Edited by: Monica Pellerone, Kore University of Enna, Italy
Reviewed by: Thelma Quince, University of Cambridge, United Kingdom; Tiziana Ramaci, Kore University of Enna, Italy
This article was submitted to Educational Psychology, a section of the journal Frontiers in Psychology
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Empathy is an important element of the physician-patient relationship and is a critical personality trait for medical students. However, research has shown that it declines during undergraduate medical education. It is still unclear how empathy interrelates with the psychological elements of medical students, in particular, self-esteem. This study examined the relationship between empathy and self-esteem to explore other possible methods to improve medical students’ empathy.
A stratified sampling strategy was used to select 1690 medical students from 3 medical institutions in Shanghai as study participants. The questionnaires used to collect data included the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), the Rosenberg Self-esteem Scale (RSES), and a self-made inventory on personal information. Descriptive analysis, independent
The mean empathy score among medical students was 102.73 with SD = 12.64. Multiple regression analysis revealed that, “age,” “perception of the importance of empathy,” “academic pressure,” “desire to be a doctor after graduation,” and “self-esteem” were significant predictors of empathy (
There was a positive association between self-esteem and empathy. Self-esteem is one of many factors which contribute to medical students’ empathy. Age, academic pressure, attitude toward empathy and future career also play a critical role in medical student empathy. Enhancing medical students’ self-esteem may be an efficacious way to improve medical students’ empathy.
Over the past 20 years, the patient-physician relationship has been deteriorating in China (
Socio-demographic and academic factors including gender (
There is limited literature on empathy’s role in medical students’ greater psychological makeup. Although expressing empathy is linked to communication (
This research study hypothesizes that self-esteem influences medical student empathy. Improving medical students’ self-esteem or discovering mediating factors between self-esteem and empathy may enhance medical students’ empathy. To our knowledge, the correlation between empathy and self-esteem in medical students has not been fully interpreted. Inconsistent past study results may have occurred from study participants spanning across different specialties and from a limited sample size. This research study consequently examines the relationship between self-esteem and empathy in medical students in China, in addition to assessing the differences in empathy scores by gender, year of study, and other academic factors via a multi-institutional design.
A total of 1958 medical students were invited to this study and 1690 chose to participate. The response rate was 86.31%. 693(41.01%) students were from Fudan University Shanghai Medical College, 576(34.08%) students were from Shanghai Jiao Tong University School of Medicine, and 421(24.91%) students were from Tongji University School of Medicine. This study used a stratified sampling strategy to select randomly select subjects by inviting 120–150 students to participate from each medical student year from each of the three universities. The sample consisted of 707(41.83%) male and 983 (58.17%) female participants. Participant age ranged from 16–27 years (M = 20.26, SD = 1.622). All participants attended medical school in Shanghai, were unmarried, high school graduates, and most were from single-child families. According to the medical undergraduate education system among the three institutions, medical students were divided into three stages by school year. 785(46.45%) students were in basic medical science courses from first to second year, 603(35.68%) students were in clinical courses from third to fourth year, and 302(17.87%) students were in internships in their fifth year.
Empathy was measured via the Jefferson Scale of Physician Empathy-Student Version (JSPE-S) (
This study evaluated self-esteem with the RSES (
Personal information was collected, including (1) socio-demographic factors: “gender” with the binary answer “1 = male” and “2 = female,” age; (2) academic factors: “year of school” with the answer “1 = Basic science course (the 1st and 2nd year),” “2 = Clinical course (the 3rd and 4th year),” “3 = Internship (the 5th year)”; “academic pressure” assessed with multiple categorical answer “1 = low,” “2 = moderate,” “3 = Important”; “perception of the importance of empathy” assessed with multiple categorical answer “1 = not important,” “2 = ambivalent,” “3 = important”; “desire to be a doctor after graduation” with the binary answer “0 = no” and “1 = yes”.
Participants were instructed to complete a questionnaire survey including measures of empathy, self-esteem and personal information in the classroom after signing informed consent forms. Three staff from Fudan University Shanghai Medical College, Shanghai Jiao Tong University School of Medicine, and Tongji University School of Medicine administered the survey. It took approximately 15 min for students to complete all the instruments. Each participant received a pen for participating in the study.
