To determine whether lower levels of empathy among a sample of medical students in the United States are associated with personal and professional distress and to explore whether a high degree of personal well-being is associated with higher levels of empathy.
Multi-institutional, cross-sectional survey.
All medical schools in Minnesota (a private medical school, a traditional public university, and a public university with a focus in primary care).
A total of 1,098 medical students.
Validated instruments were used to measure empathy, distress (i.e., burnout and symptoms of depression), and well-being (high quality of life).
Medical student empathy scores were higher than normative samples of similarly aged individuals and were similar to other medical student samples. Domains of burnout inversely correlated with empathy (depersonalization with empathy independent of gender, all P < .02, and emotional exhaustion with emotive empathy for men, P = .009). Symptoms of depression inversely correlated with empathy for women (all P ≤ .01). In contrast, students’ sense of personal accomplishment demonstrated a positive correlation with empathy independent of gender (all P < .001). Similarly, achieving a high quality of life in specific domains correlated with higher empathy scores (P < .05). On multivariate analysis evaluating measures of distress and well-being simultaneously, both burnout (negative correlation) and well-being (positive correlation) independently correlated with student empathy scores.
Both distress and well-being are related to medical student empathy. Efforts to reduce student distress should be part of broader efforts to promote student well-being, which may enhance aspects of professionalism. Additional studies of student well-being and its potential influence on professionalism are needed.
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ACGME. ACGME Outcome Project. [cited 2006 August 18]; Available from: http://www.acgme.org/Outcome/
Brownell AK, Cote L. Senior residents’ views on the meaning of professionalism and how they learn about it. Acad Med 2001;76(7):734–7.
Halpern J. What is clinical empathy? J Gen Intern Med 2003;18(8):670–4.
Hojat M, Gonnella JS, Mangione S, et al. Empathy in medical students as related to academic performance, clinical competence and gender. Med Educ 2002;36(6):522–7.
The Medical School Objectives Writing Group. Learning objectives for medical student education-guidelines for medical schools: report I of the Medical School Objectives Project. Acad Med 1999;74(1):13–8.
Diseker RA, Michielutte R. An analysis of empathy in medical students before and following clinical experience. J Med Educ. 1981;56(12):1004–10.
Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ 2004;38(9):934–41.
Bellini LM, Shea JA. Mood change and empathy decline persist during three years of internal medicine training. Acad Med 2005;80(2):164–7.
Tutton PJ. Psychometric test results associated with high achievement in basic science components of a medical curriculum. Acad Med 1996;71(2):181–6.
McManus IC, Paice E, Keeling AA. Stress, burnout, and doctors’ attitudes to work are determined by personality and learning style: A twelve year longitudinal study of UK medical graduates. BMC Med 2004;2:29.
Silver HK, Glicken AD. Medical student abuse. Incidence, severity, and significance [see comment]. JAMA 1990;263(4):527–32.
Elnicki DM, Curry RH, Fagan M, et al. Medical students’ perspectives on and responses to abuse during the internal medicine clerkship. Teach Learn Med 2002;14(2):92–7.
Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994;69(11):861–71.
Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med 1998;73(4):403–7.
Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work [see comment]. Lancet 1996;347(9003):724–8.
Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med 1997;44(7):1017–22.
Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136(5):358–67.
Bellini LM, Baime M, Shea JA. Variation of mood and empathy during internship. JAMA 2002;287(23):3143–6.
Melville A. Job satisfaction in general practice: implications for prescribing. Soc Sci Med [Med Psychol Med Sociol] 1980;14A(6):495–9.
DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol 1993;12(2):93–102.
Linn LS, Brook RH, Clark VA, Davies AR, Fink A, Kosecoff J. Physician and patient satisfaction as factors related to the organization of internal medicine group practices. Med Care 1985;23(10):1171–8.
Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med 2000;15(2):122–8.
Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. Health Care Manage Rev 2001;26(1):7–19.
Freeborn DK. Satisfaction, commitment, and psychological well-being among HMO physicians. West J Med 2001;174(1):13–8.
Lichtenstein RL. The job satisfaction and retention of physicians in organized settings: a literature review. Med Care Rev 1984;41(3):139–79.
