Justin Durham Newcastle University Framlington Place Newcastle Upon Tyne NE2 4BW UK Tel: +44 191 2227828 Fax: +44 191 2226137 e-mail: firstname.lastname@example.org
Introduction: Professionalism is a central tenet of the dental undergraduate curriculum. Dental undergraduate curricula and standards expect the dentist to put the patient’s interests first, and in this respect, an important attitude is empathy.
Objective: This study examined the self-reported empathy levels of first-year dental students before and after an early analytical exposure to behavioural sciences and the clinical encounter.
Method: First-year dental undergraduates were given an attitudinal questionnaire to complete before and after the behavioural science course. The questionnaire consisted of the HP version of the Jefferson Scale of Physician Empathy and the Patient-Practitioner Orientation Scale. Paired non-parametric tests and Spearman’s Rho correlations, along with simple descriptive statistics, were used to test the statistical significance of observations.
Results: A total of 66 paired questionnaires were returned, giving a response rate of 75%. There were no correlations between age and total mean score of JSPE or PPOS, and no gender differences. There was a significant increase (P < 0.01) in empathy as measured by the JSPE between pre- and post-course scores. The PPOS did not record any significant change in the sharing, caring or total scale scores pre- to post-course.
Conclusion: The modified JSPE has potential utility in assessing the cognitive-affective aspect of dental students’ empathy. Using the JSPE, short-term measurable empathy changes can be detected in first-year dental undergraduates after the structured and assessed analytical introduction to the clinical encounter and environment.
Professionalism is at the heart of European Union, North American and Canadian dental curricula (1–3). Professionalism encompasses the appropriate attitudes, values and behaviours needed for a practicing dentist. The most important attributes for professionalism, as determined by health professionals, are competence, respect and empathy (4). Individuals should be able to put patients’ interests first, respect their patients’ dignity and choices, and communicate effectively with patients and their families. An important aspect of dental care should be to ascertain the patient’s wishes and concerns. This consultation skill requires specific and effective communication skills. Those clinicians with empathetic communication skills have been shown to produce better patient health outcomes (5–7) such as; improved diagnostic accuracy (8), increased patient satisfaction (9), increased patient cooperation and increased adherence to orthodontic treatment (10, 11), alongside reduced litigation and patient anxiety (12, 13).
Empathy itself, however, is a difficult and complex concept to define (14). It can be considered a state, trait or ‘multistage interpersonal process’. As a state, it can be considered to be cognitive and/or affective, described as a vicarious understanding or reaction to the patient’s situation. As a trait, it relies on an innate ability within the individual to comprehend the patient’s feelings. If empathy is considered a multistage interpersonal process, then it will consist of a series of experiences between the patient and the clinician.
Hojat et al. have defined empathy within the health care setting as, ‘a cognitive attribute that involves an understanding of the inner experiences and perspectives of the patient as a separate individual, combined with a capability to communicate this understanding to the patient’ (15, 16). This cognitive-affective definition is the definition we adopt in this paper. In essence, an empathetic practitioner should be able to view things from their patient’s perspective, understand how a patient’s emotions and experiences can affect their symptoms and use this understanding to help their patients. Expressing empathy is best shown through reflective listening (17); this expression of empathy does not require agreement with, or endorsement of, everything the patient says but rather understanding and accepting their point of view (18).
There are numerous methods to assess empathy: self-ratings, patient ratings, peer ratings, psychometric tests and observation of behaviours, all of which have their advantages and disadvantages (19). Self-rating scales are the most commonly reported method used by health care professionals (20). There are generic scales designed to measure empathy within the general population (21, 22), but the Jefferson Scale of Physician Empathy (JSPE) is the only one designed to specifically measure physician empathy (19, 23, 24). There are two versions of the JSPE, one version is for use with medical students (S version), the other is aimed at practising clinicians (HP version); the difference between the two versions is that the latter is more focussed on assessing the empathetic behaviour of the individual who is completing it rather than just their empathetic orientation or attitudes (16). The JSPE has been validated for use with medical students (23), and additionally, Sherman and Cramer carried out a study in 2005 to assess the HP version of the JSPE for use with dental students, concluding that it can reliably and validly assess levels of empathy in dental student populations (25). The JSPE has been used in a longitudinal manner with medical and dental students previously, showing a decrease in empathy as the students progress through the years of the course (25, 26).
