Di Lillo, Mariangela MD, MHS; Cicchetti, Americo PhD; Scalzo, Alessandra Lo PhD; Taroni, Francesco MD; Hojat, Mohammadreza PhD
“The art of medicine,” according to Hippocrates, “has three elements: the disease, the patient and the physician … and the patient must cooperate with the physician in combating the disease.”1 The patient–physician relationship is a symbiotic alliance in which each party contributes to its effectiveness.
But what is the secret ingredient that really forms this encounter between two different human beings into a successful interaction? Empathic engagement in patient care can lead intuitively to a more meaningful interpersonal relationship and, in turn, to more optimal care. No wonder empathy is the most frequently mentioned humanistic dimension of patient care.2
The word “empathy” comes from the Greek word “empatheia,” which means appreciation of another person’s feelings. The English term “empathy” was coined in 1909 by psychologist Edward Bradner Titchener as a translation of the German word “einfühlung,” used for the first time in 1873 by Robert Vischer, an art historian and philosopher who used this word to describe an observer’s feeling elicited by works of art. In 1915 Titchener used the term empathy to convey “understanding” of other human beings, but not until 1918 did Southard describe the significance of empathy in the relationship between a clinician and a patient for facilitating diagnostic outcomes.3
Empathy within the context of medical practice has been defined in many ways. For example, empathy in patient care has been characterized as arising “out of a natural desire to care about others.”4 According to Gianakos,5 empathy is “the ability of physicians to imagine that they are the patient who has come to them for help,” and for Greenson6 empathy is “letting a part of you becoming the patient and going through her experience as if you were the patient.”
Considering these descriptions and the role of empathy in patient care, as well as a review of relevant literature, the physician empathy research team at Jefferson Medical College proposed the following definition of empathy in the context of patient care: “Empathy is a predominantly cognitive (rather than an emotional) attribute that involves an understanding (rather than feeling) of experiences, concerns and perspectives of the patient, combined with a capacity to communicate this understanding.”7–9 Cognition, understanding, and communication are the key components in this definition of empathy.
Cognition is the dimension that distinguishes empathy from sympathy. The former is predominantly a cognitive attribute, and the latter is predominantly an affective attribute. This distinction is important in the context of patient care because of the different clinical outcomes of these qualities.10–13 More detailed explanation for the distinction between cognition and affect and their impact on patient outcomes has been given elsewhere.3 When experiencing empathy, individuals are able to disentangle themselves from others’ feelings, whereas individuals experiencing sympathy have difficulty maintaining a sense of whose feelings belong to whom.14 Compassion is the bridge between sympathy and empathy, a combination of the cognitive attribute of empathy and the emotional component of sympathy.3
Understanding of others’ feelings and concerns is central to human survival.15 It is also a key ingredient of empathic engagement in the physician–patient relationship16 where it is represented by the physician’s ability to stand in a patient’s shoes without leaving his or her own personal space and to view the world from the patient’s perspective without losing sight of his or her own personal role and professional responsibilities.3
Communicating an understanding of patients’ emotional, personal, and family concerns along with the intent to help is a fundamental aspect of physician–patient relationships.3,17,18 Mutual understanding generates a dynamic feedback where both the physician and patient play an active role to foster an empathic engagement which otherwise cannot fully develop.3
To measure empathy specifically within the context of the physician–patient relationship, a psychologically sound tool was needed. In response to this need, the Jefferson Scale of Physician Empathy (JSPE) was developed in 1999. Originally designed for medical students,19 it was subsequently modified to be applicable to practicing physicians and other health professionals.8 The study of empathy in patient care is important not only within a society but also among different cultures because of variations in medical education curricula, cultural norms, and social learning.
We designed this study to examine the psychometrics of the JSPE among a sample of Italian physicians. We also compared the empathy scores between men and women and among professionals in different hospitals, with diverse specialties, and at all levels of career rank.