The Statistical Package for Social Sciences (SPSS; Version 19.0) was used for data storage, tabulation, and the generation of descriptive statistics. Statistical means were used to describe the descriptive data. Independent samples
As shown in
Descriptive analysis of JSPE-S and RSES (
JSPE-S | 102.73 | 12.64 | 60 | 140 |
Perspective taking | 54.75 | 7.78 | 31 | 70 |
Compassionate care | 39.78 | 6.05 | 12 | 56 |
Standing in the patient’s shoes | 8.20 | 2.46 | 2 | 14 |
RSES | 31.23 | 4.08 | 18 | 40 |
Independent samples
Comparison of the level of empathy among groups with different personal and academic variables.
Gender | ||||||
Male | 707 | 41.83 | 101.68 | 13.19 | –2.908 | 0.004 |
Female | 983 | 58.17 | 103.49 | 12.17 | ||
Year of school | ||||||
Basic science course (1st and 2nd) | 785 | 46.45 | 103.92 | 12.85 | 11.467 | |
Clinical course (3rd and 4th) | 603 | 35.68 | 102.64 | 12.31 | ||
Internship (5th) | 302 | 17.87 | 99.85 | 12.29 | ||
Academic pressure | ||||||
Low | 67 | 4.00 | 97.40 | 13.99 | 7.685 | |
Moderate | 861 | 50.90 | 102.46 | 12.76 | ||
High | 762 | 45.10 | 103.52 | 12.25 | ||
Perception of the importance of empathy | ||||||
Not important | 49 | 2.90 | 82.24 | 8.36 | 168.321 | |
Ambivalent | 163 | 9.54 | 91.91 | 9.19 | ||
Important | 1478 | 87.46 | 104.61 | 11.86 | ||
Desire to be a doctor after graduation | ||||||
Yes | 1588 | 94.00 | 103.11 | 12.54 | 4.891 | |
No | 102 | 6.00 | 96.84 | 12.76 |
Correlation analysis between empathy and self-esteem.
Age | −0.116∗∗ | −0.093∗∗ | −0.068∗∗ | −0.130∗∗ |
RSES | 0.430∗∗ | 0.418∗∗ | 0.230∗∗ | 0.510∗∗ |
To investigate the relationship between students’ empathy and a single factor with marked discrepancy, we took the sum of JSPE-S scores as the dependent variable, and “gender,” “age,” “year of school,” “academic pressure,” “perception of the importance of empathy,” “desire to be a doctor after graduation,” and “self-esteem” as the independent variables. A linear regression and the stepwise method were used to determine the main factors (Stepwise Criteria: Probability-of-F-to-enter ≤0.050, Probability-of-F-to-remove ≥0.100). Of the three models, the third had the highest
Stepwise model summary between empathy and the single factor with marked discrepancy.
(1) | 0.148 |
0.022 | 0.021 | 12.504 | 0.022 | 18.976 | 2 | 1687 | 0.000 |
(2) | 0.556 |
0.309 | 0.307 | 10.523 | 0.287 | 174.732 | 4 | 1683 | 0.000 |
(3) | 0.681 |
0.464 | 0.462 | 9.271 | 0.155 | 486.182 | 1 | 1682 | 0.000 |
Hierarchical linear regression of empathy and the single factor with marked discrepancy.
Socio-demographic factor | Gender Age | 0.072 (0.643, 3.062) −0.130(−1.384, −0.648) | 3.003 −5.418 | 0.003 0.000 | 0.044(0.114, 2.157) −0.046(−0.896, 0.173) | 2.179 −1.326 | 0.029 0.185 | 0.031 (−0.104, 1.697) −0.081 (−1.105, −0.162) | 1.735 −2.633 | 0.083 0.009 |
Academic factors | Year of school | 0.010(−0.989,1.322) | 0.282 | 0.778 | 0.014(−0.0775, 1.261) | 0.469 | 0.639 | |||
Academic pressure | 0.024 (−0.360, 1.426) | 1.170 | 0.242 | 0.072 (0.805, 2.390) | 3.953 | 0.000 | ||||
Perception of the importance of empathy | 0.530 (8.021, 9.354) | 25.567 | 0.001 | 0.424(6.351, 7.565) | 22.485 | 0.000 | ||||
Desire to be a doctor after graduation | 0.087 (2.510, 6.734) | 4.292 | 0.001 | 0.054 (0.994, 4.729) | 3.006 | 0.003 | ||||
Self-esteem | 0.411 (1.158, 1.385) | 22.050 | 0.000 | |||||||
Corrected Model | 18.976 | 0.000b | 125.419 | 0.000c | 207.948 | 0.000d | ||||
Adjusted |
0.021 | 0.307 | 0.462 |
Empathy has been considered the royal road to an optimal physician-patient relationship and overall physician competence in China (
“Self-esteem” was the second most important predictor of empathy in our study, which was consistent with a study on Chinese nursing students (
Furthermore, stress and anxiety have been shown to lead to occupational burnout (
In the final model of regression, “perception of the importance of empathy” was the most significant predictor of empathy. “Academic pressure” as well as “desire to be a doctor after graduation” were also positive but weak contributors of medical students’ empathy. These results suggest that medical students who had a positive attitude toward empathy and future career had higher empathy scores, which echoes a study by
Bivariate analysis showed that empathy scores of participants decreased with increasing years of medical training and were lowest during the final clerkship year. Female medical students had greater empathy scores than male participants. However, after controlling for gender and age in the regression analysis, gender and “year of school” did not significantly affect empathy. This hinted that the significant effects seen in the bivariate analysis may be because of other factors which were not controlled for in the multivariate analyses. Although the associations between gender and “year of school” were insignificant after adjusting for some covariates, previous studies illustrated that factors such as gender and “year of school” may affect empathy (
