KINGDOM OF MOROCCO MOHAMMED V UNIVERSITY OF RABAT FACULTY OF MEDECINE AND PHARMACY RABAT Year : 2022 Thesis N°:268 EMPATHY AMONG PHYSICIANS IN TRAINING AT THE UNIVERSITY HOSPITAL IBN SINA LITERATURE REVIEW AND CROSS SECTIONAL STUDY THESIS Submitted and publicly defended on the : / /2022 BY Mrs. Nour El Houda EL FILALI Born on February 09 th , 1992 FOR THE DEGREE OF Doctor of Medicine Key Words: Empathy; Empathy related factors; Jefferson scale of empathy; Physicians in training; Morocco Jury Members: Mr. Redouane ABOUQAL President Professor of Intensive Care Medicine Mrs. Jihane BELAYACHI Director Professor of Intensive Care Medicine Mr. Taoufiq DAKKA Member Professor of Physiology Mr. Fouad LABOUDI Member Professor of Psychiatry
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KINGDOM OF MOROCCO MOHAMMED V UNIVERSITY OF RABAT
FACULTY OF MEDECINE AND PHARMACY
RABAT
Year : 2022 Thesis N°:268
EMPATHY AMONG PHYSICIANS IN TRAINING AT THE UNIVERSITY HOSPITAL IBN SINA
LITERATURE REVIEW AND CROSS SECTIONAL STUDY
THESIS
Submitted and publicly defended on the : / /2022
BY Mrs. Nour El Houda EL FILALI
Born on February 09th, 1992
FOR THE DEGREE OF
Doctor of Medicine
Key Words: Empathy; Empathy related factors; Jefferson scale of empathy; Physicians in training; Morocco
Jury Members:
Mr. Redouane ABOUQAL President Professor of Intensive Care Medicine Mrs. Jihane BELAYACHI Director Professor of Intensive Care Medicine Mr. Taoufiq DAKKA Member Professor of Physiology Mr. Fouad LABOUDI Member Professor of Psychiatry
سبحانك ال علم لنا إال ما علمتنا إنك أنت العليم احلكيم
31اآلية ،البقرة
*Enseignant militaire
DOYENS HONORAIRES :
1962 – 1969: Professeur Abdelmalek FARAJ 1969 – 1974: Professeur Abdellatif BERBICH 1974 – 1981: Professeur Bachir LAZRAK 1981 – 1989: Professeur Taieb CHKILI 1989 – 1997: Professeur Mohamed Tahar ALAOUI 1997 – 2003: Professeur Abdelmajid BELMAHI 2003 - 2013: Professeur Najia HAJJAJ – HASSOUNI ORGANISATION DÉCANALE : Doyen Professeur Mohamed ADNAOUI Vice-Doyen chargé des Affaires Académiques et estudiantines Professeur Brahim LEKEHAL Vice-Doyen chargé de la Recherche et de la Coopération Professeur Taoufiq DAKKA Vice-Doyen chargé des Affaires Spécifiques à la Pharmacie Professeur Younes RAHALI Secrétaire Général : Mr. Mohamed KARRA SERVICES ADMINISTRATIFS : Chef du Service des Affaires Administratives Mr. Abdellah KHALED Chef du Service des Affaires Estudiantines, Statistiques et Suivi des Lauréats Mr. Azzeddine BOULAAJOUL Chef du Service de la Recherche, Coopération, Partenariat et des Stages Mr. Najib MOUNIR Chef du service des Finances Mr. Rachid BENNIS
*Enseignant militaire
1 - ENSEIGNANTS-CHERCHEURS MEDECINS ET PHARMACIENS PROFESSEURS DE L’ENSEIGNEMENT SUPERIEUR : Décembre 1984 Pr. MAAOUNI Abdelaziz Médecine interne – Clinique Royale Pr. MAAZOUZI Ahmed Wajdi Anesthésie -Réanimation Pr. SETTAF Abdellatif Pathologie Chirurgicale Décembre 1989 Pr. ADNAOUI Mohamed Médecine interne –Doyen de la FMPR Janvier et Novembre 1990 Pr. KHARBACH Aîcha Gynécologie -Obstétrique Pr. TAZI Saoud Anas Anesthésie Réanimation Février Avril Juillet et Décembre 1991 Pr. AZZOUZI Abderrahim Anesthésie Réanimation Pr. BAYAHIA Rabéa Néphrologie Pr. BELKOUCHI Abdelkader Chirurgie Générale Pr. BENSOUDA Yahia Pharmacie galénique Pr. BERRAHO Amina Ophtalmologie Pr. BEZAD Rachid Gynécologie Obstétrique Méd. Chef Mat. Orangers Rabat Pr. CHERRAH Yahia Pharmacologie Pr. CHOKAIRI Omar Histologie Embryologie Pr. SOULAYMANI Rachida Pharmacologie- Dir. du Centre National PV Rabat Décembre 1992 Pr. AHALLAT Mohamed Chirurgie GénéraleDoyen FMPT Pr. BENSOUDA Adil Anesthésie Réanimation Pr. EL OUAHABI Abdessamad Neurochirurgie Pr. FELLAT Rokaya Cardiologie Pr. JIDDANE Mohamed Anatomie Pr. ZOUHDI Mimoun Microbiologie Mars 1994 Pr. BENJAAFAR Noureddine Radiothérapie Pr. BEN RAIS Nozha Biophysique Pr. CAOUI Malika Biophysique Pr. CHRAIBI Abdelmjid Endocrinologie et Maladies Métaboliques Doyen FMPA Pr. EL AMRANI Sabah Gynécologie Obstétrique Pr. ERROUGANI Abdelkader Chirurgie Générale– Dir. du CHIS Rabat Pr. ESSAKALI Malika Immunologie Pr. ETTAYEBI Fouad Chirurgie Pédiatrique Pr. IFRINE Lahssan Chirurgie Générale Pr. RHRAB Brahim Gynécologie –Obstétrique Pr. SENOUCI Karima Dermatologie Mars 1994 Pr. ABBAR Mohamed* Urologie Inspecteur du SSM Pr. BENTAHILA Abdelali Pédiatrie Pr. BERRADA Mohamed Saleh Traumatologie – Orthopédie Pr. CHERKAOUI Lalla Ouafae Ophtalmologie
*Enseignant militaire
Pr. LAKHDAR Amina Gynécologie Obstétrique Pr. MOUANE Nezha Pédiatrie Mars 1995 Pr. ABOUQUAL Redouane Réanimation Médicale Pr. AMRAOUI Mohamed Chirurgie Générale Pr. BAIDADA Abdelaziz Gynécologie Obstétrique Pr. BARGACH Samir Gynécologie Obstétrique Pr. EL MESNAOUI Abbes Chirurgie Générale Pr. ESSAKALI HOUSSYNI Leila Oto-Rhino-Laryngologie Pr. IBEN ATTYA ANDALOUSSI Ahmed Urologie Pr. OUAZZANI CHAHDI Bahia Ophtalmologie Pr. SEFIANI Abdelaziz Génétique Pr. ZEGGWAGH Amine Ali Réanimation Médicale Décembre 1996 Pr. BELKACEM Rachid Chirurgie Pédiatrie Pr. BOULANOUAR Abdelkrim Ophtalmologie Pr. EL ALAMI EL FARICHA EL Hassan Chirurgie Générale Pr. GAOUZI Ahmed Pédiatrie Pr. OUZEDDOUN Naima Néphrologie Pr. ZBIR EL Mehdi* Cardiologie Dir. HMI Mohammed V Rabat Novembre 1997 Pr. ALAMI Mohamed Hassan Gynécologie-Obstétrique Pr. BIROUK Nazha Ne Urologie Pr. FELLAT Nadia Cardiologie Pr. KADDOURI Noureddine Chirurgie Pédiatrique Pr. KOUTANI Abdellatif Urologie Pr. LAHLOU Mohamed Khalid Chirurgie Générale Pr. MAHRAOUI CHAFIQ Pédiatrie Pr. TOUFIQ Jallal Psychiatrie Dir. Hôp.Ar-razi Salé Pr. YOUSFI MALKI Mounia Gynécologie Obstétrique Novembre 1998 Pr. BENOMAR ALI Neurologie Doyen de la FMP Abulcassis Rabat Pr. BOUGTAB Abdesslam Chirurgie Générale Pr. ER RIHANI Hassan Oncologie Médicale Pr. BENKIRANE Majid* Hématologie Janvier 2000 Pr. ABID Ahmed* Pneumo-phtisiologie Pr. AIT OUAMAR Hassan Pédiatrie Pr. BENJELLOUN Dakhama Badr Sououd Pédiatrie Pr. BOURKADI Jamal-Eddine Pneumo-phtisiologie Pr. CHARIF CHEFCHAOUNI Al Montacer Chirurgie Générale Pr. ECHARRAB El Mahjoub Chirurgie Générale Pr. EL FTOUH Mustapha Pneumo-phtisiologie Pr. EL MOSTARCHID Brahim* Neurochirurgie Pr. TACHINANTE Rajae Anesthésie-Réanimation Pr. TAZI MEZALEK Zoubida Médecine interne
*Enseignant militaire
Novembre 2000 Pr. AIDI Saadia Ne Urologie Pr. AJANA Fatima Zohra Gastro-Entérologie Pr. BENAMR Said Chirurgie Générale Pr. CHERTI Mohammed Cardiologie Pr. ECH-CHERIF EL KETTANI Selma Anesthésie-Réanimation Pr. EL HASSANI Amine Pédiatrie - Dir. Hôp.Cheikh Zaid Rabat Pr. EL KHADER Khalid Urologie Pr. GHARBI Mohamed El Hassan Endocrinologie et Maladies Métaboliques Pr. MDAGHRI ALAOUI Asmae Pédiatrie Décembre 2001 Pr. BALKHI Hicham* Anesthésie-Réanimation Pr. BENABDELJLIL Maria Ne Urologie Pr. BENAMAR Loubna Néphrologie Pr. BENAMOR Jouda Pneumo-phtisiologie Pr. BENELBARHDADI Imane Gastro-Entérologie Pr. BENNANI Rajae Cardiologie Pr. BENOUACHANE Thami Pédiatrie Pr. BEZZA Ahmed* Rhumatologie Pr. BOUCHIKHI IDRISSI Med Larbi Anatomie Pr. BOUMDIN El Hassane* Radiologie Pr. CHAT Latifa Radiologie Pr. EL HIJRI Ahmed Anesthésie-Réanimation Pr. EL MAAQILI Moulay Rachid Neuro-chirurgie Pr. EL MADHI Tarik Chirurgie-Pédiatrique Dir. Hôp. Des Enfants Rabat Pr. EL OUNANI Mohamed Chirurgie Générale Pr. ETTAIR Said Pédiatrie - Pr. GAZZAZ Miloudi* Neuro-chirurgie Pr. HRORA Abdelmalek Chirurgie Générale Dir. Hôpital Ibn Sina Rabat Pr. KABIRI EL Hassane* Chirurgie Thoracique Pr. LAMRANI Moulay Omar Traumatologie Orthopédie Pr. LEKEHAL Brahim Chirurgie Vasculaire Périphérique V-D. Aff Acad. Est. Pr. MEDARHRI Jalil Chirurgie Générale Pr. MOHSINE Raouf Chirurgie Générale Pr. NOUINI Yassine Urologie Pr. SABBAH Farid Chirurgie Générale Pr. SEFIANI Yasser Chirurgie Vasculaire Périphérique Pr. TAOUFIQ BENCHEKROUN Soumia Pédiatrie Décembre 2002 Pr. AMEUR Ahmed* Urologie Pr. AMRI Rachida Cardiologie Pr. AOURARH Aziz* Gastro-Entérologie Dir. HMI Moulaya Ismail-Meknès Pr. BAMOU Youssef* Biochimie-Chimie Pr. BELMEJDOUB Ghizlene* Endocrinologie et Maladies Métaboliques Pr. BENZEKRI Laila Dermatologie Pr. BENZZOUBEIR Nadia Gastro-Entérologie Pr. BERNOUSSI Zakiya Anatomie Pathologique Pr. CHOHO Abdelkrim* Chirurgie Générale Pr. CHKIRATE Bouchra Pédiatrie Pr. EL ALAMI EL Fellous Sidi Zouhair Chirurgie Pédiatrique Pr. FILALI ADIB Abdelhai Gynécologie Obstétrique
*Enseignant militaire
Pr. HAJJI Zakia Ophtalmologie Pr. KRIOUILE Yamina Pédiatrie Pr. OUJILAL Abdelilah Oto-Rhino-Laryngologie Pr. RAISS Mohamed Chirurgie Générale Pr. THIMOU Amal Pédiatrie Pr. ZENTAR Aziz* Chirurgie Générale Dir. de l’ ERPPLM Janvier 2004 Pr. ABDELLAH El Hassan Ophtalmologie Pr. AMRANI Mariam Anatomie Pathologique Pr. BENBOUZID Mohammed Anas Oto-Rhino-Laryngologie Pr. BENKIRANE Ahmed* Gastro-Entérologie Pr. BOULAADAS Malik Stomatologie et Chirurgie Maxillo-faciale Pr. BOURAZZA Ahmed* Ne Urologie Pr. CHAGAR Belkacem* Traumatologie Orthopédie Pr. CHERRADI Nadia Anatomie Pathologique Pr. EL FENNI Jamal* Radiologie Pr. EL HANCHI ZAKI Gynécologie Obstétrique Pr. EL KHORASSANI Mohamed Pédiatrie Pr. HACHI Hafid Chirurgie Générale Pr. JABOUIRIK Fatima Pédiatrie Pr. KHARMAZ Mohamed Traumatologie Orthopédie Pr. MOUGHIL Said Chirurgie Cardio-Vasculaire Pr. OUBAAZ Abdelbarre* Ophtalmologie Pr. TARIB Abdelilah* Pharmacie Clinique Pr. TIJAMI Fouad Chirurgie Générale Pr. ZARZUR Jamila Cardiologie Janvier 2005 Pr. ABBASSI Abdellah Chirurgie réparatrice et plastique Pr. AL KANDRY Sif Eddine* Chirurgie Générale Pr. ALLALI Fadoua Rhumatologie Pr. AMAZOUZI Abdellah Ophtalmologie Pr. BAHIRI Rachid Rhumatologie Dir. Hôp. Al Ayachi Salé Pr. BARKAT Amina Pédiatrie Pr. BENYASS Aatif* Cardiologie Pr. DOUDOUH Abderrahim* Biophysique Pr. HESSISSEN Leila Pédiatrie Pr. JIDAL Mohamed* Radiologie Pr. LAAROUSSI Mohamed Chirurgie Cardio-vasculaire Pr. LYAGOUBI Mohammed Parasitologie Pr. SBIHI Souad Histo-Embryologie Cytogénétique Pr. ZERAIDI Najia Gynécologie Obstétrique AVRIL 2006 Pr. ACHEMLAL Lahsen* Rhumatologie Pr. BELMEKKI Abdelkader* Hématologie Pr. BENCHEIKH Razika O.R.L Pr. BOUHAFS Mohamed El Amine Chirurgie - Pédiatrique Pr. BOULAHYA Abdellatif* Chirurgie Cardio – Vasculaire. Dir. Hôp. Ibn Sina Marr. Pr. CHENGUETI ANSARI Anas Gynécologie Obstétrique Pr. DOGHMI Nawal Cardiologie Pr. FELLAT Ibtissam Cardiologie
*Enseignant militaire
Pr. FAROUDY Mamoun Anesthésie Réanimation Pr. HARMOUCHE Hicham Médecine interne Pr. IDRISS LAHLOU Amine* Microbiologie Pr. JROUNDI Laila Radiologie Pr. KARMOUNI Tariq Urologie Pr. KILI Amina Pédiatrie Pr. KISRA Hassan Psychiatrie Pr. KISRA Mounir Chirurgie – Pédiatrique Pr. LAATIRIS Abdelkader* Pharmacie Galénique Pr. LMIMOUNI Badreddine* Parasitologie Pr. MANSOURI Hamid* Radiothérapie Pr. OUANASS Abderrazzak Psychiatrie Pr. SAFI Soumaya* Endocrinologie Pr. SOUALHI Mouna Pneumo – Phtisiologie Pr. TELLAL Saida* Biochimie Pr. ZAHRAOUI Rachida Pneumo – Phtisiologie Octobre 2007 Pr. ABIDI Khalid Réanimation médicale Pr. ACHACHI Leila Pneumo phtisiologie Pr. AMHAJJI Larbi* Traumatologie orthopédie Pr. AOUFI Sarra Parasitologie Pr. BAITE Abdelouahed* Anesthésie réanimation Pr. BALOUCH Lhousaine* Biochimie-Chimie Pr. BENZIANE Hamid* Pharmacie Clinique Pr. BOUTIMZINE Nourdine Ophtalmologie Pr. CHERKAOUI Naoual* Pharmacie galénique Pr. EL BEKKALI Youssef* Chirurgie cardio-vasculaire Pr. EL ABSI Mohamed Chirurgie Générale Pr. EL MOUSSAOUI Rachid Anesthésie réanimation Pr. EL OMARI Fatima Psychiatrie Pr. GHARIB Noureddine Chirurgie plastique et réparatrice Pr. HADADI Khalid* Radiothérapie Pr. ICHOU Mohamed* Oncologie Médicale Pr. ISMAILI Nadia Dermatologie Pr. KEBDANI Tayeb Radiothérapie Pr. LOUZI Lhoussain* Microbiologie Pr. MADANI Naoufel Réanimation médicale Pr. MARC Karima Pneumo phtisiologie Pr. MASRAR Azlarab Hématologie biologique Pr. OUZZIF Ez zohra* Biochimie-Chimie Pr. SEFFAR Myriame Microbiologie Pr. SEKHSOKH Yessine* Microbiologie Pr. SIFAT Hassan* Radiothérapie Pr. TACHFOUTI Samira Ophtalmologie Pr. TAJDINE Mohammed Tariq* Chirurgie Générale Pr. TANANE Mansour* Traumatologie-Orthopédie Pr. TLIGUI Houssain Parasitologie Pr. TOUATI Zakia Cardiologie Mars 2009 Pr. ABOUZAHIR Ali* Médecine interne Pr. AGADR Aomar* Pédiatrie
