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Year : 2013  |  Volume : 26  |  Issue : 1  |  Page : 4-8

Medical students' and residents' conceptual structure of empathy: A qualitative study

1 Department of General Medicine, Faculty of Medicine, Graduate School of Education and Human Development, Nagoya, Japan
2 Educational Sciences, Graduate School of Education and Human Development, Nagoya University, Nagoya, Japan
3 Skillslab, Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, Netherlands

Date of Web Publication31-May-2013

Correspondence Address:
Muneyoshi Aomatsu
Department of Education for Community-Oriented Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan 65 Tusurmai-cho, Showa-ku, Nagoya, 466-8550
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1357-6283.112793

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Background: Empathy is a crucial component of medicine. However, many studies that have used quantitative methods have revealed decline of learners' empathy during undergraduate and postgraduate medical education. We identified medical students' and residents' conceptual structures of empathy in medicine to examine possible differences between the groups in how they conceive empathy.
Methods: We conducted a qualitative study with two focus group discussions in which six medical students and seven residents participated separately. The transcripts of the focus group discussions were analysed combining qualitative data analysis and theoretical coding. Results: Medical students and residents had different conceptual structures of empathy. While medical students thought that sharing emotions with patients was essential to showing empathy, residents expressed empathy according to their evaluation of patients' physical and mental health status. If the residents thought that showing empathy was necessary for the care of patients, they could show it, regardless of whether they shared the patients' emotions or not. Conclusions: The comparison of medical students' and residents' conceptual structures of empathy reveals a qualitative difference. Residents show more empathy to their patients by a cognitive decision as clinicians than medical students do. Communication skills training should consider the qualitative change of students' and residents' empathy with clinical experience. We should consider the change when we evaluate learners' empathy and introduce methods that cover the qualitative range of empathy.

Keywords: Communication, empathy, medical education, qualitative research

How to cite this article:
Aomatsu M, Otani T, Tanaka A, Ban N, Dalen Jv. Medical students' and residents' conceptual structure of empathy: A qualitative study. Educ Health 2013;26:4-8

How to cite this URL:
Aomatsu M, Otani T, Tanaka A, Ban N, Dalen Jv. Medical students' and residents' conceptual structure of empathy: A qualitative study. Educ Health [serial online] 2013 [cited 2023 May 28];26:4-8. Available from:

  Introduction Top

The ability of healthcare providers to show empathy to patients is a principal part of communication skills. Empathy influences patients' outcomes, [1] like satisfaction and adherence to physician advice. [2],[3] Conveying empathy to patients is also important in encouraging them to disclose their concerns. [4],[5] In spite of the importance, a decrease in empathy in medical students and residents during their medical training has been pointed out. [6],[7] Other studies have identified positive or no correlation between students' or physicians' experiences and empathy. [8],[9],[10],[11] Since those studies were cross-sectional, the findings could be influenced by other factors in the participants' experience. In addition, there is no uniform definition of empathy, and some studies have identified various components of empathy. Morse et al. classified components into four categories: (1) emotive; (2) cognitive; (3) moral and (4) behavioural. [12] The measures used in the previous studies do not necessarily distinguish the emotive and cognitive components of empathy. [13] Furthermore, some aspects of the measures used evaluated factors that do not directly relate to empathy. [13] Therefore, it can be fruitful to re-examine the development of empathy in medical school, using a more comprehensive understanding of empathy with regard to its various components. To achieve a fuller understanding of the development of empathy, the interdependency and the complementarity among the four components need to be further clarified. The objective of this study was to identify and compare the comprehensive conceptual structure of medical students' and residents' empathy.

Context: Japanese undergraduate medical education consists of four years of preclinical and two years of clinical education. Medical students rotate through almost all specialties during their clinical education. In their preclinical years, students learn basic clinical skills, such as medical communication and physical examination, and proficiency of these skills is evaluated in the Common Achievement Test (CAT) in Year 4. Students must pass this examination to register in clinical education, which is composed of skills training and clinical clerkships. The Department of General Medicine, Nagoya University Hospital, conducts one and one-half days of medical communication skills training (including empathy) for Year 5 students during their rotation. The first author (MA) facilitated a part of the training. A mandatory two-year postgraduate medical training started in 2004, requiring residents to rotate in some compulsory and other elective disciplines. The Nagoya University Hospital conducts one half-day training for residents as part of their orientation course prior to the residency program.

