1Department of Community Medicine, Hawler Medical University, Erbil, Iraq; 2Department of Preventive Health, Public Health Institute, Erbil, Iraq *Corresponding Author e-mail: awringmaroof62@yahoo.com قياس مستوى التعاطف لدى طالب الطب الكرد يف مدينة أربيل يف العراق دراسة مقطعية اأورينك معروف روؤوف و بريف�ن عدن�ن ي��شني abstract: Objectives: Empathy is a crucial attribute within the physician-patient relationship. This study aimed to evaluate the empathy levels of students in the College of Medicine at Hawler Medical University (HMU) in Erbil city, Iraq. Methods: This cross-sectional study took place between January and May 2015 and included all medical undergraduates enrolled at HMU (n = 989). The validated self-administered English language version of the Jefferson Scale of Physician Empathy-Student Version (JSPE-SV) was used to measure empathy levels. Students reported their conformity to each statement of the 20-item questionnaire on a 7-point Likert scale. Levels of empathy were considered directly relative to their final score. Results: A total of 927 students completed the questionnaire (response rate: 93.7%). The male-to-female ratio was 0.72:1 and the mean age was 21.3 ± 1.4 years. The mean empathy score was 101.9 ± 19.2. Female students had significantly higher empathy (P = 0.023) and more frequently chose people-oriented specialties (P = 0.001) than males. First-year students reported the highest mean score (112.9 ± 20.1) while fourth-year students had the lowest (92.7 ± 16.0). There was a significant decline in mean scores between first- and second-year male students (P = 0.020) and first- and fourth-year male students (P = 0.050). Students who chose people-oriented specialties had significantly higher scores than those who chose technology- oriented specialties (P = 0.002). Conclusion: The studied cohort of HMU students demonstrated low empathy levels. As such, the inclusion of empathy instruction in medical school curricula is recommended to promote professionalism and patient welfare. Keywords: Empathy; Attitudes; Medical Students; Physician-Patient Relations; Medical Education; Iraq. امللخ�ص: الهدف: يعد التقم�ص الع�طفي �شفة مهمه يف عالقة الطبيب مع املري�ص. ك�ن الهدف من هذه الدرا�شة تقييم م�شتوى التع�طف لدى طالب كلية الطب يف ج�معة هولري الطبية )HMU( مبدينة اأربيل يف العراق. الطريقة: اأجريت هذه الدرا�شة املقطعية يف كلية الطب يف مدينة اأربيل بني �شهر ك�نون Jefferson Scale ا�شتبي�ن الطالب اإعط�ء مت .)n = 989( HMU يف للدرا�شة امل�شجلني الطالب جميع وت�شمنت ،2015 ع�م من م�يو �شهر و الث�ين املوثق ذاتي االإكم�ل ب�للغة االإنكليزية لقي��ص م�شتوى التع�طف. ت�شمن االإ�شتبي�ن ع�رضين �شوؤاال على مقي��ص ليكرت ذوي النق�ت ال�شبعة. ومت قي��ص درجة .)93.7% )ن�شبةاال�شتج�بة: ط�لب� 927 قبل من االإ�شتبي�ن اإكم�ل مت الط�لبة. النتائج: اأو الط�لب �شجله� النه�ئيةالتي النق�ط عدد اإىل من�شوب� التع�طف ك�نت ن�شبة الذكور اإىل االإن�ث 0.72:1. وك�ن معدل اأعم�رهم 1.4 ± 21.3 �شنة. ك�ن معدل التع�طف للطالب 19.2 ± 101.9 وك�نت درجة تع�طف االإن�ث .)P = 0.001( اإح�ش�ئية داللة مع الذكور اأكربمن ال�رضيرية للفروع االإن�ث اختي�ر ن�شبة وك�نت )P = 0.023( اإح�ش�ئية بداللة اأكرب الذكور اإىل ن�شبة ك�نت اأعلى الدرج�ت لطالب ال�شنة االأوىل )20.1 ± 112.9( بينم� درج�ت طالب ال�شنة الرابعة ك�نت االأقل )16.0 ± 92.7( ك�ن هن�ك نق�ش�ن يف معدل الدرج�ت لطالب ال�شنة الث�نية مق�رنة مع طالب ال�شنة االأوىل ذا داللة اإح�ش�ئية )P = 0.002( و�شجل طالب الفروع ال�رضيرية معدل اأعلى من طالب الفروع التكنولوجية. اخلال�صة: ك�ن معدل التع�طف متدني� يف املجموعة املدرو�شة من HMU. تو�شي هذه الدرا�شة ب�إعط�ء االأهمية للتوجيه املعنوي يف املن�هج الدرا�شية للكلية لتعزيز االأداء املهني ورع�ية املر�شى. مفتاح الكلمات: التع�طف؛ ال�شلوكية؛ طالب الطب؛ عالقة الطبيب مع املري�ص؛ التعليم الطبي؛ العراق. Measuring Empathy Levels among Kurdish Medical Students in Erbil City, Iraq Cross-sectional study *Awring M. Raof1 and Bervian A. Yassin2 Advances in Knowledge - Low empathy levels were reported among a group of medical undergraduate students in Erbil city, Iraq. - Female students had significantly higher empathy levels than male students among the studied group and a significant decline in empathy scores was observed among male students according to academic year. - The results of this study suggest that students with higher empathy levels may select people-oriented over technology-oriented specialties. Application to Patient Care - While the results of this study cannot be generalised to all medical students in Iraq, the low levels of empathy reported among the studied medical students have alarming implications for future patient care. The inclusion of empathy education in medical school curricula is therefore of vital importance due to the significant impact of this attribute on physician-patient relationships. clinical & basic research Sultan Qaboos University Med J, February 2016, Vol. 16, Iss. 1, pp. e62–67, Epub. 2 Feb 16 Submitted 14 Jun 15 Revision Req. 26 Jul 15; Revision Recd. 24 Aug 15 Accepted 2 Sep 15 doi: 10.18295/squmj.2016.16.01.011 Awring M. Raof and Bervian A. Yassin Clinical and Basic Research | e63 In order to be effective, physicians need to form sympathetic and beneficial relationships with their patients.1 One of the most important skills needed to form and maintain a relationship is empathy.2 Although there are several different definitions of empathy, it is generally defined as the capacity to “see the world as others see it, be nonjudgmental, understand another’s feelings, and communicate the understanding”.3 Communications between patients and caregivers rely upon the empathetic nature of the medical doctor.4 Hojat et al. verified that physician compassion is strongly related to enhanced patient outcomes, compliance and contentment and a decline in medicolegal problems.5 Previous studies have determined various factors that affect levels of empathy, including gender, academic performance and an individual’s relationship with their mother.6,7 A study from the USA observed significant differences in empathy levels between genders and between physicians in people-oriented versus technology-oriented specialties, suggesting that certain aspects of empathy may be related to gender and choice of medical specialty.8,9 The Hawler Medical University (HMU) is a public university in Erbil city, Iraq. The recently revised six- year undergraduate medical curriculum in the HMU College of Medicine includes a series of courses on medical ethics and communication skills with the aim of strengthening future patient-physician relationships. This training is intended to guarantee that medical graduates will have the necessary clinical skills to competently and empathetically consider patients’ feelings and experiences, thus improving care by reducing patient suffering and helping them to feel more relaxed. This study therefore sought to measure empathy levels among a sample of medical students at HMU. Specifically, differences in empathy levels were assessed according to gender, academic year and choice of specialty. To the best of the authors’ knowledge, no such study has yet been conducted among Kurdish medical students and this is the first time that the Jefferson Scale of Physician Empathy- Student Version (JSPE-SV) has been used in Erbil city. Methods This cross-sectional study was carried out between January and May 2015 and included all undergraduate students enrolled in the 2014–2015 academic year at the College of Medicine at HMU (n = 989; male-to-female ratio: 0.74:1). Empathy levels were determined using the JSPE-SV. This self-administered English language 20-item questionnaire was originally developed in 2001 to measure medical students’ attitudes towards physician empathy in a patient-care situation.8 It has been validated in the USA, Mexico and Japan.8,10,11 The measurement of internal consistency (Cronbach’s alpha) is 0.76.12 The English language version of the JSPE-SV questionnaire was distributed to all students at the end of each class.8 The questionnaire was completed anonymously in approximately 30 minutes and returned to the researchers. Respondents reported their degree of agreement with each item on a 7-point Likert scale; however, 10 of the items were negative statements and were marked in reverse order.9 The final score ranged between 20–140 and a participant’s level of empathy was considered directly relative to their score. A non-responder was defined as a student who failed to return the survey. Surveys with less than 16 completed items were excluded from the results. Demographic information such as age, gender and choice of specialty was also collected. Missing gender values for respondents who did not provide their gender was determined using a discriminate function test. Males and females were categorised using forms in which the gender was identified as the endpoint. This procedure was then applied to data from those in the unknown gender group. Choice of speciality was categorised as either technology- or people-oriented. Technology-oriented specialties included surgery and related subspecialties; oncology; preventative and social medicine; pathology; radiology; and anaes- thesiology.6 People-oriented specialties included family medicine; neurology; paediatrics; psychiatry; emergency medicine; obstetrics and gynaecology; ophthalmology; dermatology; and internal and rehabilitation medicine.6 Students were asked to determine their choice of speciality by rating their future likelihood of entering each