*Enseignant militaire
Pr. AIT ALI Abdelmounaim* Chirurgie Générale Pr. AKHADDAR Ali* Neuro-chirurgie Pr. ALLALI Nazik Radiologie Pr. AMINE Bouchra Rhumatologie Pr. ARKHA Yassir Neuro-chirurgie Dir. Hôp. Spécialités Rabat Pr. BELYAMANI Lahcen* Anesthésie Réanimation Pr. BJIJOU Younes Anatomie Pr. BOUHSAIN Sanae* Biochimie-Chimie Pr. BOUI Mohammed* Dermatologie Pr. BOUNAIM Ahmed* Chirurgie Générale Pr. BOUSSOUGA Mostapha* Traumatologie-Orthopédie Pr. CHTATA Hassan Toufik* Chirurgie Vasculaire Périphérique Pr. DOGHMI Kamal* Hématologie clinique Pr. EL MALKI Hadj Omar Chirurgie Générale Pr. EL OUENNASS Mostapha* Microbiologie Pr. ENNIBI Khalid* Médecine interne Pr. FATHI Khalid Gynécologie obstétrique Pr. HASSIKOU Hasna* Rhumatologie Pr. KABBAJ Nawal Gastro-entérologie Pr. KABIRI Meryem Pédiatrie Pr. KARBOUBI Lamya Pédiatrie Pr. LAMSAOURI Jamal* Chimie Thérapeutique Pr. MARMADE Lahcen Chirurgie Cardio-vasculaire Pr. MESKINI Toufik Pédiatrie Pr. MSSROURI Rahal Chirurgie Générale Pr. NASSAR Ittimade Radiologie Pr. OUKERRAJ Latifa Cardiologie Pr. RHORFI Ismail Abderrahmani* Pneumo-Phtisiologie Octobre 2010 Pr. ALILOU Mustapha Anesthésie réanimation Pr. AMEZIANE Taoufiq* Médecine interne Pr. BELAGUID Abdelaziz Physiologie Pr. CHADLI Mariama* Microbiologie Pr. CHEMSI Mohamed* Médecine Aéronautique Pr. DAMI Abdellah* Biochimie- Chimie Pr. DENDANE Mohammed Anouar Chirurgie Pédiatrique Pr. EL HAFIDI Naima Pédiatrie Pr. EL KHARRAS Abdennasser* Radiologie Pr. EL MAZOUZ Samir Chirurgie Plastique et Réparatrice Pr. EL SAYEGH Hachem Urologie Pr. ERRABIH Ikram Gastro-Entérologie Pr. LAMALMI Najat Anatomie Pathologique Pr. MOSADIK Ahlam Anesthésie Réanimation Pr. MOUJAHID Mountassir* Chirurgie Générale Pr. ZOUAIDIA Fouad Anatomie Pathologique Decembre 2010 Pr. ZNATI Kaoutar Anatomie Pathologique Mai 2012 Pr. AMRANI Abdelouahed Chirurgie Pédiatrique Pr. ABOUELALAA Khalil* Anesthésie Réanimation Pr. BENCHEBBA Driss* Traumatologie-Orthopédie
*Enseignant militaire
Pr. DRISSI Mohamed* Anesthésie Réanimation Pr. EL ALAOUI MHAMDI Mouna Chirurgie Générale Pr. EL OUAZZANI Hanane* Pneumophtisiologie Pr. ER-RAJI Mounir Chirurgie Pédiatrique Pr. JAHID Ahmed Anatomie Pathologique Février 2013 Pr. AHID Samir Pharmacologie Doyen FP de l’UM6SS Pr. AIT EL CADI Mina Toxicologie Pr. AMRANI HANCHI Laila Gastro-Entérologie Pr. AMOR Mourad Anesthésie-Réanimation Pr. AWAB Almahdi Anesthésie-Réanimation Pr. BELAYACHI Jihane Réanimation Médicale Pr. BELKHADIR Zakaria Houssain Anesthésie-Réanimation Pr. BENCHEKROUN Laila Biochimie-Chimie Pr. BENKIRANE Souad Hématologie Pr. BENSGHIR Mustapha* Anesthésie Réanimation Pr. BENYAHIA Mohammed* Néphrologie Pr. BOUATIA Mustapha Chimie Analytique et Bromatologie Pr. BOUABID Ahmed Salim* Traumatologie orthopédie Pr BOUTARBOUCH Mahjouba Anatomie Pr. CHAIB Ali* Cardiologie Pr. DENDANE Tarek Réanimation Médicale Pr. DINI Nouzha* Pédiatrie Pr. ECH-CHERIF EL KETTANI Mohamed Ali Anesthésie Réanimation Pr. ECH-CHERIF EL KETTANI Najwa Radiologie Pr. ELFATEMI NIZARE Neuro-chirurgie Pr. EL GUERROUJ Hasnae Médecine Nucléaire Pr. EL HARTI Jaouad Chimie Thérapeutique Pr. EL JAOUDI Rachid* Toxicologie Pr. EL KABABRI Maria Pédiatrie Pr. EL KHANNOUSSI Basma Anatomie Pathologique Pr. EL KHLOUFI Samir Anatomie Pr. EL KORAICHI Alae Anesthésie Réanimation Pr. EN-NOUALI Hassane* Radiologie Pr. ERRGUIG Laila Physiologie Pr. FIKRI Meryem Radiologie Pr. GHFIR Imade Médecine Nucléaire Pr. IMANE Zineb Pédiatrie Pr. IRAQI Hind Endocrinologie et maladies métaboliques Pr. KABBAJ Hakima Microbiologie Pr. KADIRI Mohamed* Psychiatrie Pr. LATIB Rachida Radiologie Pr. MAAMAR Mouna Fatima Zahra Médecine interne Pr. MEDDAH Bouchra Pharmacologie Directrice du Méd. Phar. Pr. MELHAOUI Adyl Neuro-chirurgie Pr. MRABTI Hind Oncologie Médicale Pr. NEJJARI Rachid Pharmacognosie Pr. OUBEJJA Houda Chirugie Pédiatrique Pr. OUKABLI Mohamed* Anatomie Pathologique Pr. RAHALI Younes Pharmacie Galénique Vice-Doyen à la Pharmacie Pr. RATBI Ilham Génétique Pr. RAHMANI Mounia Ne Urologie
*Enseignant militaire
Pr. REDA Karim* Ophtalmologie Pr. REGRAGUI Wafa Ne Urologie Pr. RKAIN Hanan Physiologie Pr. ROSTOM Samira Rhumatologie Pr. ROUAS Lamiaa Anatomie Pathologique Pr. ROUIBAA Fedoua* Gastro-Entérologie Pr SALIHOUN Mouna Gastro-Entérologie Pr. SAYAH Rochde Chirurgie Cardio-Vasculaire Pr. SEDDIK Hassan* Gastro-Entérologie Pr. ZERHOUNI Hicham Chirurgie Pédiatrique Pr. ZINE Ali* Traumatologie Orthopédie AVRIL 2013 Pr. EL KHATIB MOHAMED KARIM* Stomatologie et Chirurgie Maxillo-faciale MAI 2013 Pr. BOUSLIMAN Yassir* Toxicologie MARS 2014 Pr. ACHIR Abdellah Chirurgie Thoracique Pr. BENCHAKROUN Mohammed* Traumatologie- Orthopédie Pr. BOUCHIKH Mohammed Chirurgie Thoracique Pr. EL KABBAJ Driss* Néphrologie Pr. FILALI Karim* Anesthésie-Réanimation Dir. ERSSM Pr. EL MACHTANI IDRISSI Samira* Biochimie-Chimie Pr. HARDIZI Houyam Histologie- Embryologie-Cytogénétique Pr. HASSANI Amale* Pédiatrie Pr. HERRAK Laila Pneumologie Pr. JEAIDI Anass* Hématologie Biologique Pr. KOUACH Jaouad* Génycologie-Obstétrique Pr. MAKRAM Sanaa* Pharmacologie Pr. RHISSASSI Mohamed Jaafar CCV Pr. SEKKACH Youssef* Médecine interne Pr. TAZI MOUKHA Zakia Génécologie-Obstétrique DECEMBRE 2014 Pr. ABILKACEM Rachid* Pédiatrie Pr. AIT BOUGHIMA Fadila Médecine Légale Pr. BEKKALI Hicham* Anesthésie-Réanimation Pr. BENAZZOU Salma Chirurgie Maxillo-Faciale Pr. BOUABDELLAH Mounya Biochimie-Chimie Pr. BOUCHRIK Mourad* Parasitologie Pr. DERRAJI Soufiane* Pharmacie Clinique Pr. EL AYOUBI EL IDRISSI Ali Anatomie Pr. EL GHADBANE Abdedaim Hatim* Anesthésie-Réanimation Pr. EL MARJANY Mohammed* Radiothérapie Pr. FEJJAL Nawfal Chirurgie réparatrice et plastique Pr. JAHIDI Mohamed* O.R.L Pr. LAKHAL Zouhair* Cardiologie Pr. OUDGHIRI NEZHA Anesthésie-Réanimation Pr. RAMI Mohamed Chirurgie Pédiatrique Pr. SABIR Maria Psychiatrie Pr. SBAI IDRISSI Karim* Médecine préventive, santé publique et Hyg.
*Enseignant militaire
AOUT 2015 Pr. MEZIANE Meryem Dermatologie Pr. TAHIRI Latifa Rhumatologie JANVIER 2016 Pr. BENKABBOU Amine Chirurgie Générale Pr. EL ASRI Fouad* Ophtalmologie Pr. ERRAMI Noureddine* O.R.L JUIN 2017 Pr. ABI Rachid* Microbiologie Pr. ASFALOU Ilyasse* Cardiologie Pr. BOUAITI El Arbi* Médecine préventive, santé publique et Hyg. Pr. BOUTAYEB Saber Oncologie Médicale Pr. EL GHISSASSI Ibrahim Oncologie Médicale Pr. HAFIDI Jawad Anatomie Pr. MAJBAR Mohammed Anas Chirurgie Générale Pr. OURAINI Saloua* O.R.L Pr. RAZINE Rachid Médecine préventive, santé publique et Hyg. Pr. SOUADKA Amine Chirurgie Générale Pr. ZRARA Abdelhamid* Immunologie PROFESSEURS AGREGES : JANVIER 2005 Pr. HAJJI Leila Cardiologie (mise en disponibilité) MAI 2018 Pr. AMMOURI Wafa Médecine interne Pr. BENTALHA Aziza Anesthésie-Réanimation Pr. EL AHMADI Brahim Anesthésie-Réanimation Pr. EL HARRECH Youness* Urologie Pr. EL KACEMI Hanan Radiothérapie Pr. EL MAJJAOUI Sanaa Radiothérapie Pr. FATIHI Jamal* Médecine interne Pr. GHANNAM Abdel-Ilah Anesthésie-Réanimation Pr. JROUNDI Imane Médecine préventive, santé publique et Hyg. Pr. MOATASSIM BILLAH Nabil Radiologie Pr. TADILI Sidi Jawad Anesthésie-Réanimation Pr. TANZ Rachid* Oncologie Médicale NOVEMBRE 2018 Pr. AMELLAL Mina Anatomie Pr. SOULY Karim Microbiologie Pr. TAHRI Rajae Histologie-Embryologie--Cytogénétique NOVEMBRE 2019 Pr. AATIF Taoufiq* Néphrologie Pr. ACHBOUK Abdelhafid* Chirurgie réparatrice et plastique Pr. ANDALOUSSI SAGHIR Khalid Radiothérapie Pr. BABA HABIB Moulay Abdellah* Génycologie-Obstétrique Pr. BASSIR Rida Allah Anatomie Pr. BOUATTAR Tarik Néphrologie
*Enseignant militaire
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2 - ENSEIGNANTS-CHERCHEURS SCIENTIFIQUES PROFESSEURS DE L’ENSEIGNEMENT SUPERIEUR : Pr. ABOUDRAR Saadia Physiologie Pr. ALAMI OUHABI Naima Biochimie-Chimie Pr. ALAOUI KATIM Pharmacologie Pr. ALAOUI SLIMANI Lalla Naïma Histologie-Embryologie Pr. ANSAR M’hammed Chimie Organique et Pharmacie Chimique Pr. BARKIYOU Malika Histologie-Embryologie Pr. BOUHOUCHE Ahmed Génétique Humaine Pr. BOUKLOUZE Abdelaziz Applications Pharmaceutiques Pr. DAKKA Taoufiq Physiologie Vice-Doyen chargé de la Rech. et de la Coop. Pr. FAOUZI Moulay El Abbes Pharmacologie Pr. IBRAHIMI Azeddine Biologie moléculaire/Biotechnologie Pr. OULAD BOUYAHYA IDRISSI Med Chimie Organique Pr. RIDHA Ahlam Chimie Pr. TOUATI Driss Pharmacognosie Pr. ZAHIDI Ahmed Pharmacologie PROFESSEURS HABILITES : Pr. AANNIZ Tarik Microbiologie et Biologie moléculaire Pr. BENZEID Hanane Chimie Pr. CHAHED OUAZZANI Lalla Chadia Biochimie-Chimie Pr. CHERGUI Abdelhak Botanique, Biologie et physiologie végétales Pr. DOUKKALI Anass Chimie Analytique Pr. EL BAKKALI Mustapha Physiologie Pr. EL JASTIMI Jamila Chimie Pr. KHANFRI Jamal Eddine Histologie-Embryologie Pr. LAZRAK Fatima Chimie Pr. LYAHYAI Jaber Génétique Pr. OUADGHIRI Mouna Microbiologie et Biologie Pr. RAMLI Youssef Chimie Organique Pharmaco-Chimie Pr. SERRAGUI Samira Pharmacologie Pr. TAZI Ahnini Génétique Pr. YAGOUBI Maamar Eau, Environnement
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On the authority of Anas ibn Malik (May Allah be pleased with him),
that the prophet (peace and blessings be upon him) said:
"None of you [truly] believes until he wishes
for his brother what he wishes for himself"
Related by Bukhari and Muslim
Dedications
To Allah glory be to Him,
To Whom I owe everything beautiful in my life.
I ask for Your forgiveness and guidance through my existence.
To the prophets peace be upon them,
For their legacy and priceless teachings.
To my beloved parents, There are no words to express my endless gratitude to both
of you for bringing me this far, for believing in me and always supporting me even in the most difficult times.
Thank you for your unwavering patience, your unconditional love, for being my role models, for your sacrifices,
your comforting encouragements all along these years. Your abiding trust in me is a constant source of motivation.
To my beloved mother, I owe you so much for sowing the seed of scientific research in me,
for bringing me back on track when I run out of motivation, for encouraging me to move forward,
for believing in me. Your resilience, perseverance and tenacity have always inspired me.
To my much-loved father, who helped me along the way.
Thank you for providing for me and for being a substantial pillar of my success.
Thank you for setting a good example of commitment to volunteering and community service.
I am forever thankful to both of you, may Allah protect you.
To my dear sister Fatima Zahra,
I was on my first year of medical school when we celebrated your graduation. I’m blessed to have you as a tutor. You demonstrate
through your practice the ethics of the professional doctor, an example that
I have always looked up to. Thank you for taking care of me, for your presence,
your unfailing help, your advice and your encouragements
during all these years.
May Allah protect you and your adorable family.
To my cherished sister Souhaïla, I can never thank you enough for your kind love,
for always being there to listen to me, support me and comfort me. I am truly blessed to have you in my life.
I am particularly grateful to you for helping me with this work.
Without your invaluable contribution it wouldn’t have come
out with the same quality.
