Recently, medical education in community settings has received increased attention. Accordingly, as of July 2008, the Liaison Committee on Medical Education added a standard (IS-14-A),1 which mandates that “medical schools should make available sufficient opportunities for medical students to participate in service-learning activities.” Service-learning is defined as a “course-based, credit-bearing educational experience in which students participate in an organized service activity that meets identified community needs.” It includes reflection on the service activity to gain further understanding and appreciation of community work.2 A recent systematic review on service-learning and community-based medical education found considerable heterogeneity in program types with various program names including service-learning, or learning that is “community oriented” or “community based.” Despite this heterogeneity, there is evidence that service is beneficial both to the community that is being served and to the medical students.3 Reported associated factors related to service activities for students include better academic and future residency performance4 and class rank in the next-to-top quartile of the class.5 Qualitative studies about outcomes of service-learning reported improved patient education skills, enhanced student knowledge of the needs of the disadvantaged, better appreciation of community agencies and of the role of the physician in the community, better understanding of community resources and socioeconomic challenges in health care, and an enhanced sense of social responsibility.6,7 There are reports that a service-learning or community-based service experience can impact career choice with a possible increase in selection of primary care specialties.8,9 There are also reports that students benefit emotionally from community service, with feelings of fulfillment derived from their interactions with patients5 and from the meaning of their service experience.10
Other observations pertain to student attitudes and professionalism. Service activities are reported to enhance students' regard of disadvantaged patients and of community agency professionals,6 encourage initiative in improving health care services,6 and improve interpersonal communication behavior.11 Service experiences are seen as promoting professionalism,6,7,12 cultural competency,13 and empathy.12 The aforementioned systematic review found that the majority of reports are program descriptions and evaluations.3 We have not seen a study that specifically measures medical student empathy levels in relation to participation in service activities.
We were, therefore, interested in evaluating the link between service and empathy using a quantitative approach and validated instrument. As we were already conducting a longitudinal survey of student empathy at our school, in 2007 we added questions about service activities. Numerous service opportunities exist at our school including non-credit-bearing, student-organized health fairs; community teaching; hospital-based activities; and credit-bearing community education programs. Our student-run free clinic, the Student Family Health Care Center (SFHCC), is a longitudinal, credit-bearing, patient care service activity that spans all four years with credit applied in the fourth year. Because not all of these heterogeneous experiences fit the formal definition of service-learning, this article will use the more general term “service activities.” Our hypothesis was that students who participate in more service activities would have higher empathy levels.
Students from the classes of 2007, 2008, 2009, and 2010 at one institution were surveyed near graduation during class activities. All classes completed the Jefferson Scale of Physician Empathy (Student Version) (JSPE-S)14 and a short questionnaire about the number of service hours they contributed during medical school. Students from the classes of 2009 and 2010 also completed the JSPE-S at orientation. With IRB approval, the surveys were administered confidentially; completion was voluntary.
The questionnaire about service hours queried participation in any community service activity (yes/no) and participation in a specific credit-bearing service activity: the student-run free clinic for uninsured patients (SFHCC) (yes/no). Students were then asked to estimate the number of hours they participated in any service activity for each academic year (year 1 to year 4). For analysis purposes, the total number of hours for all four years was summed and stratified as 0, 1–50, 51–100, 101–200, and over 200 service hours. The stratification was based on the recommendation of the student SFHCC leaders and the SFHCC faculty director (R.S.) using their knowledge of our school's service opportunities to estimate what would constitute no, minimal, moderate, significant, and extensive participation. The number of service hours was also dichotomized to none versus any hours.
The JSPE-S's validity has been well established for medical students.14 Respondents indicate how strongly they agree, on a scale of 1 to 7, with each of 20 statements related to empathy in patient care settings. Higher scores on the JSPE-S indicate more empathy with possible scores ranging from 20 to 140. The JSPE-S also collects information about specialty selection.
The data were analyzed using SPSS (IBM Corporation, Somers, New York). Means comparison tests (ANOVA and t test) were performed between mean empathy scores and the categories of service hours for all four classes. Chi-square tests of association were performed on gender and specialty with categories of service hours for all classes. Two-factor ANOVA was conducted for gender and service hours (none versus any) with mean empathy scores. Repeated-measures analysis was used to assess mean differences for students in the classes of 2009 and 2010 who participated in both orientation and graduation administrations.
