The authors designed the present study to examine the association between individuals' scores on the Jefferson Scale of Physician Empathy (JSPE; M. Hojat, J. S. Gonnella, S. Mangione, T. J. Nasca, & M. Magee, 2003; M. Hojat, J. S. Gonnella, T. J. Nasca, S. Mangione, M. Vergare, & M. Magee, 2002; M. Hojat, S. Mangione, T. J. Nasca, M. J. M. Cohen, J. S. Gonnella, J. B. Erdmann, J. J. Veloski, & M. Magee, 2001), a selfreport empathy scale, during medical school and ratings of their empathic behavior made by directors of their residency training programs 3 years later. Participants were 106 physicians. The authors examined the relationships between scores on the JSPE (with 20 Likert-type items) at the beginning of the students' 3rd year of medical school and ratings of their empathic behavior made by directors of their residency training programs. Top scorers on the JSPE in medical school, compared to Bottom scorers, obtained a significantly higher average rating of empathic behavior in residency 3 years later (p < .05, effect size = 0.50). The findings support the long-term predictive validity of the self-report empathy scale, JSPE, despite different methods of evaluations (self-report and supervisors' ratings) and despite a time interval between evaluations (3 years). Because empathy is relevant to prosocial and helping behavior, it is important for investigators to further enhance our understanding of its correlates and outcomes among health professionals.

This study was designed to examine relationships between empathy, specialty interest, personality and perceptions of mother and father. Participants were 422 first-year medical students who completed the Jefferson Scale of Physician Empathy (JSPE), and the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ, short form). They also reported their specialty interest and their perceptions of early relationships with their parents. Results showed that women outscored men on the empathy scale. Also, we found that higher scores on the JSPE were associated with students’ interest in people-oriented specialties (as opposed to procedure- and technology-oriented specialties), higher level of satisfaction with early maternal relationship, higher sociability and lower aggressive-hostility scores. Controlling for gender and social desirability did not change the general pattern of findings.

In view of many changes taking place in today’s health care marketplace, the theme of empathy in health provider-patient relations needs to be revisited. It has been proposed that patients benefit when all members of the health care team provide empathic care. Despite the role of empathy in patient outcomes, empirical research on empathy among health professionals is scarce partly because of a lack of a psychometrically sound tool to measure it. In this study, we briefly describe the development and validation of the Jefferson Scale of Physician Empathy (JSPE), an instrument that was specifically developed to measure empathy among health professionals (20 Likert-type items). The purpose of this study was to compare nurses and physicians on their responses to the JSPE. Study participants were 56 female registered nurses and 42 female physicians in the Internal Medicine postgraduate medical education program at Thomas Jefferson University Hospital. The reliability coefficients (Chronbach’s coefficient alpha) were 0.87 for the nurses and 0.89 for physicians. Results of t test showed no significant difference between nurses and physicians on total scores of the JSPE; however, multivariate analyses of variance indicated statistically significant differences between the two groups on 5 of 20 items of the JSPE. Findings suggest that the JSPE is a reliable research tool that can be used to assess empathy among health professionals including nurses.

CONTEXT It has been reported that medical students become more cynical as they progress through medical school. This can lead to a decline in empathy. Empirical research to address this issue is scarce because the definition of empathy lacks clarity, and a tool to measure empathy specifically in medical students and doctors has been unavailable.OBJECTIVE To examine changes in empathy among medical students as they progress through medical school.MATERIALS AND SUBJECTS A newly developed scale (Jefferson Scale of Physician Empathy [JSPE], with 20 Likert-type items) was administered to 125 medical students at the beginning (pretest) and end (post-test) of Year 3 of medical school. This scale was specifically developed for measuring empathy in patient care situations and has acceptable psychometric properties.METHODS In this prospective longitudinal study, the changes in pretest/post-test empathy scores were examined by using t-test for repeated measure design; the effect size estimates were also calculated.RESULTS Statistically significant declines were observed in 5 items (P < 0.01) and the total sores of the JSPE (P < 0.05) between the 2 test administrations.CONCLUSIONS Although the decline in empathy was not clinically important for all of the statistically significant findings, the downward trend suggests that empathy could be amenable to change during medical school. Further research is needed to identify factors that contribute to changes in empathy and to examine whether targeted educational programmes can help to retain, reinforce and cultivate empathy among medical students for improving clinical outcomes.