Thank you for providing me with bibliographic resources.
Thank you for the time you dedicated to me willingly and graciously.
Thank you for your comments, your proofreading and for your patience
during the long hours spent working on this thesis.
All the help you offered was priceless.
I will never be able to repay you.
May Allah bless you and reward you.
To my dear bother Mohammed Jaber,
For the moments we shared since our childhood, for your adventurous
spirit, your love for nature, your peaceful strength,
your unfailing helpfulness and obligingness.
You are a source of family pride.
May Allah protect you.
To my Grandparents,
To my late beloved grand-father – Ahmed Nejjari, When I made the choice to pursue a medical carrier you offered me the
physician’s oath and a copy of the first medical degree in the world from Al-Qarawiyyin University.
I still remember our little enriching chat about the virtues of the physician based on which that degree was awarded.
You made me aware of medical professionalism and you instilled in me the motivation to seek it even before I knew of its existence.
You had the unique gift of making everyone around you feel special. Your scientific rigor, your soft heart, your kindness, your wisdom, your open-mindedness, and your generosity inspired not only your
family but every single person who was fortunate enough to meet you. I hope to fulfill your legacy.
May Allah bestow His mercy on you.
To my dear maternal grandmother, You showered us with your love. Thank you for your prayers,
your inspiring strong personality, your tenderness, your willingness to give endlessly,
your hospitality, and your amazing table that has always gathered us. May Allah grant you good health and protect you.
To my dear paternal grandmother, You are an unlimited source of love. Thank you for your kindness,
your stories, and mostly for your prayers. May Allah bless you and protect you.
To my adorable nephew,
To my sweetheart and most beloved nephew,
the source of joy and the pearl of our family,
your creativity, your smile,
your tender hugs fill my life with bliss and happiness.
May Allah protect your pure and beautiful heart.
To my dear cousin Hanaa,
To my faithful journey partner, my sister and best-friend.
Thank you for your support all along the way, for the moments we
shared, for being an amazing study partner, for always cheering me up,
for your unfailing smile and good mood, for your wisdom
and joyfulness.
May Allah bless you and grant you your heart desires.
To my honorable big family,
To my aunts, uncles, and cousins,
I want to express my gratitude to all of you for your support,
your advice, for making my life so beautiful, for your prayers
and encouraging words.
Your presence is always a great comfort.
May Allah protect you all.
To my late second mother Doctor Bahija Berrada,
I am deeply grateful to Allah for the gift of bringing us together.
You were my beloved second mother, my mentor and my role model.
Your golden quote
“Medicine is humane above all”
was and will always be my motto.
May Allah grant you paradise.
To the lifesaver Professor Mohammed Mouhaoui,
I am more grateful to you than words can express.
You are a model of the empathic physician and teacher.
Your brilliant initiative Pygmalion Academy has been an extremely
enriching part of my medical curriculum.
Not only I experienced with you the real joy of learning, but you also
allowed me to regain my confidence when I almost lost it.
Thank you for your availability, your sincere dedication to teaching
and your deep desire to support your students and help them progress.
May Allah reward you endlessly.
To my friends,
To the beautiful people in my life,
without you my years in medical school would not have been the same.
To Soumaya and Sara, thank you for your enriching company
during my internship. Your support has always touched me.
Your kindness and excellence have been inspiring.
To Maha, for your precious help with this work.
To my medical school and externship friends,
we shared beautiful moments and I wish you all the best.
To my childhood friends, thank you for being here for almost 20 years.
The years pass by but our friendship remains true.
May Allah protect you and your families.
To the staff of the CSM-UIASS and my students,
For the memorable moments and very enriching experience.
I am especially grateful to my dear friends Dr Nada, Dr Soumaya,
Dr Zineb and Dr Houda for their inestimable help
with the scientific content.
To my seniors, supervisors and professors,
I would like to express my gratitude to every person
who has contributed to my training.
Thank you for sharing your knowledge and
your love for your profession, for your advice, for guiding
me throughout the curriculum, and for the quality of your training.
Your contribution to my personal and professional
development was valuable.
To the study participants,
I am thankful to all the physicians in training of the UHIS who,
despite their tight schedule, took the time to answer the questionnaire.
Acknowledgements
To our thesis president,
Professor Redouane ABOUQAL
I wish to express my utmost gratitude to our honorable thesis president
Pr ABOUQAL for giving me the opportunity to carry out this work,
for his inestimable advice and valuable input, and for his tremendous
contribution to the medical research field in Morocco.
To our thesis supervisor,
Professor Jihane BELAYACHI
I would like to offer my profound recognition to my supportive
and patient thesis supervisor Pr BELAYACHI,
whose guidance and comforting encouragements have been inestimably
precious since our first meeting. Thank you, dear Professor,
for showing me how to conduct a scientific study properly
and for considering this topic that I deeply cherish.
Your kindness, your serenity, and your perseverance
have been inspiring.
To our jury member,
Professor Taoufiq DAKKA
Thank you for your commitment to research and teaching.
I was fortunate to be your student.
Please accept my deep respect and my acknowledgement
for agreeing to judge this work.
Your contribution is highly valued.
To our jury member,
Professor Fouad LABOUDI
Thank you for your warm attitude and your interest in this work.
Your knowledge and expertise is highly regarded.
I am sincerely grateful to you for accepting
to be part of my thesis jury.
To Thomas Jefferson University
Thank you for allowing us to use the JSE free of charges.
Abbreviations
ABBREVIATIONS
4HCS : Four Habits Coding Scheme
ABIM : American Board of Internal Medicine
ACGME : Accreditation Council on Graduate Medical Education
ACME : Affective and Cognitive Measure of Empathy
aMCC : anterior Mid-Cingulate Cortex
AMES : Adolescent Measure of Empathy and Sympathy
AMS : Academic Motivation Scale
BC : Before Christ
BEES : Balanced Emotional Empathy Scale
BES : Basic Empathy Scale
BLRI : Barrett-Lennard Relationship Inventory
CARE : Consultation and Relational Empathy
CASES : Cognitive, Affective, and Somatic Empathy Scale
CC : Compassionate Care
dACC : dorsal Anterior Cingulate Cortex
EC : Empathy Continuum
ECCS : Empathic Communication Coding system
ECQE : Empathy Components Questionnaire
ECRS : Empathy and Clarity Rating Scale
ECRS : Empathy Construct Rating Scale
EES : Empathic Experience Scale
EQ : Empathy Quotient
ERQ : Empathic Responsiveness Questionnaire
FASTE : Feshbach Affective Situations Test of Empathy
fMRI : functional Magnetic Resonance Imaging
GEM : Griffith Empathy Measure
HES : Hogan Empathy Scale
IRI : Interpersonal Reactivity Index JSE : Jefferson Scale of Empathy JSPPPE : Jefferson Scale of Patient Perceptions of Physician Empathy KCES : Kiersma Chen Empathy Scale KEDS : Kids' Empathic Development Scale MBI : Maslach Burnout Inventory MCS : Mental Component Summary MDEES : Multidimensional Emotional Empathy Scale MIPS : Millon Index of Personality Styles MNS : Mirror Neuron System MWQ : Mental Workload Questionnaire NEO‑FFI : Neuroticism-Extraversion-Openness Five-Factor Inventory NEO-PI : Neuroticism-Extraversion-Openness Personality Inventory OSCE : Objective Structured Clinical Examination PAQ : Personal Attributes Questionnaire PCI : Professionalism Climate Instrument PCS : Physical Component Summary PEI : Perception of Empathy Inventory PSS : Perceived Stress Scale PT : Perspective Taking QCAE : Questionnaire of Cognitive and Affective Empathy QOL : Quality Of Life RES : Reynolds Empathy Scale SD : Standard Deviation SF12 : 12-Item Short-Form Health Survey SMA : Supplementary Motor Area SPS : Standing in the Patient’s Shoes SWLS : Satisfaction with Life Scale TCI : Temperament and Character Inventory TEQ : Toronto Empathy Questionnaire UHIS : University Hospital IBN SINA ZKPQ : Zuckerman–Kuhlman Personality Questionnaire
List of Illustrations
LIST OF FIGURES Figure 1: A framework for defining medical professionalism..............................................................2 Figure 2: Empathy and sympathy as related to cognition and emotion ................................................9 Figure 3 : Gender distribution of the study population ...................................................................... 53 Figure 4 : Marital status of the study population .............................................................................. 54 Figure 5 : Percentage of the population living alone vs. living with family or friends ........................ 54 Figure 6 : Socio-economic status of the study population.................................................................. 55 Figure 7 : Parental educational level of the study population............................................................. 55 Figure 8 : Extracurricular activities of the study population .............................................................. 56 Figure 9: Presence of a chronic condition among the study population ............................................... 56 Figure 10 : Hospitalization experience among the study population .................................................. 57 Figure 11 : Specialty interest among the interns of the study population ........................................... 58 Figure 12 : Current specialty among the residents of the study population ........................................ 58 Figure 13: SF12 scores among the study population ......................................................................... 59 Figure 14: Distribution of the SWLS scores in the study population ................................................. 60 Figure 15 : work hours per week among the study population ........................................................... 61 Figure 16 : Frequency of healthcare activities among the study population ....................................... 62 Figure 17 : Frequency of scientific activities among the study population ......................................... 63 Figure 18 : Perception of patient related factors among the study population .................................... 64 Figure 19 : Perception of professional requirements among the study population .............................. 65 Figure 20 : Perception of resources and organizational factors among the study population .............. 66 Figure 21 : Perception of psychosocial work environment among the study population ..................... 67 Figure 22 : Professional exposure among the study population ......................................................... 68 Figure 23 : Motivation to pursue a medical career among the study population ................................. 68 Figure 25 : Training on doctor-patient relationship among the study population ................................ 70 Figure 24 : the relative importance accorded to knowledge, know-how, and social skills during the medical curriculum ........................................................................................................................... 69 Figure 26 : Perception of the learning environment among the study population ............................... 71 Figure 27 : Satisfaction with the medical training among the study population .................................. 72 Figure 28 : Distribution of the JSE total score among the study population ....................................... 73 Figure 29 : Distribution of the perspective taking score among the study population ......................... 74 Figure 30 : Distribution of the compassionate care score among the study population ....................... 74 Figure 31 : Distribution of the “Standing in Patient’s Shoes” score among the study population ....... 75 Figure 32 : Empathy related factors among physicians in training: multiple regression analysis results ............................................................................................................................................... 99 Figure 33 : Differences in empathy scores according to gender ....................................................... 100
LIST OF TABLES
Table 1 : Demographic characteristics and socio-economic background ............................................ 76 Table 2 : Health status and healthcare experience ............................................................................. 77 Table 3 : Professional characteristics ................................................................................................ 77 Table 4 : Quality of life measured by the SF12 ................................................................................. 78 Table 5 : Satisfaction with life measured by the SWLS ..................................................................... 78 Table 6 : Work hours per week ......................................................................................................... 79 Table 7 : Healthcare activities........................................................................................................... 79 Table 8 : Scientific activities ............................................................................................................ 80 Table 9 : Patient related factors ........................................................................................................ 81 Table 10 : Professional requirements ................................................................................................ 82 Table 11 : Resources and organizational factors................................................................................ 83 Table 12 : Psychosocial work environment ....................................................................................... 84 Table 13 : Occupational exposure ..................................................................................................... 85 Table 14 : Motivation to pursue a medical career .............................................................................. 85 Table 15 : Formal education ............................................................................................................. 86 Table 16 : Learning environment ...................................................................................................... 86 Table 17 : Satisfaction with the medical training ............................................................................... 87 Table 18 : Empathy measured by the JSE (HP-version) ..................................................................... 88 Table 19 : Univariate analysis of predictors of empathy .................................................................... 89 Table 20 : Univariate analysis of predictors of perspective taking ..................................................... 90 Table 21 : Univariate analysis of predictors of compassionate care ................................................... 91 Table 22 : Univariate analysis of predictors of “standing in patients’ shoes” ..................................... 92 Table 23 : Multivariate analysis of predictors of empathy ................................................................. 93
1-2-6-Adolescent Measure of Empathy and Sympathy (AMES) .......................... 16
1-2-7-Cognitive, Affective, and Somatic Empathy Scale (CASES) ..................... 17
2-Measurement of empathy in the adult ..................................................................... 17
2-1-Dymond’s Rating Test for the measurement of empathic ability ............................................................................................................................... 17
1-1-Opinion on the relative importance accorded to knowledge, know-how, and social skills during the medical curriculum ............................................................. 69
1-2-Training on doctor-patient relationship ............................................................. 70
II-EMPATHY RELATED FACTORS .............................................................................. 99 1-Empathy and clinician related factors ................................................................................ 99
2-Empathy and non clinician related factors ...................................................................... 102
2-1-Work-load ......................................................................................................... 102 2-2-Psychosocial work environment ........................................................................ 103
3-Empathy and formal education ........................................................................................ 104
3-1-Training level .................................................................................................... 104 3-2-Empathy and training in social skills.................................................................. 107
4-Empathy and motivation ................................................................................................... 108
III-STRENGTHS AND LIMITATIONS ......................................................................... 110 1-Limitations ......................................................................................................................... 110
Medical practice is based on human interaction between individuals seeking care and
individuals delivering it. Throughout the history of medicine, humanism and empathy in the
doctor-patient relationship have been recognized as a crucial part of professionalism in
medical practice. As long ago as 400 BC, Hippocrates wrote: “Some patients, though
conscious that their condition is perilous, recover their health simply through their
contentment with the goodness of the physician”. In the 10th century, we find the same
perspective in Al-Razi’s paradigm of an ethical physician, which counts appearance, voice
modulation, virtuosity, behaving as a role model, a life-long desire to update their knowledge,
confidentiality and empathy (1).
Nowadays, humanism is recognized to be a fundamental element of medical
professionalism as the definition of Louise Arnold and David Thomas Stern states:
“Professionalism is demonstrated through a foundation of clinical competence,
communication skills, and ethical and legal understanding, upon which is built the aspiration
to and wise application of the principles of professionalism: excellence, humanism,
accountability, and altruism” (2) (Figure 1).
Figure 1: A framework for defining medical professionalism
3
According to the American Board of Internal Medicine (ABIM), human professional attitudes are summarized in three major concepts: respect, empathy, and integrity (2). Among them, empathy is the most mentioned quality of the humanistic physician in the scientific literature (3). Hojat et al. defined it as: “A predominantly cognitive attribute that involves an understanding of experiences, concerns and perspectives of the patient combined with a capability to communicate this understanding and an intention to help” (4) (p.74).
Consequently, empathy is not a simple personality trait but a competence that can be taught, learned, assessed, developed and can increase or decrease due to several factors.
Therefore, academic vocational training in medical training institutions must not be limited to the mere transmission of knowledge, but also to developing the “know-how” and cultivating “social skills” among the future professionals (attitudes, habits, values and ethics) (5). Indeed, all parties involved in the healthcare system (physicians-in-training, physicians, training institutions and patients) expect the knowledge acquired during training to transform into effective and visible operational skills in medical practice.
However, no training can be effective if its objectives are not well defined. Furthermore, if relevant and valid monitoring and evaluation tools are absent or lacking, it becomes impossible to highlight the facts and compare them to the expectations. For instance, in Morocco, empathy and many other professional medical skills are, in most cases, neither taught nor assessed during the medical curriculum. Yet, it is today crucial to address this issue, considering that the accelerating evolution of diagnostic and therapeutic technologies pushes medical practice towards an approach centered on the disease rather than the patient.
In view of the scarcity of scientific works on empathy related factors in the population of physicians in Morocco, we decided to conduct this study with a threefold objective:
Describe some of the clinician related factors, the non clinician related factors, the perception of the quality of training, and the motivation for a medical career among the physicians in training at the UHIS.
Evaluate the level of empathy among physicians in training using the Jefferson Scale of Empathy (JSE).
Analyze the impact of the clinician related factors and the non clinician related factors on the level of empathy of the physicians in training.
4
Literature Review
5
A-THE CONCEPT OF EMPATHY
Empathy is considered as a natural and social phenomenon and is addressed in many
disciplines such as philosophy, sociology, psychoanalysis and neurology.
Despite the fact that empathy occupies a central place in human relationships,
specifically in the doctor-patient relationship, its definition is not consensual (6) (p. 217-230).
We present some of the definitions given to this concept in the scientific literature then
highlight the constructs of empathy relevant to the patient care context.
I-ORIGIN OF THE TERM “EMPATHY”
The concept of empathy was first introduced in 1873 by the German philosopher Robert
Vischer, under the German term “Einfühlung” which literally means "felt from the inside" (7).
According to Vischer, empathy is the way in which an observer relates to a work of art
allowing access to its meaning, i.e. the feelings perceived by a person observing a work of art.
Thus, the German term was not originally used to describe an interpersonal attribute but
a feeling resulting from the visual perception of the shape of any object.
