Medical Science Educator

, Volume 24, Issue 3, pp 279–290 | Cite as

Critical Thinking and Reflection on Community Service for a Medical Biochemistry Course Raise Students’ Empathy, Patient-Centered Orientation, and Examination Scores

  • Lon J. Van WinkleEmail author
  • Paulette Burdick
  • Bryan C. Bjork
  • Nalini Chandar
  • Jacalyn M. Green
  • Sean M. Lynch
  • Sophie La Salle
  • Susan M. Viselli
  • Chester Robson
Original Research


Meta-analyses of findings for nonmedical curricula show that course-based community service, such as service learning, improves students’ academic achievement and their personal, social, and citizenship outcomes. Based on this strong evidence for K-12 and undergraduate higher education, we tested the theory that biochemistry course-based community service would improve first-year medical students’ empathy, patient-centered orientation, and examination scores. Students completed the Jefferson Scale of Empathy and the patient-practitioner orientation scale at the beginning and end of the first of three biochemistry courses. During the course, biochemistry learning teams of six to seven students selected and performed community service projects and critical thinking and reflection about the projects. They then completed a survey of their opinions about the project. To assess their academic achievement in the course, individual students took biochemistry examinations composed of multiple choice questions. Course-based community service was associated with anticipated improvements in students’ empathy (p = 0.04, effect size = r = 0.44) and patient-practitioner orientation scale (p = 0.004, r = 0.61) scores and, more modestly, with examination (p = 0.02, r = 0.27) scores. Most students agreed that their team community service would help them better to see their biases toward patients (79 %) and to be engaged with them (86 %). Team community service and critical thinking and reflection about the service appear to foster empathy and academic achievement in first-year medical students. As for critical thinking and reflection about other topics, critical thinking and reflection on community service also promote a patient-centered orientation in students.


Biochemistry Critical reflection Patient care Service 


Conflict of Interest

The authors report no conflicts of interest.


