates in the doctor-patient interaction. As a strength of the study, we found that the Jefferson Medical Empathy Scale has been translated and validated into Spanish, which facilitated its use during the study without having to translate the original survey; Another strength was that the University of Jefferson allowed us to use the scale for its application in the present study, in addition to providing us with a user guide and the algorithm to make an interpretation of the information

Results

The virtual survey was sent to 483 medical students enrolled in July 2020 from the fifth to the twelfth semester. Of the total number of students, the response rate was 29.8% (143); being women with greater participation (62.9%). Table 1 shows the main demographic characteristics. The ages of the students who answered the survey ranged between 19 and 34 years. 53.1% were born in Cali and more than 80% belonged to the uppermiddle class. Regarding the extracurricular artistic activities carried out by the students, it was found that 37.3% have a predilection for reading, 13.6% for music (singing or playing an instrument), followed by writing, cinema and paint with 12.3%, 11.4% and 9.2% respectively. Regarding the performance of physical activities, the results differed from each other in terms of duration and type of exercise. 65% of the students do physical activity lasting more than 150 minutes a week; regarding the type of exercise, 83.6% had a preference for going to the gym, as well as 26.5% for functional exercise, 18.4% for walking, 16.3% for jogging and 15.3% for cycling. Regarding volunteering, more than 50% of the students stated that they had participated at some point in their lives, but 16.1% did so less than a year ago and 34.3% between 1 and 5 years. Another aspect that was evaluated was whether the students had a preference for any medical specialty, finding that both clinical and surgical specializations had a similar preference (50.4% vs. 46.8%), among the different specialties, it was found that there were favouritism for internalmedicine, paediatrics, orthopaedics/traumatology, and plastic surgery. Regarding the constitution of the students' home, they were mainly part of the family type; being the nuclear, made up of father and/or mother with or without children, the most predominant; followed by non-family households, where the single-person household (made up of a single person) was the most frequent. 14.7% of the students had different financial support for the payment of their tuition, such as the program: "being a pilo pays" and other special scholarships available to the university.

Table 1. Sociodemographic, academic, and behavioural characteristics of medical students at a private university in Cali, Colombia (N=143).

Table 2 shows the analyses regarding the Jefferson Medical Empathy Scale. The average empathy score of the medical students surveyed was 85.02 (SD=6.39), with 68 being the minimum value and 103 points the maximum value. In the different components that the scale evaluates on empathy; an average of 58.41 (SD=4.89) was evidenced for perspective taking, compassionate care of 17.34 (SD=5.7) and skills of putting oneself in the place, an average of 4.48 (SD=2.2) was obtained (Table 1).

Table 2. Empathy levels of medical students at a private university in Cali, Colombia (N=143).

In exploring the factors associated with the level of empathy (Table 3), a trend of higher scores on the empathy scale was found in students from public sector schools (p value = 0.175), also for social strata 1 to 3. (p value = 0.159), scholarship students (p value = 0.017), in those who performed physical activity for more than 150 min (p value = 0.061), and academic year 11- 12 (p value = 0.140). No statistically significant association was found between empathy and department of origin, marital status, beliefs, performing recreational activities, preferences in the desire for a medical specialty and participation in some volunteering (p value > 0.20) (Table 2 and 3).

Table 3. Comparison of the total empathy score according to Sociodemographic characteristics of the students (N=143).

The multivariate analysis (Table 4) showed that the average empathy score that does not depend on the independent variables was 85.03 points (intercept). When adjusted for the other variables in the model, it is identified that the score increases by an average of 4.38 points when the student has some type of scholarship (p value = 0.003); on the contrary, it decreases on average 1.87 points when the student practices less than 150 minutes of physical activity per week (p value = 0.090) (Table 4).

Table 4. Multivariate analysis (multiple linear regression) on the factors related to the global empathy score (N=143).

Conclusion

The empathy score was determined in students from a private university in the city of Cali, Colombia, it was found that scholarship students obtained better scores compared to those who do not have this stimulus. On the other hand, the results obtained indicate that doing less than 150 minutes of physical exercise per week decreases the result by 1.87 points compared to students who do, regardless of the type of physical activity they practice.

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