In 1897, the German philosopher Theodore Lipps brought the term “Einfühlung” from
aesthetics to psychology. He noted: ‘‘When I observe a circus performer on a hanging wire, I
feel I am inside him’’. Thereby, a person feels the same emotion that he sees expressed by
another individual (8).
In 1903, Wilhelm Wundt, the father of experimental psychology, used “Einfühlung” for
the first time in the context of human relationships (4) (p.5).
The English equivalent of “Einfühlung” was introduced by Edward Bradner Titchener
as “Empathy” in 1909 (9), which means according to the Cambridge dictionary:
“The ability to share someone else's feelings or experiences by imagining what it would
be like to be in that person's situation” (10).
6
II-DEFINITION OF EMPATHY
Since the end of the 20th century, the concept of empathy gained much interest in human
science studies and many researchers contributed to define it. Jean Decety suggested that
"there are almost as many definitions of the concept of empathy as there are authors writing
on the subject" (11).
The variety of definitions given to this concept implies that there are several approaches
to its study. On one hand, empathy can be defined cognitively, in relation to perspective
taking or understanding of others. On the other hand, empathy has also been defined as an
emotional arousal in response to the feelings or experiences of others.
Finally, there is an integrative approach which employs both cognitive and emotional
approaches to the study of empathy. Therefore, empathy has been recently conceived as a
multi-dimensional construct involving both cognition and emotion.
1-Empathy from an emotional perspective
Within this approach, empathy was defined as “a vicarious emotional response to the
perceived emotional experiences of other” (12).
Hoffman studied empathy for several decades as part of his work on social and
emotional development. He saw empathy as an “affective response more appropriate to
another’s situation than one’s own” (13) (p.8).
Many other authors adopted a similar perspective to Hoffman, including Rushton
(1981), Eisenberg (1989) and Halpern (2001) (4) (p.8). According to these authors, empathy
can be described as an emotional reaction in response to another’s emotions, involving
intuitive mechanisms and generating identical feelings.
2-Empathy from a cognitive perspective
Within this perspective empathy was defined as related to cognitive activities such as
understanding, perspective taking and role taking.
7
Among the researchers who adopted this approach we find Dymond (1949), who
described empathy as “the imaginative transposing of oneself into the thinking, feeling, and
acting of another and so structuring the world as he does” (14). Hogan (1969) defined
empathy as "the intellectual or imaginative apprehension of another's condition or state of
mind without actually experiencing that person's feelings” (15). Furthermore, Kohut (1971)
described it as “a mode of cognition that is specifically attuned to the perception of a complex
psychological configuration” (4) (p. 7)
3-Empathy as a multi-dimensional construct
Recently, empathy has been described as a multi-dimensional construct. Mark Davis
included cognitive and emotional components in his view of empathy. He stated that empathy
"can best be considered as a set of constructs, related in that they all concern responsivity to
others" (15).
In 2004, when asked about “the mental mechanisms necessary to be empathetic”, the
neuroscientist Decety asserted that “Empathy is a complex mental state in which different
perceptual, cognitive, motivational and memory processes interact. There is therefore no
empathy module or specific brain region that underlies it. The model I am developing
considers that empathy is based on two major components: an innate and unconscious
disposition to feel that other people are "like us", and a conscious capacity to mentally put
ourselves in the place of others.”(16).
Consistent with the arguments above, Cuff et al. suggested in 2016 the following
definition of empathy, acknowledging the importance of both cognitive and affective factors:
“Empathy is an emotional response (affective), dependent upon the interaction between trait
capacities and state influences. Empathic processes are automatically elicited but are also
shaped by top-down control processes. The resulting emotion is similar to one’s perception
(directly experienced or imagined) and understanding (cognitive empathy) of the stimulus
emotion, with recognition that the source of the emotion is not one’s own” (17).
8
In his literature review about the conceptualization of empathy, Hojat (4) (p.11)
concluded that both cognition and emotion, otherwise understanding and feeling, are involved
in the empathy process. However, “the key feature of empathy is the predominance of
cognitive information processing” which distinguishes empathy from two other concepts that
might be confused with its definition or share some of its aspects:
- Sympathy, which is according to Hojat, a predominantly emotional attribute (4) (p.11)
(Figure 2). In his article “The distinction between sympathy and empathy”, Wispé argued that
empathy and sympathy are two different psychological processes. He also suggested that
“sympathy refers to the heightened awareness of another's plight as something to be
alleviated, whereas empathy refers to the attempt of one’s self-aware self to understand the
subjective experiences of another” (18).
Within the same perspective, Elisabeth Pacherie suggested that “Sympathy, as its
etymology indicates supposes that we take part in the emotion felt by others, that we share
their suffering or more generally their emotional experience. [...] Empathy, on the other hand,
involves imagination that aims to understand others, not to bond emotionally. Empathy can
certainly nourish sympathy, but the latter is not a necessary consequence of the former”(19).
- Compassion: According to Velluet, compassion and empathy are two terms very often
associated in writings or speeches when they denote very different mental states (20) (p.22).
Compassion involves mostly the sharing of the same feelings as others, mainly negative
feelings, and it is often associated with pity. Based on the etymology of the term, Serge
Tisseron suggests that having compassion for another means being sad with the person, while
one is empathetic when he is sad for them (21) (p.12).
9
Figure 2: Empathy and sympathy as related to cognition and emotion
In 2020, Eklund and Meranius conducted a review of literature reviews published
between 1980 and 2019 on the conceptualization of empathy. They came to the following
conclusion summarizing the four themes mostly found in empathy conceptualizations (22):
“In empathy, the empathizer (1) understands, (2) feels, and (3) shares
another person’s world (4) with self-other differentiation.”
4-Empathy in Neurosciences
It has been theoretically proposed that the human mirror neuron system (MNS) plays an
integral role in mediating empathy (23). The neurons of the MNS are “brain cells (not visual
cells) that are activated when we observe another person who is performing a goal-directed
action as if we are performing that act” (4) (p.7).
In a recent meta-analysis aiming to investigate the association between the MNS and the
cognitive and emotional components of empathy, these two were found to be moderately
correlated with MNS activity (24).
Empirical findings from brain imaging studies suggest that certain brain areas can be
involved in empathy. An fMRI based quantitative meta-analysis investigating the core neural
network in empathy found the following results: “i)-The dorsal anterior cingulate cortex–
10
anterior mid-cingulate cortex– supplementary motor area (dACC-aMCC-SMA) and bilateral
anterior insula were consistently activated in empathy; ii)-The dorsal aMCC was
demonstrated to be recruited more frequently in the cognitive-evaluative form of empathy;
iii)-The right anterior insula was found to be involved in the affective-perceptual form of
empathy only; iv)-The left anterior insula was active in both forms of empathy” (25).
III-EMPATHY IN PATIENT CARE OR CLINICAL EMPATHY
“It is much more important to know what sort of patient has a disease than what sort of
disease a patient has”. This quotation attributed to Sir William Osler (26) was among the first
descriptions of the patient-centered approach in the doctor-patient relationship.
1-The bio-psychosocial paradigm
The patient-centered approach refers today to the bio-psychosocial paradigm in
medicine, first conceptualized by George Engel in 1977, which is consistent with the
world health organization’s definition of health in 1948: “A state of complete physical,
mental, and social well-being, and not merely an absence of disease or infirmity” (27).
The bio-psychosocial paradigm suggests that to understand a patient's medical
condition in order to cure it, it is not only the biological (physiological pathology) factors
that should be considered, but also the psychological (thoughts, emotions, and behaviors)
and social factors (socio-economical, socio-environmental, and cultural factors). These
three core elements of the illness are closely in interaction with one another (28).
2-Client centered therapy
The place of empathy in patient care cannot be discussed without mentioning the
contribution of the founder of “client centered therapy”, the American psychologist Carl
Rogers.
Rogers considered empathy as a central therapeutic construct along side with
unconditional positive regard and genuineness. He described these three factors as necessary
and sufficient for therapeutic change (13) (p.3).
11
The definition of empathy suggested by Rogers is among the most cited definitions in
the scientific literature. It is "to perceive the internal frame of reference of another with
accuracy, and with the emotional components and meanings which pertain thereto, as if one
were the other person, but without ever losing the ‘as if’ condition” (29).
In patient care, both cognitive and emotional components of empathy are important and
complete one another. In her article “what is clinical empathy?”, Halpern stated that
“physicians' emotional attunement greatly serves the cognitive goal of understanding patients'
emotions” (30).
3-The moral and behavioral components of clinical empathy
Some authors cited by Stepien and Baernstein added two other components to empathy
in the clinical context: the moral and the behavioral components. Empathy can therefore be
defined at four levels: emotive, moral, cognitive, and behavioral. Stepien and Baernstein (31)
described these aspects as follows:
- Emotive: the ability to imagine patients’ emotions and perspectives;
- Moral: the physician’s internal motivation to empathize;
- Cognitive: the intellectual ability to identify and understand patients’ emotions and
perspectives;
- Behavioral: the ability to convey understanding of those emotions and perspectives
back to the patient.
4-An operational definition of clinical empathy
In order to put clear features to this vague concept, and provide a common language to
understand it, Hojat and his research team, who studied empathy for more than 20 years,
suggested the following operational definition of empathy:
“Empathy is a predominantly cognitive (rather than an affective or emotional) attribute
that involves an understanding (rather than feeling) of experiences, concerns and perspectives
of the patient, combined with a capacity to communicate this understanding, and an intention
to help.” (4) (p.74).
12
The framework of empathy, based on the 4 key features highlighted in this definition:
cognition, understanding, communication and intention to help, established the foundation to
develop the Jefferson Scale of Empathy, a worldwide used instrument to measure empathy in
patient care.
5-Benefits of clinical empathy
5-1-Benefits of clinical empathy for the patient
Clinical empathy is fundamental for the clinician–patient relationship, not only because
it is a core element of medical professionalism, but also for its profound therapeutic potential
(32).
Clinical benefits of empathy for patients have been proved by many studies in different
contexts. A study of the relationship between physician empathy and diabetes complications
found that the patients of physicians with higher empathy scores had a significantly lower rate
of acute metabolic complications (33).
Another study showed that physician empathy, perceived by patients with chronic pain,
was significantly associated with pain relief (34).
A further positive clinical outcome of physician empathy was demonstrated among
common cold patients. In fact, physician empathy was significantly linked to a shorter cold
duration, a reduced severity and a larger increase in Interleukin-8 levels (35).
Additionally, patient perceived empathy was shown to have a strong correlation with
the patients’ satisfaction (36) and their adherence to treatment (37).
Clinical empathy may also increase diagnosis accuracy and patient’s enablement (38). It
may as well decrease patient’s anxiety and distress (39).
5-2-Benefits of clinical empathy for the healthcare provider
Clinical empathy seems to have beneficial outcomes not only for the patient, but also
for the physician who shows this professional skill. In fact, empathetic doctors experience
greater satisfaction (40) and psychological well-being (41), alongside with increased
diagnosis accuracy (42) and reduced symptoms of burnout (43) and stress (44).
13
B-MEASUREMENT OF EMPATHY
Developing instruments to measure empathy has been driven by the need to find a
common language between researchers to share and discuss empirical findings on empathy
research.
As mentioned previously, the history of research on empathy has been marked by an
agreement between researchers who consider this concept as a desirable human attribute,
involving both cognition and emotion, with positive outcomes in human interaction (45).
However, there is no consensus on its definition nor a unique and precise description of its
features (46). This explains the diversity of instruments developed to measure empathy, each
covering one or several aspects of this multidimensional concept, which justifies the difficulty
to examine their validity and reliability.
Although the term of empathy was brought to discussion in psychology since 1897 (4)
(p.5), it was not until the middle of the last century that the development of the first
instruments to measure it took place (4) (p.63) (47). Thenceforth, numerous approaches have
been developed following the emergence of several related sciences and disciplines such as
social sciences, psychological sciences, neurosciences, and medical sciences. Examples of
these approaches include behavioral measures, neuro-scientific measures, and self-report or
self-administered scales, which have been most widely used so far (47). These scales were
developed for the general population to use, without consideration to demographic, social,
professional, or other characteristics; except for age. In fact, some researchers created
instruments to assess empathy in children and adolescents.
In the healthcare context, empathy used to be assessed through scales developed for the
general population, mostly the Hogan Empathy Scale, the Mehrabian and Epstein’s Emotional
Empathy Scale, and the Interpersonal Reactivity Index (4) (p.57). However, since the
development of the Jefferson Scale of Empathy (JSE), adapted specifically to the healthcare
context, it has been broadly used.
This chapter outlines most of the instruments developed to assess empathy, first in the
general population, then in the clinical practice.
14
I-MEASUREMENT OF EMPATHY IN THE GENERAL
POPULATION
1-Measurement of empathy in children
1-1-Measurement of empathy in early childhood
Self-administered scales are clearly not adapted for the use of children of early age.
Therefore, one approach to study the perception and response of young children to others
feelings is to show them pictures or tell them stories of different situations describing
individuals in different affective states, then ask them to express how they feel about these
situations verbally, or by using images reflecting a range of emotions (happiness, sadness,
fear, etc.). The empathic response is determined by a match between the child’s feelings and
the story or picture protagonist’s ones.
This method was adopted first by Eisenberg and Lennon (48), then by Feshbach and
Roe who developed the Feshbach Affective Situations Test of Empathy (FASTE), which
measures both affective and cognitive empathy for children between 6 and 7 years old (49).
In order to make these situations more tangible and believable for participants,
researchers presented the emotion-evoking stimuli via audiotapes, videotapes, or realistic
enactments. After the exposure to the evoking stimuli (e.g., a distress film), participants report
their emotional reactions through self-ratings on a mood scale with adjectives reflecting
empathy (50).
For instance, the Empathy Continuum (EC) scoring system developed by Janet Strayer
(51) is administered by showing series of video-taped emotionally evocative vignettes. After
viewing a video, the children are asked to describe the type and intensity of emotions felt by
the vignette characters, and by themselves (e.g., happy, sad, angry, afraid, surprised,
disgusted, or neutral). The EC organizes scores at seven different levels of cognitive
mediation and integrates the degree of affective sharing reportedly experienced (the Affect
Match) with the child’s cognitive attributions for these emotions (50) (52) (53). A detailed
explanation of the EC scoring system is available in Strayer and Roberts’ article (54).
15
In 2012, Reid and colleagues (55) applied a similar approach to create the Kids'
Empathic Development Scale (KEDS), a multi‐dimensional measure of empathy in primary
school‐aged children designed to assess the affective, cognitive and behavioral components of
empathy. After showing the kids scenarios depicting a range of individual and interpersonal
situations differing in complexity, they are asked questions evaluating the three
aforementioned components (47).
1-2-Measurement of empathy in middle childhood and adolescence
1-2-1-The Index of Empathy (Bryant, 1982)
In order to facilitate the study of the variation of empathy with age, Bryant (56) adapted
Mehrabian and Epstein’s emotional scale used for adults to assess empathy in children and
adolescents. This self-report scale of 22 items is called the Index of Empathy.
6- Consultation and Relational Empathy (CARE) (Mercer, Maxwell, Heaney
and Watt, 2004)
The CARE is a measure developed and validated in primary care settings as a tool for
measuring patients’ perceptions of their doctors’ relational empathy during the consultation.
It is composed of 10 items relating to three aspects of empathy: cognitive, affective, and
behavioral. Each item is followed by a short explanatory description. All the items are direct
worded, to avoid confusion, and are answered on a 5-point Likert-type scale (101).
7-The Four Habits Coding Scheme (4HCS) (Krupat, Frankel, Stein and
Irish, 2006)
Considering the need of a simple framework to help teaching clinical communication
skills, Frankel and Stein created in 1996 a model to enable clinicians to learn how to
communicate effectively and efficiently during a clinical interview. It is called the “four
habits model”: invest in the beginning, elicit the patient’s perspective, demonstrate empathy,
and invest in the end. Each habit denotes various communication tasks during clinical
encounters, organized into families of skills, techniques, and payoffs.
The purpose of these interrelated habits according to the authors is “to establish rapport
and build trust rapidly, to facilitate the effective exchange of information, to demonstrate
caring and concern, and to increase the likelihood of adherence and positive health outcomes”
(102).
26
Based on this teaching model, Krupat, Frankel, Stein, and Irish developed in 2006 the
4HCS. It evaluates clinician communication behavior and it contains 23 items derived from
the skills referred to in the four habits model.
The coders watch videotaped clinical encounters and score each item on a 5-point
behaviorally anchored rating scale by taking into account both verbal and non-verbal signals.
The midpoint (3) and the two endpoints (1 and 5) are described in specific behavioral terms,
while scale points 2 and 4 are used only if the coder thought that the clinician’s behavior fell
directly in between (103).
