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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 109-116

Empathy assessment among medical doctors working at the university college hospital Ibadan, Nigeria


1 Department of Community Medicine, Family Medicine Unit, College of Medicine, University of Ibadan; Department of Family Medicine, University College Hospital Ibadan, Ibadan, Oyo State, Nigeria
2 Department of Surgery, Federal Medical Centre Abuja, Abuja, Nigeria
3 Blossom Specialist Medical Centre, Ibadan, Nigeria
4 General Hospital Odan, Lagos, Nigeria
5 Hospital Management Board, Ibadan, Oyo State, Nigeria
6 Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria

Date of Submission24-Aug-2021
Date of Decision25-Sep-2021
Date of Acceptance06-Nov-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
Abimbola Margaret Obimakinde
Department of Community Medicine, Family Medicine Unit, Faculty of Public Health/Clinical Sciences, College of Medicine, University of Ibadan. Ibadan, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_190_21

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  Abstract 


Background: Empathy is the competence of a physician to understand the patient's situation, perspective and feelings and to act on that understanding in a helpful therapeutic way. Empathy is the backbone of patient-physician communication in clinical care, it can be innate, learnt or acquired in the course of the medical career. This study, evaluated empathy and its correlates among medical doctors working in the University College Hospital, Ibadan, Nigeria. Methods: This was a cross-sectional study of 188 interns, resident and specialist doctors working at the University Hospital College, Ibadan in March-May 2018. Consecutive consenting doctors were given a self-administered questionnaire that collected information on sociodemography, work and empathy using the 20-items Jefferson Scale of Physician Empathy. Data were analyzed using the SPSS version 23 and statistical significance was set at P < 0.05. Results: The majority of the respondents were male (60.1%), between 30 and 39 years (60.6%) old, married (60.6%) and Christians (91.5%). Many worked in the Internal Medicine Department (38.3%), were Senior-Resident doctors (41.0%) and of Yoruba (82.4%) ethnicity. Senior-Residents doctors ([120.2 ± 15.4]; P = 0.009) and Consultants ([117.8 ± 21.4]; P = 0.009) had highest empathy scores. Doctors who are raised in lower social status families, lacked ability in taking patient's perspective ([56.2 ± 12.2]; P = 0.046). Doctors in surgical-related specialities had lower empathy scores, those in medical-related specialities, especially Psychiatrists (127.1 ± 10.1) and Family Physicians (125.8 ± 7.9) had the highest scores (P = 0.034). Doctors who had never learnt about empathy had the lowest score in perspective-taking ([50.5 ± 30.4]; P = 0.041). Duration of practice and work-hours respectively correlated positively ([rs = 0.174]; P = 0.018) and negatively ([rs = −0.206]; P = 0.005) with empathy scores. Conclusions: Medical doctors possessed varying levels of empathy relative to their sociodemographic characteristics, the speciality of choice and level of expertise. Exposure to teachings on empathy and work-related challenges underscores empathic skills.

Keywords: Compassionate-care, empathy, medical doctors, perspective-taking, speciality


How to cite this article:
Obimakinde AM, Iyoke UO, Ibiyo MJ, Emmanuel OA, Odefemi OF, Abiodun AH. Empathy assessment among medical doctors working at the university college hospital Ibadan, Nigeria. J Mental Health Hum Behav 2021;26:109-16

How to cite this URL:
Obimakinde AM, Iyoke UO, Ibiyo MJ, Emmanuel OA, Odefemi OF, Abiodun AH. Empathy assessment among medical doctors working at the university college hospital Ibadan, Nigeria. J Mental Health Hum Behav [serial online] 2021 [cited 2022 May 25];26:109-16. Available from: https://www.jmhhb.org/text.asp?2021/26/2/109/337167




