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Development of a metacognitive effort construct of empathy during clinical training: a longitudinal study of the factor structure of the Jefferson Scale of Empathy

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Abstract

Empathy is crucial for effective clinical care but appears to decline during undergraduate medical training. Understanding the nature of this decline is necessary for addressing it. The Jefferson Scale of Empathy (JSE) is used to measure medical students’ clinical empathy attitudes. One recent study described a 3-factor model of the JSE. This model was found in responses from matriculating medical students, but little is known about how the factor structure of the scale changes during clinical training. The Learning Environment Study is a longitudinal prospective study of two cohorts from 28 medical schools. At matriculation and at the end of each subsequent year, students self-reported clinical empathy attitudes using the JSE. Data from 4,797 students were randomly partitioned for exploratory (EFA) and confirmatory factor analyses using responses from preclinical and clinical years of medical school. Five models were compared for confirmatory factor analysis: two null models for control, the recent 3-factor model, and the two models resulting from the EFAs of preclinical and clinical year responses. Preclinical year responses yielded a 3-factor model similar to the recent 3-factor model. Clinical year responses yielded a 4-factor model (“feelings,” “importance,” “ease,” and “metacognitive effort”) suggesting changes in the structure of clinical empathy attitudes over time. Metacognitive effort showed the largest decline over time. The model is a better fit for both preclinical and clinical responses and may provide more insight into medical students’ clinical empathy attitudes than other models. The emergence of metacognitive effort in the clinical years suggests empathy may become more nuanced for students after clinical exposure and may account for much of the observed decline in clinical empathy attitudes.

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References

  • Association of American Medical Colleges. (2005). Recommendations for Clinical Skills Curricula for Undergraduate Medical Education. Retrieved from https://members.aamc.org/eweb/upload/Recommendations for Clinical Skills Curricula 2005.pdf

  • Beck, R. S., Daughtridge, R., & Sloane, P. D. (2002). Physician–patient communication in the primary care office: A systematic review. The Journal of the American Board of Family Practice, 15(1), 25–38.

    Google Scholar 

  • Beckman, H. B., Markakis, K. M., Suchman, A. L., & Frankel, R. M. (1994). The doctor–patient relationship: Lessons from plaintiff depositions. Archives of Internal Medicine, 154(12), 1365–1370.

    Article  Google Scholar 

  • Blatt, B., LeLacheur, S. F., Galinsky, A. D., Simmens, S. J., & Greenberg, L. (2010). Does perspective-taking increase patient satisfaction in medical encounters? Academic Medicine: Journal of the Association of American Medical Colleges, 85(9), 1445–1452.

    Article  Google Scholar 

  • Browne, M. W., & Cudeck, R. (1993). Alternating ways of assessing model fit. In K. A. Bollen & J. S. Long (Eds.), Testing structural equation models (pp. 136–144). Newbury Park: Sage Publications Inc.

    Google Scholar 

  • Byrne, B. M. (2005). Factor analytic models: Viewing the structure of an assessment instrument from three perspectives. Journal of Personality Assessment, 85(1), 17–32.

    Article  Google Scholar 

  • Chen, D., Lew, R., Hershman, W., & Orlander, J. (2007). A cross-sectional measurement of medical student empathy. Journal of General Internal Medicine, 22(10), 1434–1438.

    Article  Google Scholar 

  • Colliver, J. A., Conlee, M. J., Verhulst, S. J., & Dorsey, J. K. (2010). Reports of the decline of empathy during medical education are greatly exaggerated: A reexamination of the research. Academic Medicine, 85(4), 588–593.

    Article  Google Scholar 

  • Courtney, M. G. R. (2013). Determining the number of factors to retain in EFA: Using the SPSS R-Menu v20 to make more judicious estimations. Practical Assessment, Research & Evaluation, 18(8), 1–14.

    Google Scholar 

  • Del Canale, S., Louis, D. Z., Maio, V., Wang, X., Rossi, G., Hojat, M., & Gonnella, J. S. (2012). The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy. Academic Medicine: Journal of the Association of American Medical Colleges, 87(9), 1243–1249.

    Article  Google Scholar 

  • Fabrigar, L. R., Wegener, D. T., MacCallum, R. C., & Strahan, E. J. (1999). Evaluating the use of exploratory factor analysis in psychological research. Psychological Methods, 4(3), 272–299.

    Article  Google Scholar 

  • Gelhaus, P. (2012). The desired moral attitude of the physician: (I) empathy. Medicine, Health Care and Philosophy, 15(2), 103–113.

    Article  Google Scholar 

  • Halpern, J. (2003). What is clinical empathy? Journal of General Internal Medicine, 18(8), 670–674.

    Article  Google Scholar 

  • Hegazi, I., & Wilson, I. (2013). Maintaining empathy in medical school: It is possible. Medical Teacher, 35(12), 1002–1008.