8-Kiersma Chen Empathy Scale (KCES) (Kiersma, Chen, Yehle and Plake,
2013)
In 2013, Kiersma and colleagues created the first version the KCES, which is a 15-item
instrument dedicated to measure empathy in pharmacy and nursing students. The items assess
both the affective and the cognitive aspects of empathy and 4 of the 15 items are negatively
worded. Each item is rated on a 7-point Likert-type scale. Higher scores on the KCES indicate
greater empathy (104).
By analyzing data from multiple administrations of the KCES, a revised version was
developed recently (the KCES-R) with 2 subscales and no negatively worded items (105).
9-Empathy and Clarity Rating Scale (ECRS) (Terregino, Copeland, Sarfaty,
Lantz-Gefroh and Hoffmann-Longtin, 2019)
The ECRS was specifically developed to evaluate the effect of Medical Improv (106) on
empathetic and clear communication among first year medical students taking the Objective
Structured Clinical Examination (OSCE).
The ECRS is 7-item where each item represents a behavior. A faculty member
comments in writing the performance of the students related to every behavior then rates them
on a 5-point scale based on the following behavioral anchors: 5=desired behaviors,
1=ineffective communication and 2–4=developing based upon adjustment needed (107).
27
In this section, we briefly described different psychometric instruments developed to
measure empathy in the general population and in the clinical context. In the latter we found
that there are mainly three approaches to measuring empathy: self-assessment, patient-
assessment and expert-assessment. A summary table of all the presented instruments is
available in the appendix.
Statistically sound self-assessment measures help the study of empathy and its factors in
the clinical context. However, there might be a discrepancy between self-administered
measures and observed empathy behaviors (108). This highlights the need to teach and
evaluate professional attitudes, including empathy, in a rather practical than theoretical way.
28
C-EMPATHY RELATED FACTORS IN THE SCIENTIFIC
LITERATURE
The development of psychometric assessments of empathy in the general population
and among health professionals, in particular the JSE, enabled researchers on the subject to
study empathy related factors and their contribution, either in the improvement or the
decrease of health care providers’ empathy in the clinical context.
In the following, we expose some of the findings from related scientific literature that
will help us later in our discussion.
I-DEMOGRAPHIC CHARACTERISTICS AND SOCIO-ECONOMIC
BACKGROUND
1-Age
The variation of empathy with age has been widely studied in the clinical context (i.e.
among medical students, physicians, health professions students, and health professionals),
using different versions of the JSE.
For instance, Williams and colleagues investigated the association between empathy
and age among 1111 first to fourth year students from 8 different health disciplines and found
that students in the age range of 25 to 29 years and 35 to 39 years recoded higher empathy
scores than their younger colleagues aged less than 20 years (p=0.015, p=0.009 respectively)
(109).
On the other side, a cross-sectional study conducted on 260 medical students in the first
to the seventh year, using the Iranian version of the JSE, concluded that empathy decreased
with the students’ age (p=0.001) (110).
Nevertheless, some studies found no correlation between empathy and age. For
example, a cross-sectional study at China Medical University compared levels of empathy
using the JSE among 902 medical students, from 1st year to 4th year, of two age groups (<22
years old and ≥22 years old). The differences between age groups were not statistically
significant (111) .
29
2-Gender
Gender has been the most studied empathy related factor in the scientific literature.
Gender studies indicate that women often score higher than men on self-assessments of
empathy (4) (p.169). However, few studies found opposite results.
In a nationwide survey assessing empathy among Korean medical students using the
JSE, 5343 questionnaires were analyzed and found that the mean total score of female
students (=2056) was higher than male students (p<0.001) (112).
The same significant results were found among medical students in other countries
(113) (114) (115) (116), nursing students (117) and post graduate physicians (118).
On the opposite side, a cross-sectional study of 94 Australian undergraduate paramedic
students found men to be more empathic than women (p=0.042) (119).
Using the same scale, other studies concluded no significant correlation between gender
and empathy, neither in medical students (120) (121) (122) nor in physicians (123) (124).
3-Family
A study investigating empathy in medical residents found that being married, having
children and having siblings were factors related to higher empathy (p=0.038, p=0.005 and
p=0.007 respectively) (125).
Another study conducted among female Japanese physicians showed that living with
parents in an extended family was associated with higher empathy scores than living alone or
living in a nuclear family (p<0.05) (126). On the other hand, family loneliness showed an
inverse correlation with empathy (127).
Furthermore, a positive relationship with the mother was associated with higher
empathy among medical students both in childhood (128) and in adulthood (127).
4-Socio-economic and cultural background
A cross-sectional survey of 264 medical students conducted in Kuwait University found
empathy scores to be significantly associated with mother’s level of education (p<0.018),
satisfactory relationship with the mother (p<0.005) and household income (p<0.005) (129).
30
Empathy as related to religion and cultural background has also been explored. A study
among nursing students showed that participants who stated that they were very religious
displayed higher empathy levels (p<0.001) (117). Yet, another study found no significant
relationship between empathy scores and the importance of religion to nursing students or
their ethnicity (130).
II-HEALTH STATUS
Although standing in patient shoes is a key feature of clinical empathy, empathy as
related to health status has been rarely studied.
Hall and colleagues investigated whether this factor affected empathy scores in
undergraduate pharmacy students. They found no significant differences in scores for
participants who had a chronic condition or used regular medication in comparison to those
who did not (131).
III-PERSONALITY AND PERSONAL QUALITIES
1-Personality
Psychology considers openness, consciousness, extraversion, agreeableness, and
neuroticism as the principle dimensions of a normal personality (132). The NEO‑Five Factor
Inventory (NEO-FFI) is the short version of an instrument (NEO-PI) measuring these five
dimensions (133). Many researchers used this assessment tool to study the relationship
between empathy and personality. A positive and significant association was found between
empathy and extraversion, openness to experience, agreeableness, and conscientiousness
(132) (134) (135) (136) (137).
Using the five personality scales of the Zuckerman–Kuhlman Personality Questionnaire
(ZKPQ), Isenberg and colleagues found a positive correlation between empathy (measured by
the JSE) and sociability, as well as a negative correlation between empathy and aggression-
hostility (138). These results are in agreement with those reported by Hojat and colleagues
(128).
31
Similar patterns of findings were reported by Dávila-Pontón and colleagues using the
Millon Index of Personality Styles (MIPS), which allows the measurement of 24 personality
styles grouped into three areas: motivational goals, cognitive modes, and interpersonal
behavior. They found a positive relationship between empathy and some motivational goals
(i.e. openness, modification, protection) and an inversely proportional relationship with some
others (i.e. preservation, accommodation, and individualism) (139).
The Temperament and Character Inventory (TCI) subscales (i.e. reward dependence,
persistence, cooperativeness, self-transcendence, and self-directedness) were positively and
significantly associated with JSE score. In contrast, harm avoidance, another TCI subscale,
was negatively linked to empathy (140).
However, another study found no significant association between empathy (JSE) and
any of the personality dimensions measured by the ZKPQ (129).
2-Personal qualities
It is likely that empathy has a positive link with personal qualities that promote
interpersonal relationships and a negative link with personal qualities that impede them. This
assumption has been demonstrated through scientific studies. In fact, the positive relationship
between empathy and emotional intelligence in the clinical context has been proved in many
studies (124) (141) (142) (132). Also, empathy was found to have a positive and significant
association with grit and self-esteem (138).
IV-STRESS, DISTRESS AND BURNOUT
Higher self-reported stress level measured by the Perceived Stress Scale (PSS) was
associated with less perceived empathy (JSPPPE) among surgeons (143). It was also
negatively correlated to self-reported empathy scores (JSE) among medical students (144).
The same correlation was found between empathy and distress in a sample of 537 first year
residents (145).
Using the Maslach Burnout Inventory (MBI), many studies found a negative correlation
between empathy levels and emotional exhaustion (125) (146) (147), as well as
depersonalization (125) (146) (147) (148) (149) (150) (151); and a positive correlation
between empathy levels and personal accomplishment (146) (147) (148) (149) (150) (151).
32
V-ACADEMIC AND PROFESSIONAL CHARACTERISTICS
1-Motivation for a medical career
The underlying behavioral motivation to be empathic in healthcare is likely altruism.
The relationship between empathy and motivation for medicine was studied in a sample of
202 first-year Portuguese medical students, using the JSE and the Vaglum and colleagues’
indexes on motives for choosing medicine: the people orientated, the status/security orientated
and the natural science orientated motives (152). The people oriented index was positively
correlated with the JSE total score (p<0.001), the perspective taking subscale (p<0.05) and the
compassionate care subscale (p<0.05). On the other hand, the status/security index was
negatively correlated with the JSE total score (p<0.01), the compassionate care subscale
(p<0.05), and the standing in the patient’s shoes subscale (p<0.05) (153).
Using the Academic Motivation Scale (AMS), a measure of extrinsic and intrinsic
motivation and amotivation in education (154), Findyartini and colleagues studied the
relationship between empathy and motivation type among undergraduate medical students.
They found that the more the motivation profile is oriented towards being low intrinsic and
low controlled, the lower are the empathy scores (155).
2-Changes in empathy during medical school and residency
In a systematic review of studies published between 1990 and 2010 concerning empathy
in medical students and residents, the authors concluded that the reviewed articles, especially
those with longitudinal data, suggested that empathy decreases during the course of medical
school, particularly in the clinical phase, and during residency (156). Furthermore, a
longitudinal study noticed that the decline in empathy was lower for students with a higher
JSE scores at the beginning of medical school than for students with lower baseline empathy
scores (157).
During the last decade, many researchers noted a decline in empathy during medical
school especially in clinical years (4) (p.124) (158) (159) (160) (122) and during residency
(161). However, an increase in empathy scores during the course of medical school was also
observed in some studies (162) (163), while other ones found no significant association
between empathy scores and medical school level (164) (165) or residency level (166) (167).
33
3-Academic performance
Academic performance represented in grade point average was found correlated to self-
reported empathy (p=0.001) in a sample of 196 nursing students in Colombia (168). A Similar
study among medical students in Kuwait found no statistical correlation between the two
variables (129).
4-Clinical competence
Clinical competence is the basic component of medical professionalism. The association
between its indicators and empathy has been outlined in multiple studies.
In a study with third-year medical students, researchers reported a statistically
significant relationship between the students’ JSE scores and the faculty’s global ratings of
their clinical competence (169).
Casas and colleagues examined the association between self-reported empathy in
medical students and clinical competence evaluated by the OSCE score. They found that JSE
scores among medical students were positively associated with the OSCE communication
scores and also predictive of the overall OSCE score (170).
Using the same assessment tools, another research team found a strong association
between the behavioral manifestation of empathy rated by an independent observer and
clinical competence. However, Self-rated empathy was not associated with clinical
competence (171).
5-Empathy enhancing formal training
It is undeniable that training on any skill may lead to its improvement among the
trainees. In the scientific literature, the methods adopted to teach empathy varied from the
theoretical lectures to the use of virtual patients and videogames. Many studies showed an
increase in empathy after training.
Low empathy scores were usually observed among anesthesiologists (4) (p.114).
Canales and colleagues introduced humanism curriculum into their anesthesiology residents’
training. The effectiveness of the curriculum was evaluated with a pre and a post-program
34
assessment using the JSPPPE. Empathy scores increased with a median improvement of 12
points (p=0.013) (172). The same study population was targeted in Lamiani and colleagues
work. They implemented a 10 hours program (the program to enhance relational and
communication skills in intensive care units) after which residents reported a significant
improvement in empathy scores (173).
Similarly, three different studies among three different populations demonstrated the
efficacy of a communication skills training program on the improvement of empathy: medical
students (p<0.001) (174), oncologists (p<0.01) (175) and attending physicians (p<0.001)
(176).
Gineste and Marescotti developed in 1979 a multimodal comprehensive care
methodology called the Humanitude™ care methodology (177). Kobayashi and colleagues
studied the impact of a program based on this methodology on the improvement in empathy
toward people with dementia among oral health care professionals. They reported a
significant improvement in empathy scores in post-training compared to pre-training scores
(178). The same patterns of results were found among a sample of medical students (179).
The implication of the patient in medical training has been considered lately (180). A
patient-led educational program on Tourette Syndrome had a positive impact on residents’
empathy (181).
The effect of immersive simulation experience has been explored as well. Yu and
colleagues investigated whether a pregnancy experience program simulating physical changes
in a mother during the last trimester of pregnancy could increase empathy among healthcare
students. Another research team studied the effectiveness of this method in fostering empathy
among psychiatry residents towards elderly population using an aging simulation suit. Both
teams found this method to be effective to improve empathy (182) (183).
Gamification has also been used to teach empathy with beneficial impact in medical
context, mainly animated comics (184), video games (185) and forum theater staging (186).
35
6-Informal education and hidden curriculum
In her thesis dissertation, Marot reported that medical interns who benefited from
informal education, i.e. knowledge and experiences acquired at the hospital during internships
(visits, corridor discussions, staff meetings), scored higher on the JSE (151).
In an attempt to understand the causes of the decline of empathy during medical school,
Eikeland and colleagues conducted a qualitative study among third year medical students.
They concluded that empathy inhibitors may emerge in the hidden curriculum (42).
For instance, a study found that residents who developed a professional model in
doctor-patient relationship and had met healthcare professionals who helped them build such
model had higher empathy scores. The same result was demonstrated among residents who
experienced positive encounters with other healthcare professionals, either in their personal
life or during professional training (187). Similarly, in a sample of nursing students,
participants who were trained by clinical instructors who approached patients with emotional
understanding demonstrated statistically significant higher levels of empathy (117).
Brazeau and colleagues studied the relationship between medical students’ empathy and
their perception of the learning environment, assessed with the Professionalism Climate
Instrument (PCI). A significant positive correlation was found between medical students’
empathy scores and PCI scores (147). Also, higher levels of residents' empathy were
significantly associated with their positive perception of the faculty's teaching performance
(188).
7-The physician’s specialty
The person-oriented versus technique-oriented taxonomy is a broadly used specialty
classification system in the scientific literature (189).
Among medical students, empathy (measured by the JSE) was found to be significantly
associated with intentions to pursue person-oriented instead of technique-oriented specialties
after graduation in many studies (114) (128) (157) (162) (164) (190).
36
In parallel, physicians in training and practicing physicians in person-oriented specialties obtained a significantly higher JSE mean score than their counterparts in technique-oriented specialties (125) (126) (191) (192).
Other studies among students found no significant differences in empathy with regard to
specialty interest (140) (163).
8-Psychosocial work environment
The impact of work-related stress measured by effort-reward imbalance was studied
among a sample of Chinese nurses. It was negatively associated with empathy (193).
The impact of exposure to verbal or physical workplace violence has also been studied.
Nam and colleagues found that healthcare workers who experienced verbal violence or
physical violence or both had lower JSE scores (p<0.05) (194).
9-Other aspects of medical professionalism
Empathy had a positive correlation with life-long learning (187) (195), teamwork (196),
and inter-professional collaboration (196) (197).
VI-EXTRACURRICULAR ACTIVITIES
1-Volunteerism
Volunteerism was demonstrated to be correlated with higher empathy in the clinical
context (198) (199) (200). It was also proven to prevent empathy decline among medical
students (201).
2-Wellness activities
Wellness activities, such as practicing mindfulness, improved empathy among health
care students (202) and professionals (203). Empathy was also linked positively and
significantly to regular sport activity (151).
37
3-Exposure to humanities in a formal or informal way during medical school
Mangione and colleagues studied the impact of exposure to humanities (e.g. literature,
music, theater, and arts) on medical students. They found that students with higher exposure
to humanities had higher levels of empathy (204).
Similar patterns of findings were reported by Graham and colleagues. Using
comparison groups, they studied the impact of a medical humanities coursework on the
development of empathy among medical students. The coursework correlated with improved
empathy outcomes (205).
Through this section we showed that, in empathy related factors research, some aspects
of health care provider related factors received more attention such as gender, specialty and
burnout. Other aspects related to training, work environment and patient were less studied.
38
Materials and Methods
39
I-STUDY DESIGN
1-Study type
We conducted a cross sectional observational study with prospective data collection,
using a web-based survey (206).
2-Period
Data was collected between March and July 2019.
3-Site
This study took place at the University Hospital Ibn Sina (UHIS) in Rabat, the capital of
Morocco. This medical establishment is the teaching hospital for the Faculty of Medicine and
Pharmacy of Rabat, where medical students undertake their internships and residents undergo
the residency program.
The UHIS is a tertiary care center which provides diagnosis and treatment, alongside its
academic and research functions. It has 2,347 beds and employs 6,536 staff members. It
carries 328,730 medical encounters, performs 30,054 surgical interventions and 25,379 births
per year (207).
Ten interconnected hospitals operate in affiliation with the UHIS, which are:
- Ibn Sina Hospital: the functional structure of this hospital can be divided into three
main department groups:
- Thirteen administrative departments
- Inpatient departments: include 13 surgical departments, 10 medical departments
and 4 Emergency-Resuscitation departments.
- Medico-technical departments: include 5 medical laboratories, 2 radiology
departments, a functional exploration department, a nuclear medicine
department and a medical consultation center.