specialty mentioned above on a 4-point Likert scale ranging from 1 (very unlikely) to 4 (very likely).8 Each student was then classified as choosing either technology- or people- oriented specialties after comparing their overall scores for each group. Data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 21 (IBM Corp., Chicago, Illinois, USA). Measures of central tendencies and distributions were determined. The one-way analysis of variance (ANOVA), Bonferroni post hoc test and Student’s t-test were used to assess statistical significance. Pearson’s Chi-squared test was used for group frequency comparisons. Statistical significance was set at P ≤0.050. This study was granted ethical approval by the Research Ethics Committee at the College of Medicine of HMU (meeting #1 paper #5). All students were informed that participation in the study was voluntary and anonymity was guaranteed. All forms were coded to avoid respondent identification. Measuring Empathy Levels among Kurdish Medical Students in Erbil City, Iraq Cross-sectional study e64 | SQU Medical Journal, February 2016, Volume 16, Issue 1 Results Of the 989 students included in the study, a total of 927 completed the survey (response rate: 93.7%) [Table 1]. There were 391 male respondents (42.2%) and 536 female respondents (57.8%) with a male-to-female ratio of 0.72:1. The mean age of the respondents was 21.3 ± 1.4 years (range: 17‒25 years old). Overall, the mean empathy score of the students was 101.9 ± 19.2. Table 2 displays the mean empathy scores of male and female students, respectively (98.6 ± 16.2 versus 102.5 ± 19.9). This difference was statistically signi- ficant (P = 0.023). Mean empathy scores decreased as academic years increased; first-year medical students reported the highest mean empathy score (112.9 ± 20.1) while the lowest mean score was observed among the fourth- year medical students (92.7 ± 16.0) [Table 3]. When adjusted for age, gender and choice of future specialty, the difference in empathy scores between first- and fourth-year students was 16.1. A significant decline in mean empathy scores was noted between male students in their first versus second academic year (Bonferroni test = 8.7; P = 0.020) and between male students in their first versus fourth academic year (Bonferroni test = 10.1; P = 0.005) [Table 4]. There was a statistically significant difference between genders with regards to choice of specialty. Females more frequently chose people-oriented specialties in comparison to males (62.3% versus 25.8%; P = 0.001) [Table 5]. Furthermore, students who chose people-oriented specialties had higher mean empathy scores, whereas those who selected technology-oriented specialties had lower scores (109.9 ± 20.2 versus 99.8 ± 16.1; P = 0.002) [Table 6]. Table 1: Questionnaire distribution by academic year among students at Hawler Medical University in Erbil city, Iraq (N = 989) Academic year Total 1st year 2nd year 3rd year 4th year 5th year 6th year Students per class 172 161 170 153 161 172 989 Questionnaires distributed 172 160 169 152 159 170 982 Respondents per questionnaires (response rate, %) 165 (95.9) 159 (99.4) 167 (98.8) 150 (98.7) 155 (97.5) 131 (77.1) 927 (94.4) Response rate of class, % 95.9 98.8 98.2 98.0 96.3 76.2 93.7 Table 2: Distribution by mean empathy score* and gender of the studied sample of students at Hawler Medical University in Erbil city, Iraq (N = 927) Gender n (%) Mean empathy score ± SD P value Male 391 (42.2) 98.6 ± 16.2 0.023 Female 536 (57.8) 102.5 ± 19.9 - Total 927 (100.0) 101.9 ± 19.2 - SD = standard deviation. *Empathy was self-assessed by respondents using the English version of the 20-item Jefferson Scale of Physician Empathy-Student Version.8 Table 3: Distribution by academic year and mean empathy score* of the studied sample of students at Hawler Medical University in Erbil city, Iraq (N = 927) Academic year n (%) Empathy score Mean ± SD 95% CI Lowest score Highest score 1st year 165 (17.8) 112.9 ± 20.1 112.4–121.3 35.0 139.0 2nd year 159 (17.2) 110.5 ± 20.0 94.3–114.7 44.0 134.0 3rd year 167 (18.0) 101.8 ± 20.0 97.1–106.5 33.0 137.0 4th year 150 (16.2) 92.7 ± 16.0 91.1–101.4 53.0 130.0 5th year 155 (16.7) 94.7 ± 17.0 90.8–106.5 56.0 134.0 6th year 131 (14.1) 93.7 ± 17.0 91.8–106.5 45.0 131.0 Total 927 (100.0) 101.9 ± 19.2 99.2–104.6 33.0 139.0 SD = standard deviation; CI = confidence interval. *Empathy was self-assessed by respondents using the English version of the 20-item Jefferson Scale of Physician Empathy-Student Version.8 Awring M. Raof and Bervian A. Yassin Clinical and Basic Research | e65 Discussion The current study sought to measure self-assessed empathy levels among a sample of medical students