Age was a weak negative predictor of empathy in this study which may be because younger age is associated with increased empathy from less burnout and fatigue in the medical profession (
Empathy education is a vital part of medical students’ empathy development. Chinese medical students’ low empathy in this study suggests that current education patterns need improvement. Furthermore, our research found a positive relationship between self-esteem and empathy, as well as academic attitude and empathy. These results suggest that factors decreasing self-esteem or mediating factors such as personality, stress or burnout may subsequently negatively affect empathy levels. Improving medical students’ professional identity as well as increasing educational emphasis on empathy may help increase medical students’ self-esteem and empathy.
To our knowledge, this is the first multi-institutional study on Chinese medical students’ self-esteem and empathy. However, we also acknowledge that participants were medical students solely from Shanghai, who were unmarried, mainly from single-child families, and ranged from ages 16–27. This sample is not necessarily representative of empathy levels among medical undergraduates nationwide. Furthermore, participants responded via self-report questionnaires. While these instruments have been validated for the Chinese population, the use of self-reported assessments and the retrospective study design may decrease data validity. Additionally, as this study is cross-sectional and descriptive, future research should confirm our findings via a longitudinal and prospective study. Finally, although the relationship between self-esteem and empathy was positively correlated in this study, there is still a need for further investigation of possible mediating factors such as stress, anxiety, burnout, or wellness.
Empathy is a particularly important disposition for medical students and toward their future careers as doctors. Self-esteem is one of many influential factors toward medical students’ empathy. This study revealed that there is a positive association between self-esteem and empathy. School year, academic pressure, attitude toward empathy, and desire to be a doctor after graduation are also positively correlated with empathy level while age is indirectly related to empathy. By increasing self-esteem and empathy in medical students and physicians, the quality of the patient-physician relationship may be improved, resulting in reciprocally beneficial outcomes. Patients may become more trusting of physicians and be more open to disclosing their concerns to empathetic physicians. Likewise, empathetic, high self-esteem physicians may be more adept at handling sensitive, emotional patient situations. As such, improving self-esteem and empathy in medical students and physicians is a critical component of providing quality health care. Further research may explore additional mediating factors between self-esteem and empathy. Future studies may also investigate the relationship between self-esteem and empathy in medical students outside of Shanghai such as in more rural cities or in different regions of China. This study may also be replicated outside of China to investigate if there is a cultural influence on self-esteem and empathy.
All datasets generated for this study are included in the manuscript and/ro the
Our study had an ethics approval from the School of Medicine Ethics Committee, Tongji University School of Medicine, Shanghai, China and we acquired written informed consent from study participants.
LH contributed to study design, recruitment of participants, data analysis and interpretation and writing of the manuscript. JT and JK assisted in the interpretation of the results and draft writing. YZ and HP assisted in the data acquisition and recruitment of participants. X-DZ contributed to study design and supervision. All authors have approved the final manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors gratefully acknowledge the study participants from Fudan University Shanghai Medical College, Shanghai Jiao Tong University School of Medicine, and Tongji University School of Medicine. All research participants were college students and their informed consent to participate was obtained by virtue of survey completion after they were provided with sufficient information about the study. If they were under 18 years of age, this was obtained through their parents.
The Supplementary Material for this article can be found online at:
The Positive Association between Empathy and Self-esteem in Chinese Medical Students.