40
The hospital also includes a central operating room, an emergency operating room and a
pharmacy. In addition, the hospital has 10 consultative bodies which provide support and
advice on its management (208).
- The Specialties Hospital offers care in 5 specialties related to head and neck diseases:
neurology and its subspecialties (neurophysiology, neuroradiology, and neuro-genetics),
neurosurgery, oto-rhino-laryngology, maxillofacial surgery and ophthalmology. Its functional
SWLS items Mean ± SD Item 1 In most ways my life is close to my ideal 3.6±1.7
Item 2 The conditions of my life are excellent 3.4±1.6
Item 3 I am satisfied with my life 4.2±1.6
Item 4 So far I have gotten the important things I want in life 4.4±1.7
Item 5 If I could live my life over, I would change almost nothing 3.9±1.8
SWLS total score 19.7±6.4
Table 5 : Satisfaction with life measured by the SWLS
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II-NON-CLINICIAN RELATED FACTORS
1-Workload
1-1-Work hours per week
Variables N (%) Work hours per week 30-50 hours per week 50-70 hours per week >70 hours per week
43(41.7%) 30(29.1%) 30(29.1%)
Table 6 : Work hours per week
1-2-Healthcare activities
Variables N (%) On-call shifts Never 1/month 1/week >2/week
2(1.9%)
16(15.5%) 48(46.6%) 37(35.9%)
Consultation Never 1/month 1/week >2/week
10(9.7%) 18(17.5%) 43(41.7%) 32(31.1%)
Participating in teaching rounds and morning report Never 1/month 1/week >2/week
1(1%)
7(6.8%) 35(34%)
60(58.3%)
Table 7 : Healthcare activities
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1-3-Scientific activities
Variables N (%) Giving grand rounds presentations Never 1/month 1/week >2/week
38(36.9%) 44(42.7%) 16(15.5%)
5(4.9%) Tutoring medical students Never 1/month 1/week >2/week
25(24.3%) 26(25.2%) 24(23.3%) 28(27.2%)
Participating in research projects Never 1/month 1/week >2/week
42(40.8%) 40(38.8%) 12(11.7%)
9(8.7%)
Table 8 : Scientific activities
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2-Patient related factors
Variables N (%) Misbehavior inside the healthcare structures Never Occasionally Sometimes Often Always
2(1.9%)
19(18.4%) 27(26.2%) 37(35.9%) 18(17.5%)
Illiteracy Never Occasionally Sometimes Often Always
6(5.8%)
22(21.4%) 22(21.4%) 38(36.9%) 15(14.6%)
Unwillingness to change bad habits Never Occasionally Sometimes Often Always
3(2.9%)
17(16.5%) 38(36.9%) 34(33%)
11(10.7%) Adherence to popular beliefs Never Occasionally Sometimes Often Always
2(1.9%)
22(21.4%) 34(33%)
28(27.2%) 17(16.5%)
Inability to understand medical terminology Never Occasionally Sometimes Often Always
7(6.8%) 35(34%)
23(22.3%) 24(23.3%) 14(13.6%)
Language barrier Never Occasionally Sometimes Often Always
15(14.6%) 41(39.8%) 14(13.6%) 21(20.4%) 12(11.7%)
Ambiguity of patients’ expectations Never Occasionally Sometimes Often Always
5(4.9%)
41(39.8%) 27(26.2%) 20(19.4%) 10(9.7%)
Improper adherence to the medical prescription Never Occasionally Sometimes Often Always
3(2.9%)
31(30.1%) 41(39.8%) 23(22.3%)
5(4.9%)
Table 9 : Patient related factors
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3-Professional requirements
Variables N (%) Time requirements Never Occasionally Sometimes Often Always
6(5.8%)
17(16.5%) 33(32%)
18(17.5%) 29(28.2%)
Cognitive demands Never Occasionally Sometimes Often Always
2(1.9%)
21(20.4%) 24(23.3%) 39(37.9%) 17(16.5%)
Emotional demands Never Occasionally Sometimes Often Always
12(11.7%) 44(42.7%) 20(19.4%) 17(16.5%) 10(9.7%)
Responsibilities Never Occasionally Sometimes Often Always
5(4.9%)
13(12.6%) 19(18.4%) 34(33%)
32(31.1%) Social demands Never Occasionally Sometimes Often Always
4(3.9%)
14(13.6%) 27(26.2%) 38(36.9%) 20(19.4%)
Ethical requirements Never Occasionally Sometimes Often Always
26(25.2%) 33(32%)
25(24.3%) 13(12.6%)
6(5.8%) Physical requirements Never Occasionally Sometimes Often Always
4(3.9%)
25(24.3%) 15(14.6%) 37(35.9%) 22(21.4%)
Table 10 : Professional requirements
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4-Resources and organizational factors
Variables N (%) Lack of resources Never Occasionally Sometimes Often Always
1(1%)
9(8.7%) 11(10.7%) 35(34%)
47(45.6%) Lack of collaboration between healthcare institutions Never Occasionally Sometimes Often Always
2(1.9%)
10(9.7%) 11(10.7%) 45(43.7%) 35(34%)
Lack of collaboration between healthcare professionals Never Occasionally Sometimes Often Always
4(3.9%)
18(17.5%) 22(21.4%) 35(34%)
24(23.3%) Workplace organizational issues Never Occasionally Sometimes Often Always
3(2.9%)
11(10.7%) 23(22.3%) 28(27.2%) 38(36.9%)
Table 11 : Resources and organizational factors
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5-Psychosocial work environment
Variables N (%) Moral violence Never Occasionally Sometimes Often Always
10(9.7%) 35(34%)
29(28.2%) 23(22.3%)
6(5.8%) Abuse of authority Never Occasionally Sometimes Often Always
17(16.5%) 32(31.1%) 20(19.4%) 17(16.5%) 17(16.5%)
Lack of recognition Never Occasionally Sometimes Often Always
6(5.8%)
22(21.4%) 27(26.2%) 33(32%)
15(14.6%) Lack of support Never Occasionally Sometimes Often Always
6(5.8%)
21(20.4%) 12(11.7%) 33(32%)
31(30.1%) Physical violence Never Occasionally Sometimes Often Always
80(77.7%) 18(17.5%)
3(2.9%) 0(0%)
2(1.9%) Sexual harassment Never Occasionally Sometimes Often Always
83(80.6%) 15(14.6%)
4(3.9% 1(1%) 0(0%)
Table 12 : Psychosocial work environment
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6-Professional risk
Variables N (%) Being victim to an occupational exposure Yes No
36(35%) 67(65%)
Table 13 : Occupational exposure
III-MOTIVATION
Variables N (%) Social approval and prestige Not at all Little Somewhat Much
34(33%)
41(39.8%) 15(14.6%) 13(12.6%)
Job security Not at all Little Somewhat Much
17(16.5%) 28(27.2%) 31(30.1%) 27(26.2%)
Financial success Not at all Little Somewhat Much
20(19.4%) 34(33%) 35(34%)
14(13.6%) Desire to help others (altruism) Not at all Little Somewhat Much
2(1.9%) 5(4.9%)
32(31.1%) 64(62.1%)
Develop scientific skills Not at all Little Somewhat Much
6(5.8%) 9(8.7%)
29(28.2%) 59(57.3%)
Use personal abilities and talents Not at all Little Somewhat Much
7(6.8%)
14(13.6%) 36(35%)
46(44.7%)
Table 14 : Motivation to pursue a medical career
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IV-FORMAL EDUCATION AND HIDDEN CURRICULUM
1-Formal education
Variables N (%)/Mean ± SD Opinion on the relative importance accorded to knowledge, know-how, and social skills during the medical curriculum Knowledge Know-how Social skills
6.7±2 6.1±2.6 4.8±3.1
Training on doctor-patient relationship Yes No
37(35.9%) 66(64.1%)
Table 15 : Formal education
2-Hidden curriculum
Variables N (%) Meeting clinical role models Never Occasionally Sometimes Often Always
1(1%)
39(37.9%) 46(44.7%) 15(14.6%)
2(1.9%) Meeting humanistic role models Never Occasionally Sometimes Often Always
1(%)
48(46.6%) 33(32%)
20(19.4%) 1(1%)
Meeting negative clinical models Never Occasionally Sometimes Often Always
4(3.9%)
44(42.7%) 35(34%)
18(17.5%) 2(1.9%)
Meeting negative humanistic models Never Occasionally Sometimes Often Always
2(1.9%)
45(43.7%) 34(33%)
18(17.5%) 4(3.9%)
Table 16 : Learning environment
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3-Satisfaction with the medical training
Variables N (%) Satisfaction with the medical training Not at all Very little Somewhat Definitely
32(31.1%) 47(45.6%) 23(22.3%)
1(1%)
Table 17 : Satisfaction with the medical training
V-EMPATHY MEASURED BY THE JSE (HP-version)
JSE items Mean ± SD Item 1 My understanding of how my patients and their families feel does not influence medical or surgical treatment
3.5±1.7
Item 2 My patients feel better when I understand their feelings 5.5±1.3
Item 3 It is difficult for me to view things from my patients' perspectives 3.9±1.5
Item 4 I consider understanding my patients' body language as important as verbal communication in physician-patient relationships
5.1±1.4
Item 5 I have a good sense of humor that I think contributes to a better clinical outcome
4.6±1.5
Item 6 Because people are different, it is difficult for me to see things from my patients' perspectives
3.8±1.6
Item 7 I try not to pay attention to my patients' emotions in history taking or in asking about their physical health
3.5±1.8
Item 8 Attentiveness to my patients' personal experiences does not influence treatment outcomes
3.4±1.7
Item 9 I try to imagine myself in my patients' shoes when providing care to them
4.7±1.7
Item 10 My patients value my understanding of their feelings which is therapeutic in its own right
5.4±1.1
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Item 11 Patients' illnesses can be cured only by medical or surgical treatment; therefore, emotional ties to my patients do not have a significant influence on medical or surgical outcomes
2.2±1.4
Item 12 Asking patients about what is happening in their personal lives is not helpful in understanding their physical complaints
2.5±1.5
Item 13 I try to understand what is going on in my patients' minds by paying attention to their non-verbal cues and body language
4.6±1.6
Item 14 I believe that emotion has no place in the treatment of medical illness
2.2±1.4
Item 15 Empathy is a therapeutic skill without which success in treatment is limited
4.5±1.7
Item 16 An important component of the relationship with my patients is my understanding of their emotional status, as well as that of their families
5.2±1.3
Item 17 I try to think like my patients in order to render better care 4.3±1.6
Item 18 I do not allow myself to be influenced by strong personal bonds between my patients and their family members
4.9±1.4
Item 19 I do not enjoy reading non-medical literature or the arts 2.7±1.6
Item 20 I believe that empathy is an important therapeutic factor in medical or surgical treatment
5.5±1.4
JSE total score 96.9±13.4 JSE - Perspective Taking 49.8±8.3 JSE - Compassionate Care 38.8±6.7 JSE - Standing in Patient’s Shoes 8.2±2.7
Table 18 : Empathy measured by the JSE (HP-version)
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C-UNIVARIATE ANALYSIS
In this section, we report the variables that showed a significant relationship with
empathy.
I-PREDICTIVE VARIABLES OF EMPATHY
In the univariate analysis, the JSE total score was positively and significantly associated
with age, male gender, higher socio-economic status, higher father educational level,
abstaining from smoking, higher training level, absence of exposure to a professional risk and
a better opinion on training in social skills. On the other hand, the JSE total score was
negatively and significantly associated with more work hours per week and exposure to
physical violence at work.
Variables β coefficient 95% Confidence interval p-value Lower Upper Age 0.9 0.03 1.8 0.04 Gender Men 6.6 1 12.2 0.02 Women Reference Socio-economic status 7.4 1 13.8 0.02 Father educational level 4.2 0.4 8.1 0.03 Smoking habit No 12.5 4.3 20.6 0.003 Yes Reference Training level 1.9 0.2 3.6 0.03 Work hours per week -4.7 -7.7 -1.7 0.002 Physical violence -4 -7.7 -0.4 0.03 Professional risk No 8.6 3.4 13.9 0.001 Yes Reference Importance accorded to social skills 1.2 0.4 2 0.004
Table 19 : Univariate analysis of the predictors of empathy
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II-PREDICTIVE VARIABLES OF PERSPECTIVE TAKING
JSE subscale Perspective Taking was positively and significantly associated with male
gender, higher socio-economic status, abstaining from smoking, and absence of exposure to a
professional risk. It was negatively and significantly associated with more work hours per
week and being on-call more frequently.
Variables β coefficient 95% Confidence interval p-value Lower Upper Gender Men 4 0.5 7.5 0.02 Women Reference Socio-economic status 5.2 1.2 9.1 0.01 Smoking habit No 6.2 1 11.4 0.02 Yes Reference Work hours per week -3.6 -5.5 -1.8 <0.001 On-call -2.3 -4.4 -0.1 0.036 Professional risk No 6.3 3 9.5 <0.001 Yes Reference
Table 20 : Univariate analysis of the predictors of Perspective Taking
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III-PREDICTIVE VARIABLES OF COMPASSIONATE CARE
JSE subscale Compassionate Care was positively and significantly associated with
higher father educational level, abstaining from smoking, higher training level and a better
opinion on training in knowledge, know-how and social skills. On the other hand, it was
negatively and significantly associated with exposure to physical violence at work.
Smoking habit No 5.4 1.2 9.5 0.01 Yes Reference Training level 1 0.1 1.8 0.02 Physical violence -2.2 -4 -0.4 0.01 Importance accorded to knowledge 0.6 0.005 1.3 0.048
Importance accorded to know-how 0.5 0.02 1 0.04
Importance accorded to social skills 0.6 0.2 1 0.001
Table 21 : Univariate analysis of the predictors of Compassionate Care
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IV-PREDICTIVE VARIABLES OF STANDING IN PATIENTS’
SHOES
JSE subscale Standing In Patients’ Shoes was negatively and significantly associated
with the following patient related factors: illiteracy, unwillingness to change bad habits, low
health literacy, misbehavior inside healthcare structures, language barrier, and ambiguity of
patients’ expectations.
Variables β coefficient 95% Confidence interval p-value Lower Upper Illiteracy -0.8 -1.7 -0.005 0.049 Unwillingness to change bad habits
-1 -2 -0.1 0.03
Low health literacy -1.5 -2.3 -0.6 <0.001 Misbehavior -1.1 -2 -0.1 0.02 Language barrier -0.4 -0.8 -0.03 0.03 Ambiguity of expectations -1.9 -2.8 -1 <0.001
Table 22 : Univariate analysis of the predictors of standing in patients’ shoes
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D-MULTIVARIATE ANALYSIS
In the multivariate analysis, male gender (β=9.7; p<0.001), higher socio-economic
status (β=6.7; p=0.02), better opinion on training in social skills (β=0.9; p=0.02) and altruistic
motivation to pursue a medical career (β=4.2; p=0.01) were significant predictors of higher
levels of empathy. However, workload represented in longer working hours (β=-4.1; p=0.006)
was negatively linked to empathy.
Variables β coefficient 95% Confidence interval
p-value Lower Upper Gender Men 9.7 4.7 14.6 <0.001 Women Reference Socio-economic status 6.7 1.1 12.2 0.02 Training level 1.1 -0.4 2.6 0.2 Importance accorded to social skills 0.9 0.2 1.6 0.02
Work hours per week -4.1 -7 -1.2 0.006 Physical violence -2.8 -6 0.3 0.08 Altruistic motivation 4.2 0.9 7.6 0.01 Motivation for financial success -2.2 -4.7 0.3 0.08
Table 23 : Multivariate analysis of the predictors of empathy
94
Discussion
95
I-JSE MEAN SCORE
The overall mean score of empathy measured by the JSE (HP-version) was 96.9±13.4
out of 140.
The physicians in training at the UHIS demonstrated an average empathy score close to
the mean JSE score of 300 interns and residents training at the university hospital of another
Moroccan city (Fes) (94.7±17) (228).
When compared to other countries, our findings suggested that the physicians in
training from our sample had lower mean empathy level than the physicians in training in
some European countries such as France (106.3±12.4) (227), Romania (113.4±14.4) (229),
Spain (114±13) (187), and Portugal (116.4±12.8) (230), as well as some Asian countries such
as Pakistan (103±13) (167), Singapore (104.9±13.2) (146) and China (107.06±11.61) (145).
This score difference might be attributed to the use of a French version of the scale non
validated in the Moroccan context, even though using this version is justified considering the
fact that French is the language of instruction and daily communication in Moroccan
healthcare institutions.
Other than the aforementioned reason, the variability in JSE scores may also be related
to cultural distinctiveness, as well as the educational system and the healthcare context
specificities, considering the reality of the educational and healthcare systems in Morocco.
1-Cultural factors
Hojat hypothesized that the disparity among physicians’ empathy levels from different
countries may be explained by socio cultural differences (4) (p.109).