at a public university in Erbil city. The response rate to the questionnaire was much higher than those reported from similar studies in the USA, Iran, Portugal, Japan, Kuwait and the UK.10,11,13–16 The overall mean empathy score among the studied sample in the current study (101.9) was close to scores from studies conducted in Japan (104.3) and Iran (104.1), but lower than those reported from Western countries.11–14 However, the mean empathy score for first-year medical students in the current study (112.9) was similar to that reported in Iran (110.3) and the USA (115.5).13,14 Additionally, the higher level of empathy among female students noted in the current study was consistent with previous research.9,17,18 In the current study, the mean empathy score reported by first-year students was highest, with mean empathy scores declining in the second and subsequent academic years—second-year students displayed higher empathy scores than fourth-year students and final year students displayed lower empathy scores than students in their first academic year. This finding was consistent with other studies, which suggests that levels of empathy decline during clinical training.10,13,14 After empathy scores were adjusted for age, gender and choice of future specialty, the difference in mean scores between first- and fourth- year students in the current study (16.1) was higher than that of an American study (11.9).13 Another study conducted among dental students reported a decline in empathy levels after the introduction of clinical tasks.19 In a longitudinal study of undergraduate nursing students conducted to evaluate changes in empathy levels, Ward et al. found that students showed a decline in empathy over the course of one year.20 There are a number of possible factors which may influence the reduction in empathy levels among students as education progresses. Low levels of empathy may be reflective of the prevalent teaching methods at a particular academic institution. The education and training of medical students may be stressful and include extensive work hours and a lack of sleep. Bedside communication may also become reduced due to time constraints, leading to a decrease in empathy.21 The increasingly emotionally demanding and harsh conditions of their academic career could negatively affect feelings of compassion among medical students.22–24 Furthermore certain Table 4: Mean difference* in empathy scores† between male students according to academic year‡ among the studied sample at Hawler Medical University in Erbil city, Iraq (N = 927) Academic year Mean difference I - J P value 95% CI I J 1st year 2nd year 8.7 0.020 0.9–18.5 1st year 4th year 10.1 0.005 2.2–20.0 2nd year 1st year -8.7 0.020 -18.5–-0.9 4th year 1st year -10.1 0.005 -20.0–-2.2 CI = confidence interval. *Calculated using the Bonferroni post hoc test to assess dependent variable scores with multiple comparisons. †Empathy was self-assessed by respondents using the English version of the 20-item Jefferson Scale of Physician Empathy-Student Version.8 ‡There were no significant differences between empathy scores among female students according to academic year and between empathy scores among male students in other academic years. Table 5: Distribution by gender and choice of specialty* of the studied sample of students at Hawler Medical University in Erbil city, Iraq (N = 927) Specialty n (%) Male Female People-oriented 101 (25.8) 334 (62.3)† Technology-oriented 290 (74.2) 202 (37.7) Total 391 (100.0) 536 (100.0) *Students rated their future likelihood of entering various specialties categorised as either people- or technology-oriented on a 4-point Likert scale ranging from 1 (very unlikely) to 4 (very likely).8 Each student was then classified according to their overall scores for each group. †Statistically significant at P = 0.001. Table 6: Mean empathy scores* by academic year and choice of specialty† among the studied sample of students at Hawler Medical University in Erbil city, Iraq (N = 927) Academic year Mean score ± SD People-oriented specialty Technology- oriented specialty 1st year 120.1 ± 21.2 106.8 ± 17.2 2nd year 111.4 ± 21.2 99.0 ± 16.1 3rd year 110.8 ± 20.2 99.1 ± 16.1 4th year 110.8 ± 20.2 96.3 ± 15.1 5th year 104.2 ± 20.1 98.7 ± 16.2 6th year 102.2 ± 20.0 98.7 ± 16.1 Total 109.9 ± 20.2 99.8 ± 16.1 ANOVA 4.940 - P value 0.002 - ANOVA = one-way analysis of variance. *Empathy was self-assessed by respondents using the English version of the 20-item Jefferson Scale of Physician Empathy-Student Version.8 †Students rated their future likelihood of entering various specialties categorised as either people- or technology-oriented on a 4-point Likert scale