In 2002, we distributed the Italian version of the JSPE to 778 physicians from three hospitals in Rome. The physicians were practicing medicine at three large hospitals in Rome: Policlinico Universitario Agostino Gemelli, Ospedale San Camillo, and Ospedale Forlanini. The Policlinico Universitario Agostino Gemelli serves as a teaching hospital for the medical school of the Universita’ Cattolica del Sacro Cuore (the largest private University in Italy). It is accredited within the Italian National Health System (Lazio Region), and it is publicly funded. It provides inpatient and outpatient care and includes facilities for basic sciences, medical, and clinical research.
The Ospedali San Camillo and Forlanini, both built at the beginning of the last century, are now organized in the San Camillo–Forlanini Hospital Trust which is one of the largest public hospital trusts in Italy. The San Camillo is a high-technology, multispecialty hospital devoted to emergency medical cases, and the Forlanini has a reputation as one of the best Italian centers for the diagnosis and treatment of respiratory diseases.
The IRBs at all participating hospitals approved this study.
The JSPE, translated into Italian from English, was used in this study. The scale was constructed on the basis of an extensive review of the literature, followed by pilot studies with groups of practicing physicians, medical students and residents.3,8,9,19 There are two versions of the JSPE. One version was developed to measure medical students’ attitudes toward empathic physician–patient engagement in the context of patient care (S-Version).3,19 The other version was specifically designed for physicians and other health professionals (HP-Version).3,8 The HP-Version was used in this study. It contains 20 items, each answered on a seven-point Likert-type scale. To reduce the confounding effect of a response pattern known as “acquiescence response style,” half the items are positively worded and directly scored (1 = strongly disagree, 7 = strongly agree), and the other half are negatively worded and reversed scored (1 = strongly agree, 7 = strongly disagree). A sample of a positively (directly scored) worded item is, “My patients value my understanding of their feelings, which is therapeutic in its own right.” A sample of a negatively worded (reversed scored) item is, “Because people are different, it is difficult for me to see things from my patients’ perspectives.” A higher score denotes a higher level of empathy.
Several studies have supported the validity (construct, divergent, convergent, criterion related) and reliability (Cronbach coefficient alpha, test–retest) of the JSPE among medical students and physicians in the United States.3,7–9,20,21 Previous studies showed that scores of the JSPE were significantly correlated with ratings of clinical competence in the third year of medical school22 and with the ratings of empathic behavior given by directors of postgraduate training programs.23 Psychometric support for the Spanish and Polish versions of the JSPE has been reported.24,25 The scale has also been translated into 25 languages and used by researchers in many different countries.3
The JSPE was translated into Italian, then back-translated into English by bilingual researchers to ensure the accuracy of the translation.26,27 (Copies of the Italian version can be requested either from M.D. or M.H.). The Italian version was distributed to physicians in one university-affiliated hospital (A. Gemelli Hospital) and two public hospitals (S. Camillo and Forlanini) located in Rome.
The survey was anonymous. Respondents did not sign their names, but they were asked to voluntarily provide information on their age, gender, level of professional rank (e.g., academic rank), and specialty. Correlational analysis, factor analysis, t test, and analysis of variance were used for statistical analyses.
Of the 778 physicians who received the JSPE, 289 completed and returned the survey for an overall response rate of 37%. The sample included 229 men and 60 women (mean age: 48.7 years; range 28–69; standard deviation [SD] = 8.08). We received responses from physicians at all three hospitals: Policlinico Universitario Agostino Gemelli (n = 76), Ospedale San Camillo (n = 143), and Ospedale Forlanini (n = 70).
Descriptive statistics at item level
An examination of the item statistics showed that the study participants used the full range of all seven points on the scale for each item.
The mean score for the items ranged from a low of 3.92 (SD = 1.87) for the item, “I do not allow myself to be influenced by strong personal bonds between my patients and their family members” (a reverse scored item), to a high of 6.55 (SD = 1.28) for the item, “I do not enjoy reading nonmedical literature or the arts” (a reverse scored item).