The Patient-Practitioner Orientation Scale (PPOS) (27, 28) aims to measure whether the practitioner leans towards patient-centred care or disease/doctor-centred care. It is divided into two sections, the sharing and caring subscale. The sharing subscale measures how important the practitioner feels it is to share power and information with the patient and involve them in treatment decisions. The caring subscale measures the extent to which the practitioner considers their patient’s emotions and aims for a more holistic approach to patient care, with the patient rather than the disease being the focus of attention. The PPOS has been previously validated for use in a health care setting (29), but to our knowledge, it has never been previously used in a dental environment.
Early exposure to the concept of professionalism is particularly important in dentistry because dental students are involved in treating patients within 2 years of commencing their studies. To attempt to embed and engender professionalism as early as possible, an integrated curriculum is used at the School of Dental Sciences, Newcastle University, an approach shared by most UK dental schools. Behavioural sciences and interpersonal skills lectures and small group seminar teaching are given on the role of the practitioner–patient interaction, and the students are then allocated to ‘shadow’ senior (fourth year undergraduate) students. The first-year students are given checklists and specific points to look for, as observational aids, and they are asked to submit coursework analysing their experiences whilst on clinic.
The aim of this study was to examine the self-reported empathy levels of first-year dental students before and after an early analytical exposure to behavioural sciences and the clinical encounter.
All first-year undergraduates (n = 88) at the School of Dental Sciences, Newcastle University, were randomly given a unique identifier that was known only to them. They were asked voluntarily to complete the same attitudinal questionnaire at two points in their first year: (i) January 2008 prior to their behavioural science lectures and their first clinical experience (referred to as ‘pre-course’); (ii) April 2008 after completing the behavioural science course and associated assessment based on clinical observations (referred to as ‘post-course’).
The questionnaire contained 38 attitude questions answered on a five-point Likert-type scale; these included the 20-item JSPE (15, 16, 23) and the 18-item PPOS (27, 28). The HP version was felt to be more appropriate for use with dental students as they begin clinical treatment at an earlier stage than medical students. Use of this version also aids comparison with the study by Sherman and Cramer (25). The PPOS was used alongside the JSPE because it had been used in cohorts in Medicine (30) similar to the cohort we were studying. In addition, because of the paucity of health professional specific measures of empathy, it provided the best measure against which to assess the JSPE’s convergent validity (19, 24).
Both questionnaires were adapted for use with dentists by substitution of the words ‘physician’ and ‘doctor’ with ‘dentist’, and the word ‘medical’ with ‘dental’. The scoring and wording of the scales are shown in Table 1. An unpublished pilot study with 190 undergraduate dental students at Newcastle University showed the Cronbach alpha internal consistency was 0.75 for the modified JSPE and 0.65 for the modified PPOS. The JSPE reliability was within acceptable standards (>0.7) for a non-clinical instrument but the PPOS was slightly below acceptable standards because of both the overall scale and the subscales (31).
Table 1. Summary of modified questions and mean scores pre- and post-course
Question number for JSPE or PPOS
Scoring via Likert*
Pre-course (January) mean score (SD)
Post-course (April) mean score
*Jefferson Scale of Physician Empathy (JSPE) normal scoring: 1, strongly disagree; 5, strongly agree. Reverse scoring: 1, strongly agree; 5, strongly disagree. Higher score means greater level of empathy. Patient-Practitioner Orientation Scale (PPOS) normal scoring: 1, strongly agree; 5, strongly disagree. Reverse score: 1, strongly disagree; 5, strongly agree. Higher score means greater level of caring (empathy) and sharing decision making.
†P < 0.01 in Wilcoxon test of pre- and post-scores.
‡P < 0.05 in Wilcoxon test of pre- and post-score.
I try to imagine myself in my patients’ shoes when providing care to them.
My understanding of my patients’ feelings gives them a sense of validation that is therapeutic in its own right.
An important component of the relationship with my patients is my understanding of the emotional status of themselves and their families.
I try to understand what is going on in my patients’ minds by paying attention to their non-verbal cues and body language.
I try to think like my patients in order to render better care.
I believe that empathy is an important therapeutic factor in dental treatment.
Empathy is a therapeutic skill without which my success as a health care provider would be limited.
Patients’ illnesses can only be cured by dental treatment; therefore, affection ties to my patients cannot have a significant place in this endeavour.
I do not allow myself to be touched by intense emotional relationships between my patients and their family members.
I believe that emotion has no place in the treatment of dental illness.
Because people are different, it is almost impossible for me to see things from my patients’ perspectives.