Despite the importance of physician empathy in patient care, empirical investigation on the topic is scarce because of conceptual ambiguity and a lack of a psychometrically sound tool for measuring physician empathy. In this article we describe different conceptual views of empathy, draw a distinction between empathy and sympathy, and define physician empathy. We also describe the development and psychometric properties (ie, validity and reliability) of the Jefferson Scale of Physician Empathy (JSPE), a brief research tool (20 Likert-type items) that we developed as a response to a need for an operational measure of physician empathy. We outline an agenda for future research on physician empathy. We conclude that research regarding physician empathy is crucial considering the rapid developments in biotechnology and the current trend toward market-driven, corporate medicine, which strains the physician-patient relationships.

It is as important to know what kind of a man has the disease, as it is to know what kind of disease has the man. —Sir William Osler1 Researchers agree that empathy has a positive role in clinical outcomes2,3,4 and in improving interpersonal relationships,2 but they are divided on its definition and components. In the context of health care, we define empathy as “a cognitive (as opposed to affective) attribute that involves an understanding of the inner experiences and perspectives of the patient, combined with a capability to communicate this understanding to the patient.” With the exception of the affective domain, this definition is similar to the conceptualization of empathy by Feighny and colleagues.5 The key feature of empathy, according to our definition, is understanding, rather than affective involvement with patients' experiences. The affective domain is a key component of sympathy, rather than empathy. The Association of American Medical College's Medical School Objectives Project (MSOP)6 lists empathy among the educational objectives by emphasizing that medical schools should strive to educate altruistic physicians who are “compassionate and empathetic in caring for patients” and who can understand a patient's perspective by demonstration of empathy.6p.13 Medical educators concede that empathy is a significant factor in patient care that must be cultivated during medical education and can be assessed at admission to medical school.7 Likewise, empathy is an important component of “professionalism” in medical practice. Yet, empirical research on empathy among medical students and physicians is scarce. One reason for this dearth of empirical research is the absence of a psychometrically sound and specific research instrument. A few empathy scales for the general population exist that we previously described8,9 but to the best of our knowledge there is no psychometrically sound tool available for measuring empathy among medical students and physicians. There is a need for an operational measure of empathy for medical students and physicians. Such a measure can be used to evaluate the effectiveness of educational interventions aimed at promoting empathy.5 In response to this need, we developed the Jefferson Scale of Physician Empathy.8,9 In our previous studies with students, we found that total empathy scores were significantly associated with clinical competence ratings in medical school, but not with licensing examination scores.10 A significant overlap between empathy and clinical competence constitutes key validity evidence for the empathy scale. In another study, we noticed a significant decline in mean empathy scores during the third year of medical school.11 Such a decline was also observed among internal medicine residents, but it did not reach the conventional level of statistical significance.12 Overall, we found that female students and physicians scored higher in empathy than males.8,9,10 In our studies with physicians, we noted that physicians in “patient-oriented” specialties obtained a significantly higher average empathy score than those in “technology-oriented” specialties.13 Psychiatrists obtained the highest mean empathy score and anesthesiologists, orthopedists, neurosurgeons, and radiologists received the lowest.9 Although we found no significant difference in the total empathy scores between physicians and nurses, the two groups differed significantly on some items.14 Some of these findings that were consistent with our expectations can be considered as evidence in support of the validity of the empathy scale. This study was designed to further examine the psychometric properties of the Jefferson Scale of Physician Empathy, and to investigate differences on individual items between men and women and between physicians in specialty areas defined as “people-oriented” and “technology-oriented.” Method Participants. Participants included 704 physicians (74% men, 26% women) in the Jefferson Health System affiliated with Thomas Jefferson University Hospital and Jefferson Medical College in the greater Philadelphia region. Participants' mean age was 46.8 years, with a standard deviation of 10.5, range from 29 to 87 years. Instrument. The Jefferson Scale of Physician Empathy9 was used. This scale was originally developed to measure the orientation of medical students toward physician empathy in patient-care situations (Student or S Version).8 The scale was constructed based on an extensive review of the literature, followed by pilot studies with samples of physicians, students, and residents.8 After several refinements, the instrument included 20 Likert-type items answered on a seven-point scale (1 = “strongly disagree,” 7 = “strongly agree”). Psychometric data in support of the construct validity and criterion-related validity (convergent and discriminate) of the S-Version of the scale have been reported.8 Internal consistency reliability (coefficient alpha) of this version was .89 for medical students and .87 for medical residents.8 We also developed a revised version of the scale for physicians and health professionals (Health Professional or HP-Version).9 In this version, the wording of the S-Version was modified slightly to make the contents more relevant to the caregiver's empathetic behavior rather than to the student's empathetic orientation or attitudes. For example, the following item appeared in the S-Version: “Because people are different, it is almost impossible for physicians to see things from their patients' perspectives.” In the HP-Version this item read: “Because people are different, it is almost impossible for me to see things from my patients' perspectives.” These modifications were also intended to make the scale applicable to health care providers other than physicians. In the S-Version, only three negatively worded items appeared. Negatively worded items are usually used in psychological tests to decrease the confounding effect of the “acquiescence response style” (e.g., the tendency to constantly agree or disagree: yea-, naysayers).15 In the HP-Version, a balance was maintained by making ten items positively and ten negatively worded. The alpha reliability of the HP-Version was .81. Test—retest reliability was .65 with approximately three to four months between testings.9 (Copies of the scales can be obtained from the authors.) Procedures. The empathy scale, accompanied by a cover letter personally signed by one of the authors (TJN) to increase cooperation, was mailed to 1,007 physicians. The respondents were instructed not to identify themselves, and were assured of strict confidentiality. Two follow-up reminders at four- and eight-week intervals after the original mailing yielded a total of 704 completed surveys, representing a 70% response rate. Respondents were divided into two groups of “people-oriented” specialties (n = 462, 66% of the total respondents who were in primary