Schmoldt RA, Freeborn DK, Klevit HD. Physician burnout: recommendations for HMO managers. HMO Pract 1994;8(2):58–63.
Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med 2003;114(6):513–9.
Weiner EL, Swain GR, Wolf B, Gottlieb M. A qualitative study of physicians’ own wellness-promotion practices. West J Med 2001;174(1):19–23.
Yamey G, Wilkes M. Promoting wellbeing among doctors. BMJ 2001;322(7281):252–3.
Yiu V. Supporting the well-being of medical students. CMAJ 2005;172(7):889–90.
Spilker B. Quality of life and pharmacoeconomics in clinical trials. New York: Lippincott-Raven; 1996.
Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient [see comment]. JAMA 1997;278(6):502–9.
Novack DH, Epstein RM, Paulsen RH. Toward creating physician-healers: fostering medical students’ self-awareness, personal growth, and well-being. Acad Med 1999;74(5):516–20.
Epstein RM. Mindful practice [see comment]. JAMA 1999;282(9):833–9.
Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med 2005;20(7):559–64.
Davis MH. A multidimensional approach to individual differences in empathy. Catalog of Selected Documents in Psychology 1980;10 MS. 2124: p 85.
Davis MH. Measuring individual differences in empathy: Evidence for a multidimensional approach. J Pers Soc Psychol 1983;44(1):113–126.
Coman GJ, Evans BJ, Stanley RO. Scores on the Interpersonal Reactivity Index: a sample of Australian medical students. Psychol Rep. 1988;62(3):943–5.
Maslach C. Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press; 1986.
Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol 1986;42(3):488–92.
Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;272(22):1749–56.
Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997;12(7):439–45.
Ware J, Kosinski M, Dewey J, Gandek B. How to score and interpret single-item health status measures: a manual for users of the SF-8 health survey. Lincoln, RI: QualityMetric Incorporated; 2001.
Larson EB, Yao X. Clinical empathy as emotional labor in the patient–physician relationship. JAMA 2005;293(9):1100–6.
Brock CD, Salinsky JV. Empathy: an essential skill for understanding the physician–patient relationship in clinical practice. Fam Med 1993;25(4):245–8.
Benbassat J, Baumal R. What is empathy, and how can it be promoted during clinical clerkships? Acad Med 2004;79(9):832–9.
Charon R. The patient–physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA 2001;286(15):1897–902.
Carmel S, Glick SM. Compassionate–empathic physicians: personality traits and social-organizational factors that enhance or inhibit this behavior pattern. Soc Sci Med 1996;43(8):1253–61.
Evans BJ, Stanley RO, Burrows GD. Measuring medical students’ empathy skills. Br J Med Psychol 1993;66(Pt 2):121–33.
Evans BJ, Stanley RO, Coman GJ, Burrows GD. Psychological tests to measure the effects of medical education on students’ interpersonal skills. Med Educ 1989;23(6):492–497.
Lee RT, Ashforth BE. A meta-analytic examination of the correlates of the three dimensions of job burnout. J Appl Psychol 1996;81(2):123–33.
Leiter MP, Durup J. The discriminant validity of burnout and depression: a confirmatory factor analytic study. Anxiety Stress Coping 1994;7:357–73.
Sloan JA, Loprinzi CL, Kuross SA, et al. Randomized comparison of four tools measuring overall quality of life in patients with advanced cancer. J Clin Oncol 1998;16(11):3662–73.
Loprinzi CL, Kugler JW, Sloan JA, et al. Randomized comparison of megestrol acetate versus dexamethasone versus fluoxymesterone for the treatment of cancer anorexia/cachexia. J Clin Oncol 1999;17(10):3299–306.
Jatoi A, Yamashita J, Sloan JA, Novotny PJ, Windschitl HE, Loprinzi CL. Does megestrol acetate down-regulate interleukin-6 in patients with cancer-associated anorexia and weight loss? A North Central Cancer Treatment Group investigation [see comment]. Support Care Cancer 2002;10(1):71–5.