The overall response rate was 72.0% (462/642) for all four classes. Women composed 51.3% of all participants, which is comparable to the total number of women (49.5%, 318/642) for the four classes. There is no additional demographic information available about students who did not participate in this study.
Mean JSPE-S scores, gender, and specialty choice at graduation by categories of service hours for all four classes are presented in Table 1. Students who participated in any service activities had mean empathy scores at graduation that were significantly higher than students who did not participate at all in service activities during medical school (115.18 versus 107.97, P < .001). There is an overall trend such that students with higher empathy scores had higher numbers of service hours.
More women than men reported participating in service activities (92.8% versus 77.6%, P < .001). In a t test of empathy with gender, women had significantly higher empathy scores compared with men (116.12 versus 111.14, P < .001). However, in a two-factor ANOVA of empathy with service hours and gender, average differences in empathy scores remained significant for service hours (P = .001) but not for gender (P = .076), and the two factors did not seem to interact (P = .832). There was no significant difference in hours of participation in service activities between students choosing people-oriented specialties and students choosing technology-oriented specialties at graduation (86.7% versus 83.3%, P = .214).
Of the students completing the surveys, 36 did not provide an estimate of service hours (missing service hours). The empathy levels for students with missing service hours were lower than for students who provided service hours (108.03 versus 114.14, P < .007).
Nearly one-half of our respondents (45.0%) reported participating in our student-run free clinic, SFHCC, and according to the registrar, nearly one-half of students (319/642, 49.69%) in all four classes received credit in the fourth year for participation in SFHCC. Empathy scores of students who participated in any service activities were not significantly different from empathy scores of students who participated in SFHCC as one of their service activities (114.61 versus 114.67, P = .967).
For students from the classes of 2009 and 2010 for whom we have data at both orientation and graduation (N = 184), the empathy scores at orientation were not significantly different from the empathy scores at graduation (113.26 versus 113.22, P = .978 for 2009 and 112.15 versus 112.75, P = .690 for 2010). The group of students who reported no service hours at graduation had similar empathy scores at orientation (108.20 versus 107.12, P = .704), and the same held for students who reported any service hours (114.44 versus 114.28, P = .882).
To our knowledge, this is the first study that evaluates empathy in medical students using a validated instrument in association with participation in service activities. The difference of about seven points in empathy scores between students who reported no service versus those with any service is remarkable especially given longitudinal studies of empathy that have considered an effect size of empathy reduction of 0.54 significant.15 Although there is a clear association between empathy scores and whether or not a student participated in service activities, a causal relationship cannot be established (we cannot say if empathy leads to service activities or vice versa). However, we find it interesting that empathy scores for those with no service hours started out lower at orientation and remained lower at graduation compared with those reporting any number of service hours. Basco et al16 reported that students who participated in community service with multiple organizations and those with more than two years of service prior to medical school provided more service activities during medical school. They concluded that knowledge of an applicant's community service history could be useful to admissions committees.16 We do not know if our students with no service hours in medical school participated in service activities before medical school. However, given Basco and colleagues' study, and our data that service activity during medical school is linked to higher empathy scores both at orientation and graduation, it may be appropriate for admission committees or residency program directors to consider significant participation in service activities as an indication of empathy when selecting applicants for medical school or residency.
The stability of our students' empathy scores at orientation and graduation for the classes of 2009 and 2010 is at odds with the long-standing belief in the academic community and longitudinal studies that report a decline of empathy, particularly at the third year.14,16 Interestingly, a recent review suggests that reports of decline of empathy in U.S. medical students have been “greatly exaggerated.”17 Another study describes curriculum factors, such as providing a safe environment and protected time for students to discuss their reactions to clinical care issues during clerkships, as possible links to preservation of empathy.18 The same study found that programs that validate and recognize humanism in medical students (such as the Gold Humanism Honor Society) may reverse the decline in empathy as measured by the JSPE-S. Because service is highly regarded and recognized at our urban school, we wondered whether participation in service activities could be protective of empathy. However, because the empathy levels of students with no service hours and with any service activity were both unchanged at the end of graduation, we cannot reach that conclusion. Other, yet-unidentified curriculum or student body factors may explain the stability of empathy scores in our study population.
The fact that there was no difference between the empathy scores of students who participated in SFHCC as one of their activities and those who did not suggests that the type of service does not matter as much as devoting time to service activities. This is supported by the trend of higher empathy scores in students with higher numbers of service hours.