care specialties [such as family medicine, internal medicine, and pediatrics], obstetrics and gynecology, emergency medicine, psychiatry, and medical subspecialties) and “technology-oriented” specialties (n = 242, 34% of the respondents who were in hospital-based specialties [such as anesthesiology, radiology and pathology], surgery and surgical subspecialties). The classification of people- and technology-oriented specialties is common in medical education research.16 Statistical analyses. Partial item—total score correlations were calculated to identify items with the largest correlations. In addition to analyses of variance (ANOVA) and covariance (ANCOVA), two sets of multivariate analysis of variance (MANOVA) were used (gender was the independent variable in one set and specialty in another), followed by univariate ANOVA to test the significance of differences on each item of the empathy scale. The scores on 20 items of the scale were the dependent variables in both MANOVA models. The effect-size estimates17 were also calculated for each of the mean differences to detect the practical (clinical) importances of the statistically significant findings. Results and Discussion Psychometrics of the items. The mean item scores ranged from a low of 4.8 to a high of 6.5 on the seven-point scale. These findings indicate that responses tend to be skewed toward the upper end of the scale, although physicians actually used the full range of possible responses on all items. The two items with the highest mean score (M = 6.5, both were reverse scored) were: “My understanding of how my patients and their families feel is an irrelevant factor in medical treatment,” and “I believe that emotion has no place in the treatment of medical illness.” The item with the lowest mean score (M = 4.8) was: “I try to think like my patients in order to render better care.” The standard deviations for the items ranged from 0.9 to 1.6. The item—total score correlations (Table 1) were all positive and ranged from a low of .30 for two items: “I do not enjoy reading nonmedical literature” (reverse scored) and “My understanding of how my patients and their families feel is an irrelevant factor in medical treatment” (reversed scored), to a high of .6 for two items: “I try to imagine myself in my patients' shoes when providing care to them,” and “My understanding of my patients' feelings gives a sense of validation that is therapeutic in its own right.” All of the item—total score correlations were highly significant (p < .01). These findings reaffirm the direction of scoring (indicated by positive correlations) and the significant contribution of each item to the total score of the empathy scale (indicated by significant correlations).TABLE 1: The Jefferson Scale of Physician Empathy: Item—Total Score Correlations, Effect-size Estimates for Differences by Gender and Specialty (People-oriented vs. Technology-oriented) at Item Level¶Table 1 shows the item—total score correlations and effect-size estimates of the differences between men and women and between physicians in “people-oriented” and “technology-oriented” specialties. Gender differences. Statistically significant differences were observed on six of the 20 items of the empathy scale (Wilks' lambda = .94, related multivariate F(20,644) = 2.21, p < .01). In these items women consistently scored higher than men, confirming our previous findings of gender differences.8,9,10 The largest gender-effect size estimates were found for the following items: “My patients feel better when I understand their feelings” (d = .25), “I believe that empathy is an important therapeutic factor in medical treatment” (d = .21), and “I consider understanding my patients' body language as important as verbal communication in caregiver—patient relationships” (d = .21). According to the operational definitions suggested by Cohen17p.40 effect-size estimates around .20 are small and negligible, those around .50 are moderate, and those around .80 are large. Therefore, the gender differences are of little practical importance despite their statistical significance. Five of the six items on which women outscored men were among the items included in the “perspective taking” construct (a core ingredient of empathy), which emerged in a factor analytic study of the empathy scale.9 These findings suggest that gender differences are more pronounced on the “perspective taking” aspect of physician empathy. Specialty differences. Statistically significant differences were observed between “people-oriented” and “technology-oriented” specialties on 11 of the 20 items of the empathy scale (Wilks' lambda = .94, related multivariate F(20,661) = 2.25, p < .01). Physicians in “people-oriented” specialties consistently outscored their counterparts in “technology-oriented” specialties in all items, providing further evidence in support of our previous findings on the total scale scores.13 The largest effect size (d = .41) was found for the following item: “An important component of the relationship with my patients in my understanding of the emotional status of themselves and their families.” These findings remained unchanged when we controlled for gender using ANCOVA. Five of the 11 items on which physicians in “people-oriented” specialties scored higher than those in “technology-oriented” specialties were among the “perspective taking” component of the empathy scale. Another five items were among the “compassionate care,” and one item was among the “standing in the patient's shoes” components of the empathy scale that emerged in a factor-analytic study.9 Conclusions and Implementation Findings of this study showed that all items included in the Jefferson Scale of Physician Empathy are relevant to the operational measure of empathy, although the skewed distribution of scores at the item level suggest that some may need further editing. The significant differences between men and women, and between physicians in “people-oriented” and “technology-oriented” specialties suggest that particular aspects of empathy may be more related to gender and specialty. It is important to emphasize that the statistically significant differences among physicians do not necessarily indicate a deficiency in empathy in a low-scoring group, for two reasons. First, none of the effect-size estimates is large enough to indicate that the statistically significant difference is clinically important or is out of normal range. Second, duties involved in the “technology-oriented” specialties do not demand the degree of empathy that is required in the “people-oriented” specialties. Understanding the experiential and emotional status of patients (items with the largest effect-size estimates in Table 1) is more important in primary care than in hospital-based specialties. These findings are valuable in increasing our understanding of similarities and differences among physicians in different aspects of empathy. In recent years, the patient—physician relationship has become severely strained by changes in the economics of medical practice.18 Therefore, it is timely and important to study how empathy can be cultivated and assessed among students and physicians and how it contributes to patient outcomes. It is equally important to know what aspects of empathy are more associated with physicians' demographic and career interests. Our findings suggest that our empathy scale is a reliable and valid instrument for studying physician empathy. We are conducting a multicultural study to examine further the validity of the empathy scale by correlating its scores with patients' perceptions of their physicians' empathy. Once sufficiently validated, the scale could be used in assessing the empathy of individual learners and physicians, thereby meeting a need identified in a recent study on evaluating professional behavior.19