Item-total score partial correlations were all positive and statistically significant (P < .01), ranging from a low of 0.34 for “My patients feel better when I understand their feelings” to a high of 0.69 for “I believe that emotion has no place in the treatment of medical illness” (a reverse scored item).
The total score in calculating item-total score correlations was the sum of all item scores minus the score of the particular item used in the corresponding partial correlation. The results of item-total score correlations confirmed that the direction of scoring was appropriate (indicated by positive correlations) and that all items contributed substantially to the total empathy score (indicated by statistically significant correlations).
Descriptive statistics of the scale
The mean, SD, quartile points, and reliability coefficient of the scale are reported in Table 1.
As shown in the table, the scores for the entire sample ranged from 39 to 140 (possible range 20–140). The mean score was 115.1 (SD = 15.5), and the median was 118. The 25th and 75th percentiles were 108 and 126, respectively.
Data for the 20 items of the JSPE were subjected to factor analysis (principal component factor extraction with varimax rotation). Six factors emerged, each with an eigenvalue greater than one. The first major component of the scale (accounting for 28% of the variance) was similar to the grand factor of “perspective taking” (described as the core cognitive ingredient of empathy) that emerged in a sample of American physicians.8 Seven items had factor coefficients greater than 0.30 on this factor. The item with the largest coefficient on this factor was, “I consider understanding my patients’ body language as important as verbal communication in caregiver–patient relationships.” This is interesting to note given that body gestures are an important component of communication among Italians. Other factors accounted for less than 10% of the variance and included items from “compassionate care” (this emerged as factor 2 in both American and Italian samples) and “standing in the patient’s shoes” (this emerged as factor 3 in American and factor 4 in Italian samples). A sample item for the “compassionate care” factors was, “My understanding of how my patients and families feel does not influence medical and surgical treatment” (reverse scored). A sample item for the “standing in the patient’s shoes” factor was, “Because people are different, it is difficult for me to see things from my patients’ perspectives.”
With the exception of factors 1 and 2, the number of items with factor coefficients greater than 0.30 was three or fewer, which indicates that those factors can be considered trivial.
The Cronbach coefficient alpha, an indicator of the internal consistency reliability of the measuring instrument, was .85, which is in an acceptable range for psychological measures.
Group comparisons by gender, hospitals, specialty, and career rank
Means and SDs for Italian physicians who specified their gender are reported in Table 2.
As shown in the table, women score higher than men by three points (mean scores for women and men were 117.5 and 114.5, respectively), but the difference was not statistically significant (t(287) = 1.33, P = .17).
Comparisons of physicians in the three hospitals showed marginally statistically significant differences (F(2,287) = 2.59, P = .07) in the favor of physicians in Forlanini Hospital (mean = 118.7) compared with Gemelli Hospital (mean = 114.6) and San Camillo Hospital (mean = 113.6). No interaction effect of gender by hospital was observed.
A difference of almost three points was also detected among medical and surgical specialties (mean scores for medical specialties 117.5 and 114.2 for surgical specialties). The difference among specialties is not statistically significant (t(286) = 1.49, P = .13).
In the medical specialty group there were 40 female and 49 male physicians. In the surgical specialty group there were 49 female and 75 male physicians. No interaction effect of gender by specialty was observed.
Physicians who hold a faculty appointment as full professor or associate professor or as senior physicians (n = 200) were classified in the senior career rank; those with a faculty appointment as assistant professor or junior physicians were classified in the junior career rank (n = 52) (others with no such designations were excluded in this comparison). The mean empathy score for those in the senior career rank was lower (mean = 114.8) than others in the junior career rank (mean = 117.2); however, the difference was not statistically significant (t(250) = 0.98, P = .32). No interaction effect of gender by professional rank was observed.