Shutzberg stated that there are three main metaphors and models of the doctor-patient
relationship, depending on the distribution of power each one represents: the paternalist
model, the consumer model, and the partnership model (231). The paternalist model does not
refer to an affective relationship as in patent-child relationship, but puts power in the
physician’s side as in a parent-child disciplinary interaction.
96
Morocco is a country where hierarchical structures persist. Thus, a paternalist doctor-patient relationship is rather dominant. This can be attributed to the patriarchal and authoritarian nature of the healthcare system, influenced by the Francophone colonial heritage that shaped the Moroccan public services in general.
The paternalist physician-patient relationship is a vertical one in which the physician has an authority over his patient. In this model, physicians order and patients obey, making the expression of empathy less important. Moreover, in this kind of interaction, asking for the patient’s input may suggest the physician’s uncertainty or lack of competence (4) (p.148.). This could reflect in the physicians’ responses to the JSE (232).
Since independence, many positive changes have taken place in the Moroccan society, which may have gradually promoted the shifting from a paternalist to a partnership model in the physician-patient relationship. However, the residuals of the traditional model and the high illiteracy rate (32.2% of the Moroccan population was illiterate in 2014 (233)) may impair the transition to shared decision-making. For instance, a study of Moroccan patients with cancer found that only 5.5% of a population of 272 patients participated actively in the therapeutic decision and 94% declared that the therapeutic strategy adopted by their doctor is the right one and represents the optimal option. The main causes that explained the non-participation in the therapeutic decision were the low level of education, non-receptivity to information as well as major defects in the transmission and perception of information (234).
Another study showed that Japanese patients preferred their physician to be calm and unemotional (235). This raises the question on how far societal characteristics impact empathy and JSE scores in different cultural atmospheres.
In their review of the patient-physician relationship in specific cultural settings, Abouqal et al. presented two dimensions, namely power distance and individualism, of the multidimensional model of national culture by Geert Hofstede (236).
In fact, the Power Distance Index measures “the extent to which the less powerful members of institutions and organizations within a country expect and accept that power is distributed unequally”. At a score of 70, Morocco is a hierarchical society (237). This means that people are more likely to accept authority in the medical context with no need for further justification (236).
97
On the other hand, the Individualism versus Collectivism Index addresses the “degree of
interdependence a society maintains among its members”. Morocco is considered a
collectivistic society with an index score of 46 (237). Therefore, unanimity regarding
healthcare decisions might be difficult to achieve when many members of the patient’s family
enforce their opinions over his/her wishes (236).
Whether the cultural differences hold practical significance for empathy and JSE scores
in different cultural environments requires further study. Nonetheless, the concept of empathy
as a construct and the expression of empathy in different cultures may partially explain the
score disparities between the different countries. This implies that comparisons of empathy
scores without considering cultural differences with other countries (especially the USA,
where the JSE was developed and the studies usually compare to) may not be meaningful
(232). It also stresses the importance of a cross-cultural validation of the JSE in the Moroccan
context.
2-Educational system
Another possible explanation of our results lies in the medical educational context in
Morocco, from admission to graduation.
In Moroccan medical schools, selection is based exclusively on academic merit.
Therefore, the admission process might select students with less humanitarian motivations.
Furthermore, the humanistic aspects of the medical practice receive poor attention in the
medical curriculum. For instance, courses related to doctor-patient relationship are arranged in
the lower grades and consist of lectures of few hours. In fact, 64.1% of our study population
declared that they didn’t receive any training on doctor-patient relationship during their whole
curriculum.
At the end of the medical curriculum, the residency program evaluation in Morocco
focuses on clinical theoretical and practical knowledge. Consequently, physicians in training
do not usually put much effort into aspects on which they will not be judged in order to
graduate.
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Conversely, in Portugal, holding one of the highest JSE scores previously presented,
doctor-patient relationship training is integrated in the medical curriculum and empathy is
regularly evaluated in some universities through a research program (238).
3-Healthcare context
As mentioned earlier, notable efforts have been made to improve the Moroccan
healthcare system and the conditions of training and practice of Moroccan physicians.
However, efforts are still needed to overcome the major healthcare system issues such as
inequalities in access to healthcare services, the lack of defined professional models, disparity
between healthcare resources and the social demand that exposes physicians to work
overload.
In fact, more than half our study population reported working more than 50 hours per
week. Moreover, the participants claimed dealing in their daily practice with the lack of
resources and adverse psychosocial work environment. Job uncertainty is another feature that
may add to the physicians in training occupational stress and therefore impact their empathy,
as demonstrated by a study carried in Shanghai (239).
These factors, in addition to the differences in socio-economical conditions, may
explain the low development of empathy among physicians in Morocco compared to other
countries.
99
II-EMPATHY RELATED FACTORS
1-Empathy and clinician related factors
Using multivariate analysis, we attempted to better understand the association between
empathy and socio-demographic characteristics, professional characteristics, workload,
psychosocial work environment, motivation, and training. We built a model inspired from
Hojat’s systemic paradigm of empathy in patient care (4) (p.259).
We discuss the contribution of each factor in the light of existing literature.
Figure 32 : Empathy related factors among physicians in training:
multiple regression analysis results
100
1-1-Gender
Our results demonstrated that male physicians in training had higher mean empathy
scores (101±11.3) than their female counterparts (93±13.8) (β=9.7; p<0.001).
Gender-based difference in empathy measure in favor of men contradicts the general
trend of empirical findings reported in the literature. Many studies among medical students,
physicians in training, practicing physicians and healthcare professionals in different cultural
backgrounds found that women are more empathic than men (231) (192) (240) (241) (162)
(41) (119). Previous researches have put forward two non-exclusive explanations for the
association found between female gender and higher empathy. One is based on evolutionary
factors and biological gender differences suggesting that females are born predisposed to
acting empathically. The second is related to the differences between genders in social
learning and role expectations that prompt females to develop empathetic traits and behaviors
(240) (231).
However, our finding was supported by some previous studies in which male medical
students (242), paramedic students (119), dental students (243) (244) and physicians (245)
attained higher JSE scores than their female counterparts.
Figure 33 : Differences in empathy scores according to gender
101
One possible explanation could be the uneven gender distribution of our study sample, which resulted in the females’ score distribution being wider than that of the males. In fact, the difference between the lowest and highest scores was 43 points among men and 71 points among women (figure 33). The female sample was consequently more heterogeneous. Contrariwise, male physicians in training with particular interest in the subject matter might have chosen to participate in this study, which reflected on their empathy scores.
Rashid et al. suggested that the gender difference in empathy levels in favor of male physicians may be attributed to higher fatigue, stress and social responsibilities among women in the Pakistani context (245). Other studies found that women in healthcare professions are more at risk of factors negatively linked to empathy such as somatization (246), burnout (247), stress (248), distress (145), anxiety and depression (249); and that men had higher psychological capital (145) and a better perception of their quality of life (250), suggesting that women are more vulnerable to a difficult work environment.
Our study did not investigate these aspects, but some of our findings could explain the gender differences in the JSE scores. Women in our sample perceived that they are low skilled for their tasks, and reported higher self-doubt and increased responsibility for their training level, indicating a negative self-perception; whereas a study among healthcare professionals indicated that empathy was positively linked to self-esteem (251). Also, women in our study were more exposed to physical violence and sexual harassment at work. A previous research reported that healthcare workers who experienced verbal or physical violence had lower levels of empathy (194). Additionally, the sampled women had lower perceived quality of life in both physical and mental dimensions, which may explain their decreased empathy scores considering that well-being is positively associated with altruistic professional values according to some researchers (250).
It is relevant to mention that some studies found no significant difference in empathy scores in relation to gender in the healthcare context (125) (241) (41).
The cause of gender difference in empathy remains a subject of debate. Further studies should examine whether this divergence is attributed to biological and social gender disparities, or to individual differences. In the latter case, targeted empathy education may be able to foster medical trainees with empathy and reduce the gender gap.
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1-2-Socioeconomic level
In our study, higher socioeconomic background was significantly associated with a
higher empathy score (β=6.7; p=0.02). This could be explained by the fact that higher
socioeconomic status was found to be significantly associated with better satisfaction with life
(β=4.3; p=0.006) and higher quality of life in both its physical (β=2.9; p=0.2) and mental
(β=4.2; p=0.08) components. Family economic support may have helped in reducing job
insecurity related stress, as physicians in training from a high socioeconomic background in
our sample reported suffering less from financial issues and lack of social support.
A study conducted among medical students in Kuwait found similar results. They
reported a significant positive relationship between monthly household income and students’
empathy. The authors argued that people with economic hardship consider that society has
ignored them; therefore, they develop passive attitudes and behaviors towards their society
and overlook their compatriots (129). Another study evoked that salary dissatisfaction may
explain the high burnout level among Chinese residents, which was associated with low
empathy (239).
2-Empathy and non clinician related factors
2-1-Work-load
More than half our study population worked over 50 hours per week, which is beyond
the weekly work hours’ limit according to the European commission (252). Working long
hours was significantly associated with low empathy (β=-4.1; p=0.006). In fact, the
participants who reported working more than 70 hours per week had the lowest empathy
mean score (91±12) compared to those who worked 30 to 50 hours per week (97.3±12.8) and
less than 30 hours per week (101±13.5). These results reflect the insufficiency of human
resources in the Moroccan healthcare system and the high workload at tertiary care
institutions resulting from increasing social demand, complexity of care, and severity of
illnesses, in addition to educational and scientific activities.
103
Increased work hours are negatively associated with the physical component of the
quality of life (SF12). Although it did not reach statistical significance in this study, this may
explain our current result. More work hours means sleep deprivation and less time accorded
to wellness activities leading to work-life imbalance. In this perspective, previous studies
demonstrated that working under loaded schedule and sleep deprivation are major factors of
fatigue (245) (253), burnout (239) (254), and distress (145), which are reasons of decreased
empathy (255); they damage caregivers’ heath and impair healthcare quality (239) (245).
2-2-Psychosocial work environment
The psychosocial work environment refers to the “interpersonal and social interactions
that influence behavior and development in the workplace” (256).
Due to the nature of the services provided, healthcare facilities are an inherent
environment to occupational pressure. When an adverse psychosocial work environment is
added to that, it becomes a major source of stress and burnout in the medical context (239)
(257). Some researchers demonstrated that stress, fear, and tension impair the function of
mirror neurons which are the neuronal basis for empathy (156) (255).
The participants’ perception of their psychosocial work environment was rather
negative. For instance, the participants reported suffering from moral violence, abuse of
authority, lack of support and lack of recognition. Whereas our study did not prove a direct
impact of these factors on empathy, physicians in training may be adapting to their work
conditions by shedding empathy away as a passive coping strategy in order to become less
vulnerable to the negative impact of their adverse psychosocial work environment (250).
Furthermore, univariate analysis showed a negative significant association between the
mental component of quality of life and moral violence (β=-5.4; p<0.001), abuse of authority
(β=-4.4; p=0.001) and lack of support (β=-4.3; p=0.006). These factors may therefore affect
the physicians in training empathy by impairing their mental well being.
According to our descriptive statistics, physical violence was a one-off thing compared
to moral violence which occured in a more persistent manner. Our multivariate analysis
showed that physical violence victims demonstrated a low level of empathy, yet the
association did not reach statistical significance (β=-2.8; p=0.08).
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Our results are nonetheless in consonance with those of previous studies. Nam et al
studied the impact of workplace violence on health care workers’ empathy. They found that
healthcare workers who experienced verbal or physical violence had low levels of empathy.
They reported however that verbal violence had higher impact. The authors argued that legal
interventions and social support are not generally given for verbal abuse and that enduring
such situations is often considered as part of the health worker’s job (194). Another study
among residents in Shanghai stated that empathy and social support from the work
environment were protective factors from experiencing burnout (239).
Based on the above, adverse psychosocial working environment impedes healthcare
workers ability to be empathetic, either directly or by affecting their mental health. Faculty
should recognize these problems and allow physicians in training to discuss them in a
supportive environment. Appropriate measures, legal systems, and effective training on
workplace well-being are requested to prevent physicians in training from burnout and help
them maintain satisfaction with their job and consequently, treat their patients empathically
(194) (258).
3-Empathy and formal education
3-1-Training level
Characterizing changes in empathy throughout medical training is one of the most
studied aspects in clinical empathy literature. Many studies indicated an erosion of empathy
scores with increased years of medical studies and residency, even though no causal
association could be concluded because of the cross-sectional design of the majority of these
studies (156).
In our study, the positive association between higher training level and empathy did not
reach statistical significance in the multiple regression analysis. However, the comparison of
empathy scores among two cohorts (interns and residents) showed higher self-reported
empathy in residents (98.9±13.3) than interns (93±12.8) (β=5.9; p=0.03). In fact, empathy
declines between year one and year two of internship but improves thereafter with higher
levels of residency training.
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The higher empathy scores among senior physicians in training observed in our study
could reflect the influence of different training experiences and how these experiences shape
their perception of illness, physician-patient relationship, and empathy (162).
Interns integrate the pre-residency internship program, which lasts two years, through a
highly competitive selection process. The possible development of a sense of belonging to an
elite group might contribute to empathy decline as suggested by some researchers (259).
The internship program is also characterized by a brutal transition from being a medical
student to becoming a responsible practicing physician. Several explanations have been
provided in the scientific literature to the drop in empathy levels in the “transition period”
characterized by intensified patient contact, which itself has been reported as a justification
for empathy decline (235).
Some researchers also suggested that at early stages of clinical training, trainees focus
on learning technical procedures of diagnosis and treatment which limits their vision for the
importance of communication with patients; therefore, they become skilled at treating
diseases rather than treating patients (129) (156) (232) (235) (259). More technology-based
medical practice encourages trainees to see patients “as part of work” and may lead them to
concentrate only on “getting the job done” (198).
A different hypothesis pointed out the increased workload and related sleep deprivation,
stress, exhaustion, and burnout as one traverses the early stages of clinical training (129)
(198) (235) (250) (257) (260). This hypothesis can be relevant in our context. Pre-residency
internship program in Morocco marks the transition to independent practice and is therefore
known for its heavy workload and stressful work conditions. For instance, 47.2% of the
studied interns reported working more than 70 hours per week and 61.1% were on call more
than twice a week. In contrast, 52.2% of the residents’ population worked less than 30 hours
per week and only 22.4% of them were on call more than twice a week.
Interns ensure on call duties in emergency departments and carry the responsibility of
continually managing patients and their families experiencing critical and sometimes fatal
illnesses. This busy work schedule makes it almost impossible for the young trainees to spend
an optimal amount of time with their patients. As beginner practitioners, interns’ unrealistic
106
expectations from themselves and their job may lead them to cope negatively with their
overwhelming responsibilities (255). Facing such adversity alone with a lack of support might
cause them to develop detachment and emotional distance and lose their compassionate
concern as a protection strategy against psychological distress, fear and insecurity in the
clinical setting (156) (235) (259).
Concisely, new training environments, interaction with patients under stressful
circumstances, time pressure, focus on acquiring technical knowledge, increased
responsibility, high expectations, lack of support and the resulting distress and exhaustion
may diminish the opportunities to learn humanistic skills and develop empathic engagement.
Holmes et al. suggested a developmental trajectory to elucidate the mechanisms of the
empathy decline during early clinical training. They concluded that “students started with
feelings of excitement, transitioned quickly to 'shock and awe', progressed into 'survival
mode' and then passed into a stage of 'recovery'” (261). This progression can be pertinent to
our results, where the highest training levels are associated with the recovery stage.
Residents have more clinical experience, which has been found to positively impact
empathy (118) (125) (260). They have more opportunities to observe, reflect and get feedback
on their clinical behaviors including humanistic ones. Additionally, residents are more
accustomed to the hospital environment, spend more time in training focused on their future
specialty profession, and have increased occasions to interact with the faculties (262).
The professional development is likely to make residents more aware of the importance
of empathy in the patient-physician relationship and more resilient to occupational stress, in
addition to acquiring moral reasoning and communication skills. A recent study argued that
most physicians learn about healthcare professionalism and communication skills after
starting residency (253). Training also increases self-confidence which may reflect on self-
assessment responses (263).
Specialty choice can explain why residents outscored interns as well. In fact, 68.7% of the residents’ population was pursuing a person-oriented specialty and only 19.4% of the interns’ population intended to pursue a person-oriented specialty. Hojat advanced that one’s social skills affect their choice of future medical profession (129) and previous studies
107
demonstrated that trainees who preferred people-oriented specialties were more empathic (129) (241) (264).
These results suggest that empathy might have increased with clinical training, yet only a longitudinal study can confirm this assumption.
3-2-Empathy and training in social skills
Exploring the impact of training in social skills on empathy levels among physicians in training was beyond the objectives of this study. However, our multivariate analysis found that participants who perceived that social skills were given importance during their training scored higher in empathy.