Gill P, Kaur JS, Rummans T, Novotny PJ, Sloan JA. The hospice patient’s primary caregiver. What is their quality of life? J Psychosom Res 2003;55(5):445–51.
Loprinzi L, Barton DL, Sloan JA, et al. Pilot evaluation of gabapentin for treating hot flashes [see comment]. Mayo Clin Proc 2002;77(11):1159–63.
Grunberg SM, Groshen S, Steingass S, Zaretsky S, Meyerowitz B. Comparison of conditional quality of life terminology and visual analogue scale measurements. Qual Life Res 1996;5(1):65–72.
Gudex C, Dolan P, Kind P, Williams A. Health state valuations from the general public using the visual analogue scale. Qual Life Res 1996;5(6):521–31.
Hyland ME, Sodergren SC. Development of a new type of global quality of life scale, and comparison of performance and preference for 12 global scales. Qual Life Res 1996;5(5):469–80.
Sriwatanakul K, Kelvie W, Lasagna L, Calimlim JF, Weis OF, Mehta G. Studies with different types of visual analog scales for measurement of pain. Clin Pharmacol Ther 1983;34(2):234–9.
Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena [see comment]. Res Nurs Health 1990;13(4):227–36.
Shanafelt TD, Novotny P, Johnson ME, et al. The well-being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group. Oncology 2005;68(1):23–32.
Armitage P. Tests for linear trend in proportions and frequencies. Biometrics 1955;11:375–386.
Dyrbye LN, Thomas MR, Shanafelt TD, et al. Personal life events and medical student burnout: a multicenter study. Acad Med 2006;81(4):374–84.
Newton BW, Savidge MA, Barber L, et al. Differences in medical students’ empathy. Acad Med. 2000;75(12):1215.
Crandall SJ, Volk RJ, Loemker V. Medical students’ attitudes toward providing care for the underserved. Are we training socially responsible physicians? JAMA 1993;269(19):2519–23.
Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ 2004;38(5):522–34.
Patenaude J, Niyonsenga T, Fafard D. Changes in students’ moral development during medical school: a cohort study [see comment]. CMAJ 2003;168(7):840–4.
McCue JD. The effects of stress on physicians and their medical practice. N Engl J Med 1982;306(8):458–63.
Melville A. Job satisfaction in general practice: implications for prescribing. Soc Sci Med 1980;14A:495–499.
Firth-Cozens J. Emotional distress in junior house officers. Br Med J (Clin Res Ed) 1987;295(6597):533–6.
Firth-Cozens J. Interventions to improve physicians’ well-being and patient care. Soc Sci Med 2001;52:215–222.
Purdy RR, Lemkau JP, Rafferty JP, Rudisill JR. Resident physicians in family practice: who’s burned out and who knows? Fam Med 1987;19(3):203–8.
Whippen DA, Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1,000 oncologists. J Clin Oncol 1991;9(10):1916–20.
Lemkau J, Rafferty J, Gordon R, Jr. Burnout and career-choice regret among family practice physicians in early practice. Fam Pract Res J 1994;14(3):213–22.
Whitley TW, Allison EJ, Jr., Gallery ME, et al. Work-related stress and depression among practicing emergency physicians: an international study. Ann Emerg Med 1994;23(5):1068–71.
Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians [see comment]. Br J Cancer. 1995;71(6):1263–9.
Campbell DA, Jr., Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery 2001;130(4):696–702; discussion 702–5.
Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: a five-year prospective longitudinal study. J R Soc Med 1998;91(5):237–43.
Daly MG, Willcock SM. Examining stress and responses to stress in medical students and new medical graduates. Med J Aust. 2002;177(suppl):S14–5.
Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc 2005;80(12):1613–1622.
Collier VU, McCue JD, Markus A, Smith L. Stress in medical residency: status quo after a decade of reform? Ann Intern Med 2002;136(5):384–90.
Stress and impairment during residency training: strategies for reduction, identification, and management. Resident Services Committee, Association of Program Directors in Internal Medicine. Ann Intern Med 1988;109(2):154–61.
Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study [see comment]. J Gen Intern Med 2000;15(7):441–50.