  Introduction Top


Empathy is the ability to form a mental imitation, to gain knowledge of the other person's mindset to understand and share the feelings of that other person.[1],[2] Empathy in the context of patient-physician communication and encounter is referred to as clinical empathy.[1],[2],[3] Clinical empathy is the backbone of all effective consultations and interactions between a patient and a physician.[2],[3] Empathy on the part of the physician is essential during interpersonal communication to understand the perceptions and needs of the patient, empower the patient to cope more effectively and resolve the patient's problems.[1],[4],[5] It plays a vital role in patients' perception of the quality of care received.[3] Clinical empathy is not just about the physician's subjective emotional response to a patient's case but it is a form of skills needed for professional interaction with the patient.[1],[3] It is an intellectual ability of the physician to relate with, care about and understand the patient's situation and perspectives, plus the ability to communicate that understanding to the patient and act on that understanding in a helpful therapeutic way.[1],[3],[4]

Empathy can be defined at cognitive, affective, and behavioural levels.[1],[3],[6] The competency of the physician to be empathic is at the cognitive level, at the affective level is the attitude of the physician and at the behavioural level is the display of empathy.[1],[3],[6] “Perspective-taking” is the cognitive ability of the physician to put himself or herself in the patients' “shoes” and the willingness to resolve other patient's concern.[3] This cognitive empathic competency can be subdivided into communication skill and the skill to build up a therapeutic relationship with a patient.[1],[2],[3],[7] Communication skill is used to check, clarify, support, understand, and reflect on the perception of a patient's thoughts and feelings.[1],[3] The skill to build up a trusting patient-physician relationship is that skill needed to resonate with the patient emotionally.[8],[9] The physicians' attitude regarding clinical empathy is based on moral standards such as respectfulness for the personality and authenticity of the other person, interest in the other person and receptivity.[1],[2],[3],[7] These moral standards are formed by the physician's family background, biopsychosocial development, personal experience with patients, knowledge gained from medical and professional training.[1],[2],[3],[7] Empathic behaviour has a cognitive and an affective part.[6],[10] The cognitive part includes verbal and nonverbal skills.[6],[10] The affective part includes recognition of the emotional state or situation of the patient, including being moved and recognizing the feeling of the patient.[6],[10] After this recognition, the physician, in their behaviour reflects on the patient's feeling and communicates their understanding to the patient.[6],[8],[9],[10] Summarily clinical empathy is the approach by which the physician elicit the inner world of the patient and get as much information as possible from the patient, while at the same time recognizing and solving the patient's problem.[9],[11]

Empathy can be taught during undergraduate medical education and improved on during postgraduate training, also empathy can be learned, self-taught or acquired.[1],[6] Medical care has advanced over time with new technology but empathy in the context of the patient-physician therapeutic relationship is still core to quality health care.[7] It has been said that medical doctors may lack training on clinical empathy particularly in this era, where evidence-based and technology-based health care seems to be the trend and preference.[1],[7] However, it is possible to learn and teach empathy, especially if it is assessed as lacking.[1],[6],[10] Physicians' family background, sociodemographic characteristics, medical training and practice experiences influence their empathic behaviour.[1],[3]

This study was conducted to assess empathy and its correlates amongst medical doctors working at the University College Hospital (UCH), Ibadan, Nigeria.


  Methods Top


Setting and participants

The study was a cross-sectional study conducted April-June 2018 at the UCH, Ibadan, Nigeria. The UCH is a Federal Government owned tertiary health institution with 850 beds located in Ibadan North Local Government Area, Ibadan, south-west Nigeria. The UCH, Ibadan is the premier Nigerian teaching hospital located in the southwestern part of Nigeria and it was established in 1957 to train medical students, resident doctors and other health professionals.