OBJECTIVE There is a dearth of empirical research on physician empathy despite its mediating role in patient-physician relationships and clinical outcomes. This study was designed to investigate the components of physician empathy, its measurement properties, and group differences in empathy scores. METHOD A revised version of the Jefferson Scale of Physician Empathy (with 20 Likert-type items) was mailed to 1,007 physicians affiliated with the Jefferson Health System in the greater Philadelphia region; 704 (70%) responded. Construct validity, reliability of the empathy scale, and the differences on mean empathy scores by physicians' gender and specialty were examined. RESULTS Three meaningful factors emerged (perspective taking, compassionate care, and standing in the patient's shoes) to provide support for the construct validity of the empathy scale that was also found to be internally consistent with relatively stable scores over time. Women scored higher than men to a degree that was nearly significant. With control for gender, psychiatrists scored a mean empathy rating that was significantly higher than that of physicians specializing in anesthesiology, orthopedic surgery, neurosurgery, radiology, cardiovascular surgery, obstetrics and gynecology, and general surgery. No significant difference was observed on empathy scores among physicians specializing in psychiatry, internal medicine, pediatrics, emergency medicine, and family medicine. CONCLUSIONS Empathy is a multidimensional concept that varies among physicians and can be measured with a psychometrically sound tool. Implications for specialty selection and career counseling are discussed.