Frank E, McMurray JE, Linzer M, Elon L. Career satisfaction of US women physicians: results from the Women Physicians’ Health Study. Society of General Internal Medicine Career Satisfaction Study Group. Arch Intern Med 1999;159(13):1417–26.
Stoddard JJ, Hargraves JL, Reed M, Vratil A. Managed care, professional autonomy, and income: effects on physician career satisfaction. J Gen Intern Med 2001;16(10):675–84.
Catalan J, Burgess A, Pergami A, Hulme N, Gazzard B, Phillips R. The psychological impact on staff of caring for people with serious diseases: the case of HIV infection and oncology. J Psychosom Res 1996;40(4):425–35.
Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA 2001;286(23):3007–14.
Myers DG. The funds, friends, and faith of happy people. Am Psychol. 2000;55(1):56–67.
Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med 1990;150(9):1857–61.
Shanafelt TD. Finding meaning, balance, and personal satisfaction in the practice of oncology. J Support Oncol 2005;3(2):157–62, 164.
Rabow MW, McPhee SJ. Doctoring to heal: fostering well-being among physicians through personal reflection. West J Med 2001;174(1):66–9.
Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50(10):1129–36.
Kellerman SE, Herold J. Physician response to surveys. A review of the literature. Am J Prev Med 2001;20(1):61–7.
Clark DC, Eckenfels EJ, Daugherty SR, Fawcett J. Alcohol-use patterns through medical school. A longitudinal study of one class. JAMA 1987;257(21):2921–6.
Mangus RS, Hawkins CE, Miller MJ. Tobacco and alcohol use among 1996 medical school graduates. JAMA 1998;280(13):1192–3, 1195.
Clark DC, Daugherty SR, Zeldow PB, Gotterer GS, Hedeker D. The relationship between academic performance and severity of depressed mood during medical school. Compr Psychiatry 1988;29(4):409–20.
Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med 2002;77(9):911–7.
Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students’ depression at one medical school. Acad Med 1997;72(6):542–6.
Winefield HR, Chur-Hansen A. Evaluating the outcome of communication skill teaching for entry-level medical students: does knowledge of empathy increase? Med Educ 2000;34(2):90–4.
Kopelman LM. Values and virtues: how should they be taught? Acad Med 1999;74(12):1307–10.
Spiro H. What is empathy and can it be taught? Ann Intern Med 1992;116(10):843–6.
More ES. Empathy as a hermeneutic practice. Theor Med 1996;17:243–254.
Branch WT, Jr. Supporting the moral development of medical students. J Gen Intern Med 2000;15(7):503–8.
DiLalla LF, Hull SK, Dorsey JK. Effect of gender, age, and relevant course work on attitudes toward empathy, patient spirituality, and physician wellness. Teach Learn Med 2004;16(2):165–70.
Kopelman LM. Philosophy and medical education. Acad Med 1995;70(9):795–805.
Roter DL, Stewart M, Putnam SM, Lipkin M, Jr., Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA 1997;277(4):350–6.
Hornblow AR, Kidson MA, Jones KV. Measuring medical students’ empathy: a validation study. Med Educ 1977;11(1):7–12.
Nightingale SD, Yarnold PR, Greenberg MS. Sympathy, empathy, and physician resource utilization. J Gen Intern Med 1991;6(5):420–3.
Hojat M, Gonnella JS, Nasca TJ, Mangione S, Veloksi JJ, Magee M. The Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item level. Acad Med 2002;77(10 Suppl):S58–60.
Oswald PA. Does the interpersonal Reactivity Index Perspective-taking scale predict who will volunteer time to counsel adults entering college? Percept Mot Skills 2003;97(3 Pt 2):1184–6.
This study was funded through an Academic Primary Care Grant, provided by the division of Primary Care Internal Medicine, Mayo Clinic College of Medicine, and through a Professionalism Grant, provided by the Department of Medicine, Mayo Clinic College of Medicine. The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. The primary author had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
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Thomas, M.R., Dyrbye, L.N., Huntington, J.L. et al. How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study. J GEN INTERN MED 22, 177–183 (2007). https://doi.org/10.1007/s11606-006-0039-6
- quality of life
- undergraduate medical education