Theoretical framework: We use Morse's classification [12] as a framework to analyse the development of medical students' and residents' empathy during their medical education. The classification is described as: (1) emotive: The ability to subjectively experience and share in another's psychological state and emotions; (2) moral: An internal altruistic force that motivates the practice of empathy; (3) cognitive: The intellectual ability to identify and understand another's emotions and perspective from an objective stance and (4) behavioural: Communicative response to convey understanding of another's perspective. Our study was designed to reveal how medical students and residents understand empathy composed of several components, and to compare their constructive components of empathy in different phases of their training.

  Methods Top

Participants: Recruitment of study participants was done through convenience sampling. Year 5 medical students of our 6-year curriculum, who had finished skills training and the clinical clerkship in the Department of General Medicine, as well as residents of Nagoya University Hospital were asked by the first author (MA) to participate in the study. The six medical students were from a class of 106 Year 5 students. The seven residents were from a cohort of 22 residents. All residents had graduated from different medical schools. Four were in their first year of training, while two had graduated from universities and received a bachelor in social and human sciences before their entry to medical school. The study was approved by the Ethical Committee of Nagoya University, School of Medicine.

Data collection: Qualitative methods were chosen to allow in-depth exploration of the participants' views on the topic of empathy and its components. Specifically, we used Focus Group Discussions as a data collection method. Homogeneous focus groups will not suffer much from a power imbalance between the researcher and participants. [14] Since the researcher was an attending physician, and consequently higher in rank and status than the participants, we judged Focus Group Discussions to be more appropriate than personal interviews to collect opinions. The interview scheme to guide the focus group discussions is available from the first author, upon request.

Two focus group discussions were conducted, with medical students and residents participating separately. The participants were initially asked the open-ended question: "What do you think about the role of empathy in clinical practice?". Based on the responses to this first question, the moderator (MA) added specific questions to deepen discussion among the participants. Examples of these questions: "What do you think about the difference of empathy in medical communication and empathy in communication with your friends?" and "How do you feel you have been taught about empathy in undergraduate medical education?". Each focus group discussion lasted about 80 minutes. They were audio- and video-recorded with participants' permission. The facilitator wrote the transcripts of the records immediately after the recording.

Data analysis: The transcripts were analysed according to the "Steps for Coding and Theorization" method (SCAT), [15] a sequential and thematic qualitative data analysis technique. It consists of steps of coding from open to selective, a story-line writing using the final selective codes, and writing theories from the story-line. We chose this approach for its explicit process of analysis, the characteristic that the process integrates the qualitative data analysis with the theoretical coding, and for its efficiency and validity of theorisation from relatively small scale data. The principal researcher engaged in each step of the analysis and a co-researcher (AT) read the transcripts and the results of the analysis as an independent auditor to assess dependability and confirmability of the analysis. [16] Finally, we identified the conceptual structure of empathy that medical students and residents reported.

  Results Top

The median age of participating students was 24; three of the six were female. Among residents, the median age was 27, with two of the seven being female.

Realisation about empathy: Both medical students and residents considered showing empathy to patients to be important for good healthcare. They especially valued the emotive component of empathy, in other words feeling patients' suffering as their own.

"…I think it may be important to stand in the patient's position without being conscious of my role as a physician" (Student 6, 160).

"…I think it is appropriate to tell a patient that they are not the only person feeling like that" (Resident 3, 102).