Attentiveness to my patients’ personal experiences is irrelevant to treatment effectiveness.
My patients feel better when I understand their feelings.
I have a good sense of humour that I think contributes to a better clinical outcome.
I consider understanding my patients’ body language as important as verbal communication in caregiver–patient relationships.
I try not to pay attention to my patients’ emotions in interviewing and history taking.
I consider asking patients about what is happening in their lives as an unimportant factor in understanding their physical complaints.
It is difficult for me to view things from my patients’ perspectives.
I do not enjoy reading non-dental literature and the arts.
My understanding of how my patients and their families feel is an irrelevant factor in dental treatment.
PPOS 1 (Sharing)
The dentist is the one who should decide what gets talked about during a visit.
PPOS 2 (Caring)
Although health care is less personal these days, it is a small price to pay for dental advances.
PPOS 3 (Caring)
The most important part of the standard dental visit is the exam.
PPOS 4 (Sharing)
It is often best for patients if they do not have a full explanation of their dental condition.
PPOS 5 (Sharing)
Patients should rely on their dentists’ knowledge and not try to find out about their conditions on their own.
PPOS 6 (Caring)
When dentists ask many questions about a patient’s background, they are prying too much into personal matters.
PPOS 7 (Caring)
If dentists are truly good at diagnosis and treatment, the way they relate to patients is not that important.
PPOS 8 (Sharing)
Many patients continue asking questions even though they are not learning anything new.
PPOS 9 (Sharing)
Patients should be treated as if they were partners with the dentist, equal in power and status.
PPOS 10 (Caring)
Patients generally want reassurance rather than information about their health.
PPOS 11 (Caring)
If a dentist’s primary tools are being open and warm, the dentist will not have much success.
PPOS 12 (Sharing)
When patients disagree with their dentist, this is a sign that the dentist does not have the patient’s respect and trust.
PPOS 13 (Caring)
A treatment plan cannot succeed if it is in conflict with a patient’s lifestyle or values.
PPOS 14 (Sharing)
Most patients want to get in and out of the dentist’s office as quickly as possible.
PPOS 15 (Sharing)
The patient must always be aware that the dentist is in charge.
PPOS 16 (Caring)
It is not that important to know a patient’s culture and background in order to treat the person’s illness.
PPOS 17 (Caring)
Humour is a major ingredient in the dentist’s treatment of the patient.
PPOS 18 (Sharing)
When patients look up dental information on their own, this usually confuses more than it helps.
Both scales consist of both positively and negatively worded questions to control for acquiescence bias. For analysis, the negatively worded questions were reverse-scored in the JSPE and the positively worded questions reverse-scored in the PPOS (Table 1). The JSPE has a minimum score of 20 and a maximum of 100, with 18 and 90 correspondingly for the PPOS.
The anonymous and unique identifier used by the students completing the questionnaire meant that paired non-parametric Wilcoxon tests could be used on the data. Two-tailed Spearman’s Rho and simple descriptive statistics were used. Data analysis was performed using SPSS® version 17.0 (SPSS®, Chicago, IL, USA).
Sixty-six students completed the questionnaire twice (pre- and post-behavioural science course), giving a response rate of 75%. The gender ratio of responders (46 females, 20 males) was slightly higher than the School’s usual ratio of female to male students and that of UK dental schools as a whole (32). In total, there were 11 female and 11 male non-responders, and there was no significant difference (P > 0.05) between genders in their response rate. The age range was from 17 to 30, with 89% of the respondents aged between 17 and 21 years. No statistically significant correlation (P > 0.05) was found between age and total mean score (pre- and post-course) on either the JSPE or the PPOS, and there were no significant gender differences.
The mean item scores ranged from 2.59 to 4.55, where higher scores indicate more empathetic behaviours. The mean JSPE total score pre-course was 78.74 (SD 6.77) and post-course was 81.55 (SD 6.87), a statistically significant change (P < 0.01), indicating a more empathetic score after the first clinical exposure. Further, when looking at individual items within the JSPE, six statistically significant results were obtained in the predicted direction of greater empathy. These are shown in Table 1.
No significant difference (P > 0.05) was found between the mean total PPOS scores for pre-course 61.88 (SD 5.9) and post-course 60.73 (SD 3.37). There was no significant change in the pre- to post-course scores in either the sharing or the caring subscales (P > 0.05, Fig. 1). Inspection of the individual items in the PPOS revealed two statistically significant changes that are shown in Table 1.