  1. 1.
    Baeten M, Kyndt E, Struyven K, Dochy F. Using student-centered learning environments to stimulate deep approaches to learning: factors encouraging or discouraging their effectiveness. Educ Res Rev. 2010;5:243–60.CrossRefGoogle Scholar
  2. 2.
    Batt-Rawden SA, Chisolm MS, Anton B, Flickinger TE. Teaching empathy to medical students: an updated, systematic review. Acad Med. 2013;88:1171–7.CrossRefGoogle Scholar
  3. 3.
    Bell SK, Krupat E, Fazio SB, Roberts DH, Schwartzstein RM. Longitudinal pedagogy: a successful response to the fragmentation of the third-year medical student clerkship experience. Acad Med. 2008;83:467–75.CrossRefGoogle Scholar
  4. 4.
    Burrows MS, Chauvin S, Lazarus CJ, Chehardy P. Required service learning for medical students: program description and student response. Teach Learn Med Int J. 1999;11:223–31.CrossRefGoogle Scholar
  5. 5.
    Conway JM, Amel EL, Gerwien DP. Teaching and learning in a social context: a meta-analysis of service learning’s effects on academic, personal, social and citizenship outcomes. Teach Psychol. 2009;36:233–45.CrossRefGoogle Scholar
  6. 6.
    Cooke M, Irby DM, O’Brien BC. Educating physicians: a call for reform of medical school and residency. The Carnegie Foundation for the advancement of Teaching, Stanford, CA; 2010.Google Scholar
  7. 7.
    Del Canale S, Louis DZ, Maio V, Wang X, Rossi G, Hojat M, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med. 2012;87:1243–9.CrossRefGoogle Scholar
  8. 8.
    Dewey J. How we think. Buffalo, NY: Prometheus Books; 1933.Google Scholar
  9. 9.
    Fjortoft N, Van Winkle LJ, Hojat M. Measuring empathy in pharmacy students. Am J Pharm Ed 75: Article 109; 2011.Google Scholar
  10. 10.
    Flexner A. Medical education in the United States and Canada. The Carnegie Foundation for the advancement of Teaching, NY; 1910.Google Scholar
  11. 11.
    Godfrey P, Illes LM, Berry GR. Creating breadth in business education through service-learning. Acad Manag Lear Educ. 2005;4:309–23.CrossRefGoogle Scholar
  12. 12.
    Haidet P, Kelly PA, Chou C. Communication curriculum and culture study group: characterizing the patient-centeredness of hidden curricula in medical schools: development and validation of a new measure. Acad Med. 2005;80:44–50.CrossRefGoogle Scholar
  13. 13.
    Hojat M, Gonnella JS, Mangione S, Nasca TJ, Veloski JJ, Erdmann JB, et al. Empathy in medical students as related to academic performance, clinical competence and gender. Med Educ. 2002;36:522–7.CrossRefGoogle Scholar
  14. 14.
    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:S58–60.CrossRefGoogle Scholar
  15. 15.
    Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry. 2002;159:1563–9.CrossRefGoogle Scholar
  16. 16.
    Hojat M, Louis DZ, Maio V, Gonnella JS. Empathy and health care quality. Am J Med Qual. 2013;28:6–7.CrossRefGoogle Scholar
  17. 17.
    Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86:359–64.CrossRefGoogle Scholar
  18. 18.
    Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonnella JS, Erdmann JB, et al. The Jefferson scale of physician empathy: development and preliminary psychometric data. Educ Psychol Meas. 2001;61:349–65.CrossRefGoogle Scholar
  19. 19.
    Hojat M, Mangione S, Nasca TJ, Gonnella JS, Magee M. Empathy scores in medical school and ratings of empathic behavior in residency training 3 years later. J Soc Pychol. 2005;145:663–72.CrossRefGoogle Scholar
  20. 20.
    Hojat M, Xu G. A visitor’s guide to effect size: statistical versus practical significance of research findings. Adv Health Sci Educ. 2004;9:241–9.CrossRefGoogle Scholar
  21. 21.
    Hojat M. Empathy in patient care: antecedents, development, measurement, and outcomes. New York: Springer; 2007.Google Scholar
  22. 22.
    Hunt JB, Bonham C, Jones L. Understanding the goals of service learning and community-based medical education: a systematic review. Acad Med. 2011;86:246–51.CrossRefGoogle Scholar
  23. 23.
    Krupat E, Bell RA, Kravitz RL, Thom D, Azari R. When patients and physicians think alike: patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract. 2001;50:1057–62.Google Scholar
  24. 24.
    Krupat E, Pelletier S, Alexander EK, Hirsh D, Ogur B, Schwartzstein R. Can changes in the principal clinical year prevent the erosion of students’ patient-centered beliefs? Acad Med. 2009;84:582–6.CrossRefGoogle Scholar
  25. 25.
    Krupat E, Rosenkranz SL, Yeager CM, Barnard K, Putnam SM, Inui TS. The practice orientations of physicians and patients: the effect of doctor-patient congruence on satisfaction. Patient Educ Couns. 2000;39:49–59.CrossRefGoogle Scholar
  26. 26.