    Article  Google Scholar 

  • Hojat, M., Axelrod, D., Spandorfer, J., & Mangione, S. (2013). Enhancing and sustaining empathy in medical students. Medical Teacher, 35(12), 996–1001.

    Article  Google Scholar 

  • Hojat, M., Gonnella, J. S., Mangione, S., Nasca, T. J., Veloski, J. J., Erdmann, J. B., et al. (2002a). Empathy in medical students as related to academic performance, clinical competence and gender. Medical Education, 36(6), 522–527.

    Article  Google Scholar 

  • Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Veloksi, J. J., & Magee, M. (2002b). The Jefferson Scale of Physician Empathy: Further psychometric data and differences by gender and specialty at item level. Academic Medicine: Journal of the Association of American Medical Colleges, 77(10 Suppl), S58–S60.

    Article  Google Scholar 

  • Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M., & Magee, M. (2002c). Physician empathy: Definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 159(9), 1563–1569.

    Article  Google Scholar 

  • Hojat, M., & LaNoue, M. (2014). Exploration and confirmation of the latent variable structure of the Jefferson Scale of Empathy. International Journal of Medical Education, 5, 73–81.

    Article  Google Scholar 

  • Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C., & Gonnella, J. S. (2011). Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine: Journal of the Association of American Medical Colleges, 86(3), 359–364.

    Article  Google Scholar 

  • Hojat, M., Mangione, S., Kane, G. C., & Gonnella, J. S. (2005). Relationships between scores of the Jefferson Scale of Physician Empathy (JSPE) and the Interpersonal Reactivity Index (IRI). Medical Teacher, 27(7), 625–628.

    Article  Google Scholar 

  • Hojat, M., Mangione, S., Nasca, T. J., Cohen, M. J. M., Gonnella, J. S., Erdmann, J. B., et al. (2001). The Jefferson Scale of Physician Empathy: Development and preliminary psychometric data. Educational and Psychological Measurement, 61(2), 349–365.

    Article  Google Scholar 

  • Hoyle, R. H. (2000). Confirmatory factor analysis. Handbook of applied multivariate statistics and mathematical modeling, 465-497.

  • Hu, L., & Bentler, P. M. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychological Methods, 3(4), 424–453.

    Article  Google Scholar 

  • Kelly, K. J., & Metcalfe, J. (2011). Metacognition of emotional face recognition. Emotion, 11(4), 896–906.

    Article  Google Scholar 

  • Lamm, C., Batson, C. D., & Decety, J. (2007). The neural substrate of human empathy: Effects of perspective-taking and cognitive appraisal. Journal of Cognitive Neuroscience, 19(1), 42–58.

    Article  Google Scholar 

  • Larson, E. B., & Yao, X. (2005). Clinical empathy as emotional labor in the patient–physician relationship. JAMA, 293(9), 1100–1106.

    Article  Google Scholar 

  • May, W. (2013). Maintaining empathy in medical school. Medical Teacher, 35(12), 977–978.

    Article  Google Scholar 

  • Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., et al. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine: Journal of the Association of American Medical Colleges, 86(8), 996–1009.

    Article  Google Scholar 

  • Newton, B. W., Barber, L., Clardy, J., Cleveland, E., & O’Sullivan, P. (2008). Is there hardening of the heart during medical school? Academic Medicine: Journal of the Association of American Medical Colleges, 83(3), 244–249.

    Article  Google Scholar 

  • Ogle, J., Bushnell, J. A., & Caputi, P. (2013). Empathy is related to clinical competence in medical care. Medical Education, 47(8), 824–831.

    Article  Google Scholar 

  • Preston, S. D., & de Waal, F. B. M. (2002). Empathy: Its ultimate and proximate bases. The Behavioral and Brain Sciences, 25(1), 1–71.

    Google Scholar 

  • Preston, S. D., & Stansfield, R. B. (2008). I know how you feel: Task-irrelevant facial expressions are spontaneously processed at a semantic level. Cognitive, Affective, & Behavioral Neuroscience, 8(1), 54–64.

    Article  Google Scholar 

  • Steiger, J. H. (1994). Factor analysis in the 1980’s and the 1990’s: Some old debates and some new developments. In I. Borg & P. P. Mohler (Eds.), Trends and perspectives in empirical social research. Berlin: Walter de Gruyter.

    Google Scholar 

  • Warne, R. T., & Larson, R. (2014). Evaluating a proposed modification of the Guttman rule for determining the number of factors in an exploratory factor analysis. Psychological Test and Assessment Modeling, 56(1), 104–123.

    Google Scholar 

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Correspondence to R. Brent Stansfield.

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Stansfield, R.B., Schwartz, A., O’Brien, C.L. et al. Development of a metacognitive effort construct of empathy during clinical training: a longitudinal study of the factor structure of the Jefferson Scale of Empathy. Adv in Health Sci Educ 21, 5–17 (2016). https://doi.org/10.1007/s10459-015-9605-1

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  • DOI: https://doi.org/10.1007/s10459-015-9605-1

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