Only 35.9% reported receiving training on physician-patient relationship during the whole curriculum, which reflects an insufficient regard to the humanistic dimension of the physician-patient relationship in the medical educational system in Morocco.
Multiple studies have demonstrated that targeted educational activities can promote empathy among medical students and physicians (41) (255) (265) (266). Educational interventions could increase, maintain, or at least slow a potential decline in empathy (267).
Hojat et al. cited ten didactic approaches to the enhancement of empathy described in the literature of medical education: improving interpersonal skills, analyzing audio or video-taped encounters with patients, being exposed to role models, role-playing, shadowing patients, experiencing hospitalization, studying literature and arts, improving narrative skills, watching theatrical performances, and engaging in the Balint method of small-group discussion (268).
Indeed, communication skills are one of the main interventions used in improving empathy (41). Lamiani et al. reported the effectiveness of a communication skills program on the enhancement of empathy among anesthesia and intensive care residents at the University of Milan (173). Similarly, training residents on family-centered skills elicited a statistically significant amelioration in empathy (269). A specialized training in electronic medical records specific communication resulted in an improvement of medical students’ empathic engagement in patient care and communication skills (270). Another curriculum focused on human kindness resulted in significant growth in medical students’ empathy (271).
108
However, this short term interventions can be ineffective in some cases. DelPrete et al.
found no change in empathy following a simulated patient role-playing activity. They
suggested that the development and maintain of empathy and humanistic skills require longer
frames of time, which highlights the importance of integrating empathy teaching and
assessment all along the curriculum (267).
Researchers in Portugal explained the higher empathy levels among Minho university
medical senior students in comparison to freshmen by the emphasis on humanism and patient
centeredness. The curriculum integrates a humanities program starting from the 1st year and a
communication skills training from the 2nd year. It also includes regular assessments on
professionalism (162).
The UK experience demonstrated similar outcomes. Communication skills are a formal
part of the UK medical education. Workshops focusing on the behavioral aspects of empathy
were found to have the biggest impact on enhancing it (41).
The positive outcomes of humanism education in many contexts show the importance
of such intervention in supporting and maintaining humanistic skills such as empathy. It also
stresses the need to integrate these skills in the medical curriculum in Morocco on the same
level of importance as any other professional skill.
4-Empathy and motivation
Our results demonstrated a positive and significant association between an altruistic
motivation to pursue a medical career and empathy (β=4.2; p=0.01) and a negative association
between motivation for financial success and empathy (β=-2.2; p=0.08).
To the best of our knowledge, there appear to be a lack of evidence on the association
between the motivation behind the choice of becoming a physician and the physician’s
empathy. However, some researchers investigated this aspect and found results similar to
ours.
For instance, Gonçalves-Pereira et al. studied the association between the Vaglum and
colleagues’ indexes on motives for choosing medicine and empathy scores. They found a
positive correlation between the people orientation index and the JSE total score, which
109
suggested a link between an empathic attitude and choosing a medical career to help others.
They also found a negative correlation between the status/security index and the JSE total
score (153).
Using the Medical Situations Questionnaire to assess the generic motivations for a
medical career, other researchers found that participants giving greater importance to helping
people scored higher on the perspective taking scale of the Interpersonal Reactivity Index
(272).
In is intuitive that an association would be expected between empathy and altruistic
motivations for a medical career. This raises the question on whether motivation should be
taken into consideration in the selection criteria to integrate medical schools.
110
III-STRENGTHS AND LIMITATIONS
1-Limitations
Our study was subject to certain limitations which should be acknowledged and
considered in future research.
First, the generalization of our findings was limited by our single institution and
relatively small sample in comparison to the total number of the physicians in training in
Morocco at the time of the study. Moreover, this sample included two subgroups: interns and
residents, which did not allow us to better explore the professional characteristics specific to
each group nor, represent all the residents’ specialties with adequate numbers.
Second, due to the cross-sectional design of our study, we could only interpret our
findings as associations without making causal inferences. Also, this study design did not
permit an evolutionary assessment of the variation of empathy over time.
Third, a selection bias might be present. We approached the available trainees at their
respective training departments and were not sure if all the targeted population was aware of
the study. Additionally, responses could originate from those who were already interested in
the subject.
Fourth, we collected data through a self-administrated survey. Thus, the responses were
subject to a potential social desirability bias. Furthermore, these assessment tools might
reflect attitudes but lack accuracy to evaluate actual behaviors.
Finally, our questionnaire had a few shortcomings. It was rather lengthy. Also, even
though we relied on validated assessments to evaluate empathy, quality of life and satisfaction
with life, we did not use standardized instruments to assess the rest of the variables. In
addition, we used a French version of the JSE that was not validated in the Moroccan context.
The aforementioned limitations could restrict the statistical power of our findings.
111
2-Strengths
Despite the limitations, our work also had a number of merits.
First, this study was one of the very few studies in Morocco to assess empathy among
the physicians in training and its correlates. Hence, our work offers valuable findings about
empathy related factors in the learning environment of the physicians in training in our
context.
Second, we used a reliable and valid scale for measuring empathy, which provided a
consistent assessment of its level among the physicians in training and allowed comparison
with other studies.
Third, we used an electronic survey platform which enabled participants to take part in
the study at their convenience without any external influence.
Fourth, our study was one of the very few illustrations of male physicians in training
showing higher empathy scores than their female counterparts. Also, this was, to the best of
our knowledge, the first study in our context to explore the relationship between non clinician
related factors and empathy. In fact, participants were invited to provide their perspective on
their work environment and the quality of the training they receive. Additionally, we
constructed the linear regression model based on previous literature which is more pertinent.
Finally, our results showed parallels with existing research, and added evidence to
previous literature on empathy in patient care. We believe that our conclusions could provide
an important foundation for further research and pave the way for practical implications in
both medical training and health care.
112
Recommendations
113
Taking into account the relatively low empathy level among the physicians in training
in our population and the very limited importance given to this crucial professional
competence in the Moroccan medical curriculum, some elements must be considered. Here
are some propositions for training and research.
Suggestions to mitigate the limitations of the present study
- The generalization of our results was limited by the use of a single-institution small
sample. Therefore, a multi-center study including a more representative sample is
warranted to externally validate our findings.
- Since we could only interpret our findings as associations, we suggest that future
studies should employ other research designs to investigate causal relationships
between empathy and its related factors.
- Longitudinal studies are needed to explore the changes over time of empathy during
medical training.
Implications for future research
- Given the scarcity of research on empathy in our country, it is necessary to conduct
in depth qualitative studies among physicians in training, faculty members and
patients on the factors they believe can influence empathy in the Moroccan
healthcare context. Such studies may help put forward theoretical frameworks and
hypotheses for future quantitative studies.
- In consonance with anterior literature, our study proved that empathy in medical
practice might be impacted by many factors. Therefore, it is necessary to further
investigate empathy predictors and determinants and identify the modifiable ones in
order to target them in interventions aimed at enhancing empathy.
- The outcomes of empathy for both the patient and the physician should be explored
in the Moroccan context.
114
- Since the JSE is the most used measure to assess empathy in healthcare worldwide
and the predominant comparison tool within international literature, a trans-cultural
validation of the JSE in Moroccan samples is needed.
- It is required to develop national norm tables and cutoff scores for the JSE based on
national samples (116) to categorize empathy levels and identify low and high JSE
scores in the Moroccan context.
Implications for medical training
- Empathy must be recognized on an institutional level as a fundamental component of
medical professionalism.
- Initiatives should be taken at the national level to develop educational programs
targeting humanistic skills among healthcare students and trainees.
- It is necessary to monitor, inspect, and constantly improve the teaching strategies and
programs in order to have effective and tangible outcomes in practice.
- While teaching empathy, it is important to consider the specificity of each training
level (undergraduate, post-graduate, and continuing medical education), especially
during the transition to professional autonomy.
- Alongside theoretical lecturing, it is pivotal to integrate experiential learning and
practice-based training through simulation in healthcare as teaching methods.
- There is a need to raise awareness about the responsibility of faculty members,
educators and seniors as role models influencing the perceptions and the behaviors of
the trainees.
- Medical schools and training institutions are solicited to implement measures to
improve the students’ and the trainees’ learning environment and work conditions
and reduce their workload.
- Efforts should be made to support and protect the psychological and physical
wellbeing of the trainees since the early training years.
115
- Assessment is an integral part of the teaching-learning process. Empathy evaluation
should not be restrained to the caregiver’s self-report, who may over or under
estimate their empathic abilities. Henceforth, it is important to take into account the
point of view of the patient, as well as faculty members, supervisors and peers.
- Self-assessments explore perceptions and may help predict actions. The question
remains whether these perceptions translate into actual behaviors. Therefore, we
suggest to adjunct behavioral measures to self-report in practice settings in order to
assess empathy and other humanistic skills more accurately.
116
Conclusion
117
Empathy in patient care represents the ability to understand patients’ experiences and
communicate this understanding. It is a core competence for medical professionals with
positive outcomes for both the patient and the physician.
Among the many instruments developed to measure empathy, the JSE was designed to
assess it in the particular context of patient care.
Using this scale, our study found a relatively low empathy level among the physicians
in training at the UHIS when compared to the international literature. This result highlights
the importance of integrating humanistic skills in the medical training curriculum in Morocco.
Our linear regression model provided evidence of a positive and significant association
between physicians’ in training self-reported empathy scores and male gender, higher
socioeconomic status and altruistic motivation to pursue a medical career. Empathy was
negatively and significantly associated with longer work hours. Our results also suggested
that on one hand, medical training may have a positive impact on empathy and on the other
hand, an adverse work environment could be detrimental to empathy. However, we could not
detect an association between empathy scores and the quality of life of the physicians in
training.
A deeper investigation of the determinants of empathy on the basis of these findings
should be considered.
118
Summary
119
ABSTRACT
Title: Empathy among physicians in training at the University Hospital IBN SINA: literature review
and cross sectional study
Author: Nourelhouda ELFILALI
Keywords: Empathy, Empathy related factors, Jefferson Scale of Empathy, Physicians in training,
Morocco
Introduction
Empathy is a key component of medical professionalism. Our study aimed to evaluate empathy and
explore its related factors among the physicians in training at the university hospital IBN SINA.
Method
We conducted a cross sectional study, both descriptive and analytic, between March and July 2019
through an online survey. We collected personal and professional characteristics. We used
standardized scales to evaluate Empathy (JSE), quality of life (SF-12) and satisfaction with life
(SWLS). The statistical analysis was carried out in Jamovi Statistics.
Results
We included 103 physicians in training, 69.9% of which were women. The JSE mean score for the
total sample was 96.9 (SD=13.4, range=64-135). Cronbach’s coefficient α for the JSE was 0.76. In the
multivariate analysis, male gender (β=9.7; p<0.001), higher socio-economic status (β=6.7; p=0.02)
and altruistic motivation (β=4.2; p=0.01) were significant predictors of higher empathy levels. On the
other hand, working long hours was negatively linked to empathy (β=-4.1; p=0.006). Additionally, we
could not detect any association between empathy and the quality of life of the physicians in training.
Conclusion
Our results highlighted some empathy related factors among the physicians in training. Further
research is necessary to investigate these factors in order to implement targeted measures for education
and training.
120
RESUME
Titre: L’empathie chez les médecins en formation à l’Hopital Universitaire IBN SINA: revue de
littérature et étude transversale
Auteur: Nourelhouda ELFILALI
Mots clés: Empathie, Facteurs liés à l’empathie, Echelle de Jefferson de l’Empathie, Médecins en
formation, Maroc
Introduction
L'empathie est un élément clé du professionnalisme médical. Notre étude visait à évaluer l'empathie et
à explorer ses facteurs associés chez les médecins en formation à l’hôpital universitaire IBN SINA.
Méthodologie
Nous avons mené une étude transversale, descriptive et analytique, par le biais d'une enquête en ligne
entre mars et juillet 2019. Nous avons recueilli des caractéristiques personnelles et professionnelles.
Nous avons utilisé des échelles standardisées pour évaluer l'empathie (JSE), la qualité de vie (SF-12)
et la satisfaction de vie (SWLS). L'analyse statistique a été effectuée à l’aide de Jamovi Statistics.
Résultats
Nous avons inclus 103 médecins en formation. 69,9 % étaient des femmes. Le score moyen de la JSE
pour la totalité de l'échantillon était de 96,9±13,4. Le coefficient α de Cronbach pour la JSE était de
0,76. En analyse multivariée, le sexe masculin (β=9,7; p<0,001), le haut niveau socio-économique
(β=6,7; p=0,02) et la motivation altruiste (β=4,2; p=0,01) étaient des prédicteurs significatifs d’un
niveau d'empathie plus élevé. Par ailleurs, travailler pour de plus longues heures était négativement lié
à l'empathie (β=-4,1; p=0,006). Aucun lien n’a été démontré entre l’empathie et la qualité de vie des
médecins en formation.
Conclusion
Nos résultats ont mis en évidence quelques facteurs liés à l'empathie chez les médecins en formation.
Des études supplémentaires sont nécessaires pour mieux explorer ces facteurs afin d’implémenter des
mesures ciblées pour la formation.
121
ملخص
التعاطف لدى األطباء تحت التدریب بالمستشفى الجامعي ابن سینا: مراجعة لألدبیات ودراسة أفقیةالعنوان:
نورالھدى الفیاللي الكاتبة:
التعاطف، العوامل المتعلقة بالتعاطف، مقیاس جیفرسون للتعاطف، األطباء تحت التدریب، المغربالكلمات المفتاحیة:
المقدمة
ھدفت دراستنا إلى تقییم التعاطف واستكشاف العوامل یشكل التعاطف عنصرا أساسیا للمھنیة الطبیة. من ھذا المنطلق،
المرتبطة بھ لدى األطباء تحت التدریب في المستشفى الجامعي ابن سینا.
المنھجیة
، عن طریق استطالع عبر 2019 وشھر یولیوز سشھر مار الفترة الممتدة بین أجرینا دراسة أفقیة وصفیة وتحلیلیة خالل
.Jamovi Statisticsتم تحلیل المعطیات باستخدام برنامج ).SWLS)، والرضا عن الحیاة (SF-12وجودة الحیاة (
جالنتائ
منھم نساء. وقد بلغ متوسط درجة التعاطف عند أفراد العینة % 69.9أطباء تحت التدریب، 103شملت عینة الدراسة
در معامل ألفا كرونباخ (االتساق الداخلي) ل13.4±96.9 . أما فیما یخص التحلیل 0.76مقیاس جیفرسون للتعاطف في . كما ق
عالقة إیجابیة بین مستوى التعاطف وكون الطبیب ذكرا، وكذا االنتماء لطبقة متعدد المتغیرات، فقد بینت النتائج وجود
مستوى اجتماعیة علیا، واختیار مھنة الطب بدافع اإلیثار. وفي المقابل، اتضح أن العمل لساعات طویلة یؤثر سلبا على
تحت التدریب.التعاطف. كما لم یتم إیجاد أي عالقة بین جودة الحیاة ومستوى التعاطف لدى األطباء
الخاتمة
سلطت نتائجنا الضوء على بعض العوامل المتعلقة بالتعاطف لدى األطباء تحت التدریب. لكن تظل ھناك حاجة لدراسة ھذه
العوامل بشكل أعمق من أجل أخذ تدابیر فعالة فیما یخص التكوین.
122
Appendix
123
APPENDIX: SUMMARY TABLE OF EMPATHY MEASUREMENT INSTRUMENTS
Instrument Creator(s)
(Publication year)
Description Target population
References for psychometric
properties
Dymond’s Rating Test
Dymond (1949)
- 5-point scale - Respondents rate themselves and one another on 6 characteristics
General population
(4)(p.63-64) (65) (68)
Barrett-Lennard Relationship Inventory (BLRI)
Barrett-Lennard (1962)
- 64 items (1986 version) - 7-point Likert-type scale - Completed by the clinician or the client. - 4 Subscales: 1-Empathic understanding 2-Level of regard 3-Unconditionality of regard 4-Congruence
Psycho-therapeutic context
(4) (p.64) (89) (90) (91) (68) (267) (274)
Feshbach Affective Situations Test of Empathy (FASTE)
Feshbach and Roe (1968)
- Uses picture and/or story method - Measures cognitive and affective dimensions of empathy
Children (4) (p.59) (50) (68)
Hogan Empathy scale (HES)
Hogan (1969)
- 64 true-false items - Self-administered
General population
(4) (p.60-61) (68) (66) (69)
Emotional Empathy Scale
Mehrabian and Epstein (1972)
- 33 items - 9-point Likert-type scale - Self-administered - 4 subscales: 1-Extreme emotional responsiveness 2-Appreciation of the feelings of unfamiliar and distant others 3-Tendency to be moved by others’ emotional experience 4-Tendency to be sympathetic
![Title] user DOCTOR OF PHILOSOPHY](https://static.documents.pub/doc/80x56/631c3acda906b217b906da05/title-user-doctor-of-philosophy.jpg)