    Leung AYM, Chan SSC, Kwan CW, Cheung MTK, Leung SSK, Fong DYT. Service learning in medical and nursing training: a randomized controlled trial. Adv Health Sci Educ. 2012;17:529–45.CrossRefGoogle Scholar
  27. 27.
    Leung DYP, Kember D. The relationship between approaches to learning and reflection upon practice. Educ Psychol. 2003;23:61–71.CrossRefGoogle Scholar
  28. 28.
    Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86:996–1009.CrossRefGoogle Scholar
  29. 29.
    Nunes P, Williams S, Sa B, Stevenson K. A study of empathy decline in students from five health disciplines during their first year of training. Int J Med Educ. 2011;2:12–7.CrossRefGoogle Scholar
  30. 30.
    Post DM, Kundt FS, Mehl E, Hudson WA, Stone LC, Banks FR. Twenty years of experience in service-learning at the Ohio State College of Medicine. J Community Engagement Scholarsh. 2009;2:18–30.Google Scholar
  31. 31.
    Ribeiro MM, Krupat E, Amaral C. Brazilian medical students’ attitudes toward patient-centered care. Med Teach. 2007;29:e204–8.CrossRefGoogle Scholar
  32. 32.
    Rosenthal R, Rubin DB. A simple, general purpose display of magnitude of experimental effect. J Educ Psychol. 1982;74:166–9.CrossRefGoogle Scholar
  33. 33.
    Smith KL, Meah Y, Reininger B, Farr M, Zeidman J, Thomas JDC. Integrating service learning into the curriculum: lessons from the field. Med Teach. 2013;35:e1139–48.CrossRefGoogle Scholar
  34. 34.
    Svinicki MD, McKeachie WJ. McKeachie’s teaching tips: strategies, research, and theory for college and university teachers. Belmont, NY: Wadsworth; 2014.Google Scholar
  35. 35.
    Tsimtsiou Z, Kerasidou O, Efstathiou N, Papaharitou S, Hatzimouratidis K, Hatzichristou D. Medical students’ attitudes toward patient-centered care: a longitudinal survey. Med Educ. 2007;41:146–53.CrossRefGoogle Scholar
  36. 36.
    Van Winkle LJ, Chandar N, Green JM, Lynch SM, Viselli SM, Burdick P. Does critical reflection by biochemistry learning teams foster patient-centered beliefs among medical students? Med Sci Educ. 2011;21:158–68.CrossRefGoogle Scholar
  37. 37.
    Van Winkle LJ, Dobie S, Ross VR, Sharma U, Green JM, Lynch SM. Acute intervention to foster reflection on reciprocity in relationships increased participants’ patient- or student-centered orientation scores in association with a medical biochemistry course. Internet J Med Educ 1: Number 2; 2011b.Google Scholar
  38. 38.
    Van Winkle LJ, Cornell S, Fjortoft N, Bjork BC, Chandar N, Green JM, et al. Critical thinking and reflection exercises in a biochemistry course to improve prospective health professions students’ attitudes toward physician-pharmacist collaboration, Am J Pharm Educ 77: Article 169; 2013aGoogle Scholar
  39. 39.
    Van Winkle LJ, Fjortoft N, Hojat M. Impact of a workshop about aging on the empathy scores of pharmacy and medical students. Am J Pharm Educ 76: Article 9; 2012.Google Scholar
  40. 40.
    Van Winkle LJ, La Salle S, Richardson L, Bjork BC, Burdick P, Chandar N, et al. Challenging medical students to confront their biases: a case study simulation approach. Med Sci Educ. 2013;23(2):217–24.CrossRefGoogle Scholar
  41. 41.
    Van Winkle LJ, Robson C, Chandar N, Green JM, Viselli SM, Donovan K. Use of poems written by physicians to elicit critical reflection by students in a medical biochemistry course. Journal for Learning Through the Arts 7: Number 1; 2011c.Google Scholar
  42. 42.
    Vogelgesang LJ, Astin AW. Comparing the effects of community service and service-learning. Mich J Community Serv Learn. 2000;7:25–34.Google Scholar
  43. 43.
    Warren JL. Does service-learning increase student learning?: A meta-analysis. Mich J Community Serv Learn. 2012;18:56–61.Google Scholar
  44. 44.
    Wimmers PF, Stuber ML. Assessing medical students’ empathy and attitudes towards patient-centered care with existing clinical performance exam (OSCE). Proc Soc Behav Sci. 2010;2:1911–3.CrossRefGoogle Scholar
  45. 45.
    Yorio PL, Ye F. A meta-analysis on the effects of service-learning on the social, personal, and cognitive outcomes of learning. Acad Manag Learn Educ. 2012;11:9–27.CrossRefGoogle Scholar
  46. 46.
    Zull JE. The art of changing the brain. Sterling, Virginia: Stylus; 2002.Google Scholar

Copyright information

© International Association of Medical Science Educators 2014

Authors and Affiliations

  • Lon J. Van Winkle
    • 1
    Email author
  • Paulette Burdick
    • 1
  • Bryan C. Bjork
    • 1
  • Nalini Chandar
    • 1
  • Jacalyn M. Green
    • 1
  • Sean M. Lynch
    • 1
  • Sophie La Salle
    • 1
  • Susan M. Viselli
    • 1
  • Chester Robson
    • 1
  1. 1.Department of Biochemistry, Chicago College of Osteopathic MedicineMidwestern UniversityDowners GroveUSA

Personalised recommendations