Although medical students and residents had similar realisations, they had different conceptual structures of empathy conveyed to a patient [Figure 1] and [Figure 2].
Figure 1: Students' Concept of Empathy, Grey arrows indicate the infl uence of each component on the others. A white arrow indicates the inhibition to show empathy

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Figure 2: Residents' Concept of Empathy, Grey arrows indicate the infl uence of each component on the others. The width of the arrows shows the strength of the infl uence. A white arrow indicates the inhibition to show empathy

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Difference in conceptual structure of empathy between medical students and residents: Although both medical students' and residents' conceptualisation of empathy demonstrated Morse's four components, their conceptual structures differed. Medical students thought showing empathy to a patient was important (moral component), but sharing the patient's feeling (emotive component) was indispensable for actual conveyance of empathy (behavioural component).

"If I can share a patient's complaint naturally and understand the patient's situation, then I will show empathy to the patient" (Student 3, 397 and 402).

When medical students could not share a patient's feeling, they tried to compare and find similarity between their past experiences and the patient's current situation for the inference of the patient's feeling (cognitive component). If the students could infer the patient's feeling, they made the inference an opportunity to share the patient's feeling and show empathy.

"… for example, when a patient experiences sleeplessness because of abdominal pain, I could say 'sleeplessness is actual suffering' naturally, imaging my experience that the abdominal pain restricts my housework and felt inconvenient" (Student 3, 467).

However, medical students reported showing empathy in objective structured clinical examination (OSCE)-circumstances regardless of sharing emotions, because they knew that showing empathy resulted in a higher score.

"We formulated rules for medical communication through communication skills training. According to what a patient says, I think like "This is the moment to show empathy", "Let's ask an open ended question here". These are like a manual or a game" (Student 4, 286).

The higher score, resulting from an empathetic attitude, without sharing a patient's emotion, seemed to be a message to the students that puts less emphasis on the emotional component of empathy. As a result, their empathy relying on the emotional component would be inhibited.

While the moral component was also an important starting point for the residents' empathy, the interrelation among the four components they reported was different from students' empathy. When showing empathy, residents more frequently referred to the cognitive component than medical students. They showed empathy to a patient when they thought it necessary according to the analysis of the patient's illness or background, regardless of whether they could share feeling with the patient or not.

"When a patient complained of a symptom so much, I understand that the patient is worried about their illness being underestimated. Therefore, I empathise with some exaggeration" (Resident 3, 107).

"Even if a patient is aggressive, I try to understand the reason of the behaviour, asking about the past course. Then I think of the reason0" (Resident 6, 253).

The residents thought that the progress of their clinical experience caused insensitivity for patients' suffering, therefore they could not share the patient's feelings the way they could as medical students. Complementing the insensitivity, they used the cognitive component more frequently.

"It is a bad influence of experiencing clinical practice that I cannot empathise with a patient, although I could empathise to a similar patient when I just started my postgraduate training" (Resident 3, 111).

" Actually, I cannot react to a patient's suffering like a medical student" (Resident 5, 130).

Thus, the residents compensated for the decrease in empathy based on the emotive component by empathy based on the cognitive component, and the residents' reflection about their daily practices brought the compensation.

"I can understand patients' anxieties as well as when I was a student, but I find that I cannot empathise with the patients by sharing their emotion as a student. So, I want to compensate for it by saying some words or showing empathetic attitude to them" (Resident 3, 144).

Comparison of medical students and residents: In addition to the difference in conceptual structures, the residents' empathy was different from the students' in the moral component. Although both the residents and the students recognised that empathy for a patient was important to healthcare, the students gave up empathising when they could not share emotion with a patient.

"Although, it is written in a textbook that showing empathy is important, I think that to show or not to show empathy depends on the situation. Frankly, I rather think not to show empathy is better than to show when I feel difficulty" (Student 3, 397).

However, the residents recognised conveying empathy to patients in consideration of their illness or anxiety as one of the professional roles, even if they themselves felt difficulty. Thus, the residents had a stronger motivation than the students; in other words, the residents had a stronger developed moral component.

"Sometimes we meet patients with unreasonable complaints in our sense, but we should construct therapeutic relationships as professionals, even with such patients" (Resident 5, 215).

