Empathy Impact on Clinical Competence in Medical Education

1. Empathy in Medical CareJessica Ogle (D. Psych (Clin) Candidate), John Bushnell (PhD FNZCCPsych), & Peter Caputi (PhD) Jessica Ogle

2. Background • The role of empathy in a clinician-patient interaction has been explored more often in the context of psychotherapy than in medical practice • In medical care, the definition of empathy emphasises three specific features of empathy: cognition, understanding, and communication • Conceptually, empathic communication and behaviour should play a critical role in the effectiveness of the clinical encounter • Given the aim of medical schools to produce clinically competent doctors it is important to investigate the relationship between empathy and competence

3. A Theoretical Framework • The theoretical link between empathic clinician-patient engagement and clinical competence is based on three perspectives(Hojat, 2007). • Medical perspective – empathic relationship enables increased honesty regarding symptoms and concerns leading to a more accurate medical history and therefore more precise diagnosis • Psychological perspective – empathic relationship enables patient to view clinician as a secure base leading to a genuine human connection and space to explore their illness and disclose real fears • Sociological perspective - an empathic relationships enables to patient to view the clinician as a helpful member of a social support system

4. Hypotheses • There has been recent evidence that higher levels of empathy are associated with higher levels of clinical competence and positive patient outcomes • The purpose of this study was to investigate the relationship of empathy to clinical competence among medical students. • It was hypothesised that those students who were more empathic during the clinical interaction would gain higher clinical competence scores. It was also expected that self-ratings of empathy would be positively associated with clinical competence scores.

5. Methods • Participants: • Year 3 students of a regional and rural Australian Graduate School of Medicine • 23 males, 37 females • OSCE Background • The OSCE was originally developed as a way of obtaining reliable and objective assessment of clinical skills • Medical students enter a simulated clinical encounter (known as a 'station') and demonstrate their clinical skills on a standardised patient (SP), with the aim to show competence in a particular skill or management of the patient.

6. Methods • Assessment of Clinical Competence • Students participated in a summative OSCE • 13 x 9 minute SP cases (surgery, paediatrics, obstetrics an gynaecology, general medicine, and psychiatry) • The current study assessed 10 of the 13 stations • Total Competence Score (judged by medical professionals): • Process Score • Content Score • Patient Rating • Videotaping of the OSCE

7. Method • Assessment of Empathy • Jefferson Scale of Physician Empathy (JSPE-S): • Self report of empathy applicable to medical care as provided by medical students • 20 items on a 7 point Likert scale • Total score ranges from 20-140 • Rating Scales for the Assessment of Empathic Communication in Medical Interviews (REM) • Comprises of 6 items related to empathy and 3 items related to confrontation • Empathy is measured on a seven-point Likert scale - the two endpoints are described in specific behavioural terms • A higher value indicates greater empathy and less confrontation

8. Method • Procedure • Participants were asked to complete the JSPE-S, in addition to consenting to release their grades and video recordings of the summative OSCE. • The summative OSCE was videotaped for the purpose of enabling additional examiners to rate the student performance should there be uncertainty or disagreement about the level of student performance. • Participants were graded by examiners and patients on their OSCE performance. • Participant empathy was assessed in each videotaped simulated consultation using the REM.

9. Results: Correlation Analysis (REM)

10. Results: Correlation Analysis (JSPE-S)

11. Results: Descriptive Statistics

12. Results: Comparison of Mean Scores

13. Results • Rating of student empathy by an independent observer was strongly associated with examiners judgements of greater clinical competence. • Self-rated empathy, however, was not associated with clinical competence. • The results of this study indicate an association between observed empathy and clinical competence across a range of medical conditions and disorders, and different clinical tasks involving history-taking, procedural and examination skills, and patient education. • The reasons for a lack of congruence between the independent-observer rated measure of empathy, and the student’s self reported empathy are not immediately obvious.

14. Discussion • Two major findings: • Strong association between clinical competence and observer-rated empathy • Discrepancy between self- and observer-ratings of empathy • Reasons for lack of congruence between self- and observer-ratings of empathy? • Self-report instruments may not be indicative of the quality and effectiveness of the use of empathy in a clinical interaction • Rating scales may be measuring different constructs • Medical students modify their behaviours in the context of a summative examination in order to perform in a way they believe the examiners desire

15. Future Research • Explore the discrepancies between self- and observer-ratings of empathy by comparing individual differences among medical students. • Specifically, whether medical students who demonstrated discrepancies in self- and observer-ratings of empathy differ from those who did not demonstrate discrepancies with regards to personality constructs, attachment subscales, and clinical competence

16. Conclusion • The use of self-assessment tools may not sufficiently predict empathic behaviour • Empathy may be an enabling factor in clinical competence • Despite the discrepancy between self- and observer-ratings, the patient’s need for an empathic doctor will always be important.