ranging from 1 (very unlikely) to 4 (very likely).8 Each student was then classified according to their overall scores for each group. Measuring Empathy Levels among Kurdish Medical Students in Erbil City, Iraq Cross-sectional study e66 | SQU Medical Journal, February 2016, Volume 16, Issue 1 humanities topics are not included in most medical curricula; these subjects may help improve students’ empathetic abilities.25 Another possible explanation for the observed decrease in empathy among medical students is the sense of privilege that grows throughout a doctor’s medical training; being part of an advantaged group has been suggested to contribute to changes in an individual’s capacity for empathy.26 In the current study, students who chose a people- oriented specialty reported significantly higher empathy level scores than those who selected technology-oriented specialties. These findings are similar to another study which found that students who chose internal medicine, family medicine, psychiatry, paediatrics or obstetrics and gynaecology as specialties had higher empathy scores.27 These specialties require more patient contact; students may therefore have scored higher on the empathy scale because of increased patient interaction. The authors of the current study believe that students with higher empathy levels may gravitate towards people-oriented careers. This construct does not imply that future career preference calibrates empathy but rather that students with greater empathy may naturally prefer specialties that require higher levels of patient contact. Nevertheless, it is important to note that the mean differences in empathy levels between the people- oriented and technology-oriented specialty groups were low. This may be because many students were not yet definite in their future speciality career decisions; additionally, many of them may change preferences during the course of their undergraduate studies. Future research should seek to determine whether the promotion of empathy skills impacts students’ career preferences. One of the limitations of this study was that the measurement of empathy was self-reported, focusing on the students’ perceptions of empathy rather than their performance. A second limitation was the use of a cross-sectional study design, which did not allow for demonstration of causal relationships. Lack of significant clinical exposure may also have affected how the students answered the questions on the survey as the first three years of medical school include only partial clinical exposure; this may have influenced empathy. Furthermore, participation in the survey and understanding of the questionnaire items may have been biased by events during data collection. Finally, as this study was limited to the College of Medicine at HMU in Erbil city, the results cannot be generalised to other medical colleges in Iraq. Nevertheless, the results of this study are still worthy of consideration. The development of empathy is vital to the advancement of a student’s professionalism during their undergraduate education.28 In order to increase levels of empathy among medical students, programmes teaching empathetic skills are recommended for incorporation into medical syllabi. These programmes should involve small group teaching and include training in practical skills that can be maintained and reinforced throughout a student’s medical training, such as effective patient interviewing and interpersonal communication techniques. Further research on empathy among medical students should focus on factors that contribute to the development of high empathy levels and methods for augmenting these factors in both medical education and practice. Conclusion Low empathy levels were reported among the studied group of medical students at HMU, which may be a reason for concern. Specifically, males demonstrated significantly lower overall mean empathy levels in comparison to females. Mean empathy scores were also found to decline with academic progression. Programmes highlighting empathy are therefore recommended for incorporation into medical curri- cula in order to encourage the development of empathetic skills among medical students. c o n f l i c t o f i n t e r e s t The authors declare no conflicts of interest. References 1. Jani BD, Blane DN, Mercer SW. The role of empathy in therapy and the physician-patient relationship. Forsch Komplementmed 2012; 19:252–7. doi: 10.1159/000342998. 2. Charon R. The patient-physician relationship: Narrative medicine - A model for empathy, reflection, profession, and trust. JAMA 2001; 286:1897–902. doi: 10.1001/jama.286.15. 1897. 3. 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