Limitations of this study include the fact that the total number of service hours for the four years of medical school was based on recall for each academic year. In addition, the resulting data were skewed such that eight students reported 1,000 or more hours across the four years, resulting in large standard deviations. Although 1,000 hours or more may be viewed as suspicious, we know that this is possible at our school on the basis of our discussions with our SFHCC faculty (R.S.) and student-leaders and on the extensive number of available service experiences. Others have noted wide variations in reported service hours as well.4 Categorization of service hours reduced the impact of the skewed data.
We do not have information about the students who did not attend the activities during which the surveys were distributed (nonparticipants). However, this is mitigated by the fact that our sample of participants is representative of the class as a whole in terms of gender distribution and participation in the SFHCC. The results represent an urban school with numerous service opportunities and may not be representative of schools with other resources and demographic attributes.
Medical students who participated in any service activity during medical school had higher empathy scores at graduation than students who did not participate. Additionally, there was a trend that students with higher numbers of service hours had higher empathy scores. Students who did not participate in any service activities had lower empathy scores both at orientation and graduation. These results may have implications for medical school admissions committees and residency program directors.
The authors acknowledge Dr. Tatiana Perez, Ms. Tina Varghese, and Mr. Shane Reid for their contribution to this project.
The authors thank the Arnold P. Gold Foundation for its support and funding of this work.
This study was approved by the University of Medicine and Dentistry of New Jersey-Newark Campus institutional review board.
1Liaison Committee on Medical Education. Current LCME Accreditation Standards: Functions and Structure of a Medical School. http://www.lcme.org/standard.htm
. Accessed June 13, 2011.
2Bringle RG, Hatcher JA. Campus-community partnerships: The terms of engagement. J Soc Issues. 2002;58:503–516.
3Hunt JB, Bonham C, Jones L. Understanding the goals of service learning and community-based medical education: A systematic review. Acad Med. 2011;86:246–251.
4Blue AV, Geesey ME, Sheridan ME, Basco WT Jr. Performance outcomes associated with medical school community service. Acad Med. 2006;81(10 suppl):S79–S82.
5Brush DR, Markert RJ, Lazarus CJ. The relationship between service learning and medical student academic and professional outcomes. Teach Learn Med. 2006;18:9–13.
6Olney CA, Livingston JE, Fisch SI, Talamantes MA. Becoming better health care providers: Outcomes of a primary care service-learning project in medical school. J Prev Interv Community. 2006;32:133–147.
7O'Toole TP, Kathuria N, Mishra M, Schukart D. Teaching professionalism within a community context: Perspectives from a national demonstration project. Acad Med. 2005;80:339–343.
8Stearns JA, Stearns MA, Glasser M, Londo RA. Illinois RMED: A comprehensive program to improve the supply of rural family physicians. Fam Med. 2000;32:17–21.
9Davidson RA. Community-based education and problem-solving: The Community Health Scholars Program at the University of Florida. Teach Learn Med. 2002;14:178–181.
10Eckenfels E. Contemporary medical students' quest for self-fulfillment through community service. Acad Med. 1997;12:1043–1050.
11Olm-Shipman C, Reed V, Christian JG. Teaching children about health, part II: The effect of an academic-community partnership on medical students' communication skills. Educ Health (Abingdon). 2003;16:339–347.
12Wear D, Kuczewski MG. Perspective: Medical students' perceptions of the poor: What impact can medical education have? Acad Med. 2008;83:639–645.
13Mays VM, Ly L, Allen E, et al. Engaging student health organizations in reducing health disparities in underserved communities through volunteerism: Developing a student health corps. J Health Care Poor Underserved. 2009;20:914–928.
14Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ. 2004;38:934–941.
15Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182–1191.
16Basco WT Jr, Blue AV, Geesey ME, Thiedke C, Sheridan L, Elam CL. How does pre-admission community service compare with community service during medical school? J Investig Med. 2005;53:S308–S310.
17Colliver JA, Conlee MJ, Verhulst SJ, Dorsey JK. Reports of the decline of empathy during medical education are greatly exaggerated: A reexamination of the research. Acad Med. 2010;85:588–593.
18Rosenthal S, Howard B, Schlussel Y, et al. Humanism at heart: Preserving empathy in third-year medical students. Acad Med. 2011;86:350–358.