Our study confirmed some previous observations about physician empathy and other qualities. For example, the mean score of 6.55 (SD = 1.28) for the item, “I do not enjoy reading nonmedical literature or the arts” (a reverse scored item) supports what has been noted by several authors, that “the humanities will not improve the technical care of our patients, but they may help to civilize that care.”28
The reliability coefficient we found (r = 0.85) is similar to one reported for American physicians completing the JSPE (r = 0.81).8 In both cases, the JSPE is shown to be a reliable measure of physician empathy.
However, we also observed some unexpected results as compared with previous studies of physician empathy. The mean score for our Italian sample is lower than that reported by Hojat et al8 for American physicians (mean = 120, SD = 12) (t(991) = 4.1, P < .01). Expression of empathy in different cultures3 can provide a partial explanation for the score disparity between Italian and American physicians. It is also important to note that between-culture comparisons could be more meaningful when the scale scores are calibrated (e.g., making scale scores equivalent) in different cultures.
Given findings from American3,8,19 and Mexican24 samples, we expected to obtain a significant gender difference on empathy scores in favor of women. Although we observed a slightly higher score for women, the difference was not statistically significant. This unexpected finding probably could be due to the sampling, or the volunteerism factor (i.e., a lower response rate for women than men).29
We observed only a slight difference in empathy scores between medical specialties and surgical specialties. These results do not reach the level of statistical significance to confirm results obtained from three previous studies with American samples where “people-oriented” (mostly medical) and “procedure-oriented” (mostly surgical) specialties were compared.7,8,30 Again, the volunteerism factor (i.e., lower response rate from the generalists) could partially explain this finding.29
Our findings of no statistically significant differences in empathy scores among men and women and among specialties were inconsistent with those reported with American samples.3,7–9,19 and need further scrutiny to investigate whether such findings can be related to cultural peculiarities, to the translation of the instrument, or to sampling used in this study.
It is interesting that we observed statistically significant differences in the scores of physicians from different hospitals. The profile of the three different hospitals studied indicates that the Forlanini is the only one devoted to the diagnosis and therapy of a specific patient population (patients affected by respiratory diseases). San Camillo specializes in emergency care, and Gemelli focuses on medical care and high-level surgical/technical procedures. Therefore, patient–physician relationships may last longer at Forlanini Hospital, which can contribute to the relatively higher empathy score of physicians at that location.
Although participation of multiple institutions is a positive feature of this study, it should be noted that physicians in the three selected hospitals may not represent the population of all physicians in Italy. In addition, the relatively low response rate, especially among key groups like women and medical specialists, may jeopardize the generalization of the findings. A replication of the study with a larger and more representative sample of Italian physicians can add to our confidence about the external validity of the findings.
Further studies are also needed among Italian physicians to confirm the stability of our findings. This is the first study that examines the “empathy dimension” among Italian physicians. However, more research is needed for better characterization of the effect of medical education on medical students’ empathic skills and to determine the effect of medical care experiences on physicians’ empathy.
The Italian translated version of the JSPE scale that we used in this study proved to be psychometrically sound for use in Italian samples. The positive and significant item-total score correlations, coefficient alpha reliability, and prominent underlying construct of “perspective taking,” which is an important dimension of empathy, provided support for the validity and reliability of the translated scale.
This Italian version of the JSPE provides a tool with sound psychometric support to address empathy in the context of patient care from a cultural and sociologic point of view, and to examine predictors and outcomes of empathy in medical education and patient care. Given the evolving universal changes in the health care systems around the world, it is important and timely to examine cross-cultural similarities and differences31 in patient–physician relationships in general, and in empathic engagement in particular.
The authors would like to thank Joseph Gonnella, MD, for his critical review of the paper, Daniel Louis, MS, and Vittorio Maio, PharmD, for reviewing and refining the translation of the Jefferson Scale of Physician Empathy, and Dorissa Bolinksi for her editorial assistance.
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