Context Empathy is a major component of a satisfactory doctor-patient relationship and the cultivation of empathy is a learning objective proposed by the Association of American Medical Colleges (AAMC) for all American medical schools. Therefore, it is important to address the measurement of empathy, its development and its correlates in medical schools.Objectives We designed this study to test two hypotheses: firstly, that medical students with higher empathy scores would obtain higher ratings of clinical competence in core clinical clerkships; and secondly, that women would obtain higher empathy scores than men.Materials and subjects A 20-item empathy scale developed by the authors (Jefferson Scale of Physician Empathy ) was completed by 371 third-year medical students (198 men, 173 women).Methods Associations between empathy scores and ratings of clinical competence in six core clerkships, gender, and performance on objective examinations were studied by using t -test, analysis of variance, chi-square and correlation coefficients.Results Both research hypotheses were confirmed. Empathy scores were associated with ratings of clinical competence and gender, but not with performance in objective examinations such as the Medical College Admission Test (MCAT), and Steps 1 and 2 of the US Medical Licensing Examinations (USMLE).Conclusions Empathy scores are associated with ratings of clinical competence and gender. The operational measure of empathy used in this study provides opportunities to further examine educational and clinical correlates of empathy, as well as stability and changes in empathy at different stages of undergraduate and graduate medical education.

This study was designed to investigate the impact of physicians' perceptions of the health care system on their discontent with their profession. By using a random digit dialing technique, a structured telephone interview was conducted with 401 generalist physicians (343 men, 56 women) who were practicing medicine at least for five years and were younger than 65 years. Physicians' willingness to choose medicine again was correlated with their perceptions of different aspects of the health care system. Of the total participants, 288 (72 percent) indicated that they would choose medicine again, 91 (23 percent) would not choose medicine, and 22 (5 percent) were not sure. Results of the step-wise logistic regression showed that after adjustment for physicians' gender and age, those who would not choose medicine again were more than twice as likely as other physicians who would choose medicine to believe that the health care environment will deteriorate more in the future (odds ratio = 2.1, p < .01), were less than half as likely to believe that physicians nowadays share more responsibilities with other health care professionals (odds ratio = .42, p < .01), and were less than half as likely to confirm that patients understand their health insurance better than before (odds ratio = .46, p < .01). Findings suggest that physicians' discontent can be predicted by their negative perceptions of the health care environment. Findings have implications for improving the quality of professional and personal life of the physician, thus improving the quality of care and satisfaction of the patient.

The present study was designed to develop a brief instrument to measure empathy in health care providers in patient care situations. Three groups participated in the study: Group 1 consisted of 55 physicians, Group 2 was 41 internal medicine residents, and Group 3 was composed of 193 third-year medical students. A 90-item preliminary version of the Empathy scale was developed based on a review of the literature and distributed to Group 1 for feedback. After pilot testing, a revised and shortened 45-item version of the instrument was distributed to Groups 2 and 3. A final version of the Jefferson Scale of Physician Empathy containing 20 items based on statistical analyses was constructed. Psychometric findings provided support for the construct validity, criterion-related validity (convergent and discriminant), and internal consistency reliability (coefficient alpha) of the scale scores.

