Letters To The Editor: Change in Empathy in Medical School

letters to the editor
Change in empathy in medical school

Mohammadreza Hojat
Editor, cognition versus affect, and of Thirdly, the utility of an empathy-

Smith et al.1 reported controversial understanding versus feeling in measuring instrument in health
findings showing that, as students clinical encounters4 (e.g. in professions education and patient
progressed through medical clinical decision making, care is determined by its
school, their empathy declined professional exhaustion and significant link to pertinent
when measured by the Jefferson burnout), we deliberately defined criterion measures of clinical
Scale of Empathy (JSE), but empathy as a predominantly competence and tangible patient
improved when measured by the cognitive (rather than affective) outcomes. Such validity evidence is
Questionnaire of Cognitive and attribute with which to readily available for the JSE with
Affective Empathy (QCAE). The understand (rather than to feel) respect to predicting clinical
authors1 challenge the findings on patients’ pain and suffering. competence in medical students6
erosion of empathy in medical Thus, the JSE may be more and positive patient outcomes in
students in the United States sensitive in detecting changes in diabetes patients.7
published for the first time by my clinical empathy because it was
team in this journal2 and reported developed based on a pertinent Thus, differences between the
subsequently in another study3 and cognitive conceptualisation of JSE and QCAE in sensitivity,
elsewhere.4 As the author of the empathy. specificity and utility provide a
JSE, I maintain that the sensitivity, plausible explanation for the
specificity and utility of the Secondly, the target population for inconsistency of findings in the
empathy instruments used in Smith the instrument determines the study by Smith et al.,1 although
et al.’s study1 can explain the specificity of the language used in the authors reported significant
inconsistency of their results. the test (face validity). The JSE is and positive correlations between
more content-specific and context- scores obtained using the
Firstly, differences in a germane relevant to patient care because it respective instruments, an
definition of empathy in the was developed for administration indication of convergent validity
context of patient care to health professions students and of the JSE.
determine the content validity of practitioners. In addition, its
the test. In conceptualising psychometric properties have been
empathy in patient care, we supported exclusively in the target REFERENCES
made distinctions between population. This is not the case
cognition and affect, and with other empathy-measuring 1 Smith KE, Norman GJ, Decety J.
between understanding and instruments developed for The complexity of empathy during
feeling. With regard to the administration to the general medical school training: evidence
consequential outcomes of population. This feature of the JSE for positive changes. Med Educ
may make it a more suitable 2017;51 (11):1146–59.
2 Hojat M, Mangione S, Nasca TJ,
Center for Research in Medical Education and measure of empathy in the target
Rattner S, Erdmann JB, Gonnella
Health Care, Sidney Kimmel Medical College population. Items of the QCAE5
at Thomas Jefferson University, Philadelphia, JS, Magee M. An empirical study of
Pennsylvania, USA
were derived from the Empathy decline in empathy in medical
Quotient (used to assess social school. Med Educ 2004;38
Correspondence: Mohammadreza Hojat, impairment in subjects with (9):934–41.
Center for Research in Medical Education Asperger syndrome), the Hogan 3 Hojat M, Vergare M, Maxwell K,
and Health Care, Sidney Kimmel Medical
College at Thomas Jefferson University, Empathy Scale, the Impulsiveness– Brainard G, Herrine SK, Isenberg
1015 Walnut Street, Suite 320, Philadelphia, Venturesomeness–Empathy GA, Veloski JJ, Gonnella JS. The
Pennsylvania 19107, USA. Inventory and the Interpersonal devil is in the third year: a
Tel: 00 1 215 955 9459/8907; longitudinal study of erosion of
Reactivity Index, developed for
E-mail: [email protected] empathy in medical school. Acad
administration to the general
Med 2009;84 (9):1182–91.
doi: 10.1111/medu.13497 public.
456 ª 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education;
MEDICAL EDUCATION 2018 52: 456–458
letters to the editor
4 Hojat M. Empathy in Health 6 Hojat M, Gonnella JS, Mangione S, Gonnella JS. The relationship
Professions Education and Patient Nasca TJ, Veloski JJ, Erdmann JB, between physician empathy and
Care. New York, NY: Springer Callahan CA, Magee M. Empathy in disease complications: an empirical
International Publishing 2016. medical students as related to study of primary care physicians
5 Reniers RL, Corcoran R, Drake R, academic performance, clinical and their diabetic patients in
Shryane NM, V€ ollm BA. The competence and gender. Med Educ Parma, Italy. Acad Med 2012;87
QCAE: a questionnaire of cognitive 2002;36 (6):522–7. (9):1243–9.
and affective empathy. J Pers Assess 7 Del Canale S, Louis DZ, Maio V,
2011;93 (1):84–95. Wang X, Rossi G, Hojat M,
Predictive utility cannot substitute for construct validity

Jean Decety, Karen E Smith & Greg J Norman
In response to the letter by Hojat,1 empathy.5 Findings from our study programmes. Using unitary and
it is important to keep in mind demonstrate that empathy oversimplified measures will not
that psychological constructs, such improves, rather than declines, result in satisfactory explanations.
as empathy, are useful to describe suggesting that changes in
phenomenological experiences, empathy during medical school Because clinical empathy is so
but they are rarely unitary are more complex than initially valuable for both the patient and
structures. Instead, they are thought. Students appear to the physician, it seems more than
composed of processes and maintain a capacity for empathy, reasonable that the field would
representations that work together at least outside of the clinical welcome new findings, especially
to serve particular functions that context. The differences we when they are based upon the most
have evolved via natural observe in our study could be due accurate evidence-based models.
selection.2,3 Focusing on only one to the specificity of the Jefferson After all, no form of measurement
component or single measure Scale of Empathy (JSE) to clinical is infallible. The iterative dynamic
neglects this complexity, resulting contexts. However, our work process between theory
in oversimplifications and limited builds upon previous research development and empirical
explanatory power. Decomposing demonstrating that empathy as validation is fundamental to
psychological constructs into their measured by the JSE does not scientific understanding, and when
component processes that can correlate with observer-reported more powerful models or
then be mapped onto empathy,6 a factor that is pertinent explanations exist, there are very
neurobiological mechanisms, only to the physician–patient few valid reasons to not incorporate
results in more sophisticated relationship, and studies that have them. What is more, measures do
explanations.4 This is what our failed to find changes in empathy not possess explanatory power;
study did by using a variety of during medical school,7 pointing theories do. To advance this
assessments, both self-reports and again to a need within the field to process, theories and measures
behavioural measures, to gain a expand how empathy is must be recognised as separate
more accurate depiction of conceptualised and measured in entities, with neither being reified.
order to better understand the
influence of medical training and
Department of Psychology and Psychiatry, REFERENCES
University of Chicago, Chicago, IL, USA practice on this complex
psychological phenomenon. If the
Correspondence: Jean Decety, Department of goal is to accurately understand 1 Hojat M. Change in empathy in
Psychology and Psychiatry, University of medical school. Med Educ 2018;52
Chicago, 5848 S. University avenue,
how and why empathy changes in
(4):456–7.
Chicago, Illinois 60637, USA. medical school, more complex,
2 Decety J. The neural pathways,
Tel: 773 834 3711; evidence-based models and development and functions of
E-mail: [email protected] measures of empathy are necessary empathy. Curr Opin Behav Sci
doi: 10.1111/medu.13506
to inform medical training 2015;3:1–6.
ª 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education; 457
MEDICAL EDUCATION 2018 52: 456–458
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letters to the editor

Change in empathy in medical school

Editor, cognition versus affect, and of Thirdly, the utility of an empathy-

Predictive utility cannot substitute for construct validity

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