There was a significant correlation between the PPOS caring subscale score and JSPE empathy score pre-course (r = 0.357, P < 0.05); however, this was not found post-course.
The results show a significant increase in self-reported empathy levels, as measured by the JSPE post-course. This is encouraging, especially as ‘teaching empathy’ is fraught with problems. It is difficult to attribute the increase solely to the course but it is likely that it has had some impact, especially as the majority of items showing significant changes are items specific to the areas students were directly assessing.
In contrast to our results, Sherman and Cramer found that empathy levels decreased in the second year of dental school, which in their cohort correlated with first patient contact (25). The increased levels of empathy demonstrated by our cohort may be accounted for by a Hawthorne effect. Senior students and teachers, aware of observational activity, may alter their usual interactions with patients resulting in the first years witnessing almost ‘textbook’ behaviours (33).
The increased levels of empathy could also be attributed to a shorter exposure to the clinical environment. Empathy can be ‘taught’ by lectures, role-playing and interviewing skills, but what Hafferty describes as the informal curriculum can also have a significant impact (34). We may seek to develop empathy in the formal curriculum but students also learn through their interpersonal interactions outside of official learning environments; a process of ‘medical (dental) socialisation’ where students may become immunised against humanistic tendencies through, amongst other factors, the behaviour of role models (35, 36). The first years may not have been sufficiently incorporated into the clinical environment to observe this informal curriculum.
We cannot therefore expect, on the basis of these data, that the increase in empathy is stable in the longer term and we will be following the current cohort through the course to see whether there are further changes in the self-reported levels of empathy. In contrast to the study by Sherman and Cramer, our cohort is answering at present based on an observational experience, rather than an actual clinical interaction (25). This distance from the patient may allow a more idealised response and it will be interesting to see the effect on empathy levels once they are reporting as operators, with all the inherent pressures involved.
The PPOS data show no statistically significant change in orientation, following exposure to patients. A major difference between the JSPE and the PPOS is that the latter is phrased in the third person. By being phrased in such a manner, it may pose questions that students, unfamiliar with the full depth and breadth of the clinical encounter, find difficult to answer. Given that the shadowing period for the first years only lasts a week and a half, this time period may be insufficient to change the pre-existing concepts the students hold about ‘the dentist’ or ‘the patient’, which may be based on strong social constructs imparted since childhood. The JSPE is phrased in the first person and contains fewer social constructs so may be more intuitive in the earlier years of the course. However, the first-person perspective of the JSPE may be more suited to second-year students who can answer as an actual operator.
The discussion to this point has assumed that the JSPE and PPOS, as stand-alone instruments, are sufficient to measure the complex construct of empathy. It may be that these need to be supplemented by a patient report (37) on the empathy they felt they received and/or a peer observational study of the individual’s behaviour in the clinical environment. This would be a more representative assessment of the entire concept of empathy and could be used to assess the validity and reliability of the relevant scales. Despite this, dental educators still need to be able to examine constructs such as empathy as part of the professionalism demanded by the various dental curricula. To this end, JSPE seemed to have reasonable convergent validity with the next best scale, the PPOS, and was responsive to change in the short term at measuring the cognitive-affective aspect of empathy. This does not, however, give us data on the future behaviours of those displaying the increased level of empathy.
This study is limited by its small gender-skewed sample and the fact that it focuses solely on first-year students. Female students have been shown to be inherently more emotionally expressive and sensitive, which has been correlated with better communication skills. However, a consultation skills’ course has been shown to remove any significant gender difference, with regard to dentist/patient communication (38). Nonetheless, in studies by both Hojat et al. and Sherman and Cramer, women have consistently higher JSPE scores than men (16, 25, 26).
This study does show that changes in the cognitive-affective aspect of empathy may be occurring during early exposures to the clinical environment. Further qualitative research is required to help understand the factors influencing this change during the shadowing period. Longitudinal research using a combination of observational methods, self-report questionnaires and in-depth interviews is required to help understand the role of the informal and hidden curricula on the students, as they progress through the course.
The modified JSPE has potential utility in assessing the cognitive-affective aspect of dental students’ empathy. Using the JSPE, ‘short-term’ measurable empathy changes can be detected in first-year dental undergraduates after the structured and assessed analytical introduction to the clinical encounter and environment. A dental-specific assessment scale could be produced but as the JSPE has been shown to be reliable, construction of further instruments may only confuse the issue. Observational studies to investigate dental students’ attitudes, and the function of both teaching and role models in the formation of these attitudes, warrant further research.