On the basis of the belief that measuring instruments that were developed for the general population did not tap the essence of empathy in the context of patient care, we developed an operational measure of empathy specifi- cally applicable to medical care. This chapter describes the steps taken in the development and psychometric analyses of the Jefferson Scale of Physician Empathy (JSPE). The evidence presented in support of the JSPE’s validity (face, content, construct, criterion-related, convergent, and discriminant validities) and reliability (coefficient alpha in support of internal consistency and test–retest reliability in support of score stability) can enhance the confidence of researchers who are searching for a psychometrically sound instrument developed specifically to study empathy in the context of patient care. The general findings on the JSPE’s measurement properties suggest that the instrument can serve as an operational measure of empathy among students (S-Version) and practitioners in the health professions (HP-Version). Further research is needed to investigate the relationship between scores on the JSPE and clinical outcomes, such as accuracy of diagnosis, patient satisfaction, patient compliance, and reduced risk of malpractice claims.

Purpose: During arthroscopy of the shoulder, the ability to pass the arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the inferior glenohumeral ligament is considered a positive drive-through sign. The drive-through sign has been considered diagnostic of shoulder instability and has been associated with shoulder laxity and with SLAP lesions. The goal of this study was to examine the prevalence of the drive-through sign in patients undergoing shoulder arthroscopy and to determine its relationship to shoulder instability, shoulder laxity, and to SLAP lesions. Type of Study: Case series. Methods: We prospectively studied 339 patients undergoing arthroscopy of the shoulder for a variety of diagnosis from 1992 to 1998. The drive-through sign was performed with the patients in a lateral decubitus position and under general anesthesia. The drive-through sign was correlated with preoperative physical findings, intraoperative laxity testing, and with intra-articular pathology at the time of arthroscopy. Results: The arthroscopic evaluation showed that drive-through sign was positive in 234 (69%) shoulders. For the diagnosis of instability, the drive-through sign had a sensitivity of 92%, a specificity of 37.6%, a positive predictive value of 29.9%, a negative predictive value of 94.2%, and an overall accuracy of 49%. There was an association between the drive-through sign and increasing shoulder laxity, but not with SLAP lesions. Conclusions: This study shows that a positive drive-through sign is not specific for shoulder instability but is associated with shoulder laxity. This arthroscopic sign should be incorporated with other factors when considering the diagnosis of instability.

PURPOSE: To compare personality profiles of internal medicine residents with those of the general population and positive role models in medicine. METHOD: A widely used personality inventory, NEO PI-R, which measures five major personality factors and 30 important personality facets, was administered in 1998 to 104 physicians in internal medicine residency and earlier to a nationwide sample of 188 physicians selected as positive role models in medicine. RESULTS: The internal medicine residents, compared with the general population, were more likely to be attentive, to have deeper intellectual curiosity, to have higher aspiration levels, to have more vivid imaginations, to be more receptive to their emotions, to be interested in mental stimulation, and to think carefully before acting. The residents, compared with role models in medicine, were less eager to face challenges, less able to control their impulses, less able to cope with adversity, less easygoing, and less relaxed, but were more likely to crave excitement. CONCLUSION: Internal medicine residents and positive role models in medicine have some distinct personal qualities. Understanding the qualities of successful physicians can be helpful in career counseling of medical students and young physicians.

This study was designed to investigate the personality profile of positive role models in medicine. Participants were a national sample of 188 physicians (164 men, 24 women) who had been nominated by the chief executive officers of their institutions as positive role models and who completed the Revised NEO Personality Inventory. Compared to the general population, these 188 male and female positive role models in medicine scored higher on Conscientious factor, and on Achievement Striving, Activity, Competence, Dutifulness, Trust, Assertiveness, and Altruism facets, but they scored lower on the Vulnerability facet than the general population. In addition, the male role models scored significantly higher than men in the general population on the Agreeableness factor, and the female role models obtained significantly higher scores than the population norms on Extraversion and Openness factors, and on Feelings, Ideas, Positive Emotions, Values, Warmth, Aesthetics, and Fantasy facets. The female role models scored far below their sex-related norms on Neuroticism factor and on Angry Hostility facet. Comparisons between the male and female role models showed that the female role models scored higher on the Openness factor, and on the Feelings, Positive Emotions, Aesthetics, and Fantasy facets of personality. Implications in medical education and in explaining, assessing, and improving the qualities that contribute to professional success and in promoting the concept of “positive medicine” are discussed.