  Discussion Top

We examined how medical students and residents report their understanding of empathy and the differences between their conceptual structures of empathy. As a theoretical framework, we adopted Morse's classification of components composing empathy: (1) emotive; (2) cognitive; (3) moral and (4) behavioural. We found that both groups recognised the emotive component as an important part of empathy.

However, the importance of the emotive component showed a relative decrease with the increase of clinical experience, and empathy based on the cognitive component took on a major role. The result implies that the decrease of empathy driven by the emotive component shown in previous studies does not necessarily mean a decrease in empathy. Moreover, it also suggests that we underestimate a physician's empathy if we do not consider the development of the cognitive component with progress in clinical training. Pedersen [13] also suggests the similar risk of partial assessment of empathy. The medical students and the residents were not aware of these changes through their training. The residents especially attributed the difficulty in showing empathy by the emotive component to their insensitiveness to patients' suffering, and felt guilty. Thus, ignorance of the change can result in inappropriately low self-efficacy among students and residents. Since low self-efficacy can negatively affect future performance, [17] we, as educators, should discuss the changes in empathy with learners' development as healthcare providers in medical communication skills programs .

Considering factors contributing to the developmental change of empathy, the developed moral component seems to be a major factor. Kohlberg's moral developmental stage [18] is a model describing the extent of moral maturity in six stages: (1) Heteronomous Morality; (2) Individualism, Instrumental Purpose and Exchange; (3) Mutual Interpersonal Expectations, Relationships and Interpersonal Conformity; (4) Social System and Conscience; (5) Social Contract or Utility and Individual Rights and (6) Universal Ethical Principles. We compared the moral components of the residents and students against these stages. The residents' moral component (showing empathy as professional in response to patients' requirement) corresponds to the fifth stage of "Social Contract or Utility and Individual Rights". In contrast, the students' moral component corresponds to the third stage of "Mutual Interpersonal Expectation, Relationships, and Interpersonal Conformity". Consequently, the residents had developed a stronger moral component than the students. The developed moral helps the residents understand patients' background and show empathy to them, even when the residents cannot share the patient's emotion. The participants did not refer to factors fostering the development of the moral component.

Comparing the backgrounds of students and residents, we believe that clinical experiences promote the development in empathy because that is the greatest difference between the groups. The residents learned the importance of empathy as a professional, especially through reflection on their own clinical practices. Therefore, the findings suggest the importance of reflection in moral development, supporting Branch [19] who states the importance of critical reflection for moral development.

A limitation of the study is that it uses data collected from a convenience sample of learners from a single university. The variety of universities that the residents had graduated from might reflect differences in undergraduate education about empathy among the universities. More focus groups would have to be added to analyse the interrelation among the conceptual structures of empathy, the change of the structures by clinical experiences and factors affecting the change. Another limitation is the narrow range of the residents' experiences as physicians. Therefore, focus groups for more experienced physicians are also necessary to verify a relationship between physicians' experiences and the development of the cognitive component-centred empathy. However, the present study is exploratory in nature, attempting to construct a conceptual framework to establish the structures of empathy of medical students and physicians. Therefore, further research is required to investigate whether the models of empathy can be adapted to other medical students and professionals.

Overall, this study has shown that medical students' and residents' concepts about empathy consist of the same four components. Although both students and residents consider empathy important in clinical medicine, the structures of the concepts differ between them. The difference suggests that empathy of medicals students and residents does not simply decline but it changes qualitatively in clinical practice. As factors contributing to the change of empathy, we identify reflection on clinical behaviours and the development of the moral component.

These results suggest that consideration for not only the emotive component but also the other three components is necessary when physicians' empathy is assessed, especially in the case of experienced physicians. The suggestion is consistent with the conclusions of a previous study that assessment from various viewpoints is necessary for empathy. [20]

However, previous studies have revealed a low correlation between physicians' self-assessment and actual clinical competencies. [21],[22],[23] Therefore, we have to introduce assessment from other people, for example patients, [24] for a more valid assessment of physician empathy.

  References Top

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