The study population included medical interns, resident doctors (specialist in training) and consultants (specialist) of the hospital. Interns are medical graduates who are undergoing 1-year rotational closely supervised medical practice after they have acquired the bachelor of medicine and surgery post 6 years of undergraduate training in Nigeria medical schools.[12],[13] Resident doctors are in postgraduate medical training after the compulsory internship and the postinternship 1-year medical practice.[12],[13] This postinternship duty is a remotely supervised practice as a medical officer in any hospital selected by the Nigerian government. Residency training is for medical graduates who have acquired a bachelor of medicine and surgery after 6 years of undergraduate training in Nigeria medical schools and has completed the internship, postinternship duties and is fully registered by the Medical and Dental Council of Nigeria.[12],[13] Residency training is supervised specialist medical training in any arm of medicine and surgery and there are two main exams to be taken at a minimum of 3 years apart.[12],[13] A resident doctor is referred to as a Junior Registrar before passing the first exams and a Senior Registrar after passing the first exams, and the resident is certified as a specialist after passing the second exam.[12],[13] A specialist doctor in Nigeria hospital is referred to as a consultant.[12],[13] The overall population of medical interns, residents and specialists working at the UCH varies widely at each point in a year depending on the academic calendar, training schedules, outstations and extramural postings, postgraduate examinations, sub-speciality advanced training, national and international conferences and workshops. The overall population of medical doctors in UCH at any point in the year could be in the range of 400 and an estimated minimum of 200 medical doctors should be at work, daily in the hospital.

Data collection and instruments

A sample size of 188 medical doctors participated in this study. The study utilized a convenient sampling of consenting medical doctors encountered in the hospital during the data collection period. A self-administered questionnaire was used to collect data. The questionnaire collected information on sociodemography, family, work and contained the Jefferson Scale of Physician Empathy (JSPE) assessment tool.

The JSPE is a 20-item questionnaire used to measure empathy in the context of the doctor-patient relationship.[5],[14],[15] The JSPE has a Cronbach α of 0.82, has been translated into more than 56 languages, culturally adapted, validated and used in more than 80 countries of the world.[5],[15] A study on the validity of the JSPE among medical doctors working in a tertiary hospital in south-south Nigeria, reported it as a reliable measure of clinical empathy with Cronbach α of 0.73.[16] The JSPE items are answered on a graded 7-point Likert scale; a score of 1 indicated “strongly disagree” and a score of 7 indicated “strongly agree.” The possible overall total empathy score ranged from 20 to 140 points and higher scores mean a greater degree of empathy.[5],[14],[15] The JSPE has three dimensions; dimension 1 measures “Perspective Taking” reflecting cognitive empathy, dimension 2 measures “Compassionate Care” reflecting emotional empathy and dimension 3 is a residual dimension which measure “Standing in the Patient's Shoes.”[14],[15] Of the 20 items of the JSPE, items 2, 4, 5, 9, 10, 13, 15, 16, 17 and 20 measures “Perspective Taking” with total possible score of 10–70. “Compassionate care” is measured using items 1, 7, 8, 11, 12, 14, 18, 19 with a possible scores range of 8–56 while items 3 and 6 measures “Standing in the Patient's Shoes” with possible scores of 2–14.[5],[14],[15]

Occupational social classification by Olatawura and Boroffka was used to categorize the medical doctors' family of origin into upper, middle and lower social class, using the highest paying of either parents' occupation.[17] The highest and lowest social classification was Class I and VI respectively. Class I and II was categorized as upper social class, Class III and IV as middle social class and Class to V and VI were categorized as a lower social class. Professions such as physicians, lawyers, lecturers, senior governments officials and large scale entrepreneurs are in the upper social class. Examples of occupation in the middle social class were mechanics, tailors, small scale entrepreneurs and occupations in the lower social class included labourers, petty traders, vulcanizers and vendors.

Data analysis

Data was inputted and analyzed using the SPSS version 23.0 (IBM Corp., Armonk, New York, USA).[18] The scores for the “total JSPE,” the “Perspective Taking” and “Compassionate Care” sub-domains of the JSPE were used for data analysis. Descriptive statistics were done to identify the frequencies for the sociodemographic, work and family data. Analysis of variance and correlation analysis was conducted to evaluate the relationship between the JSPE scores and characteristics of the studied participants. Statistical significance was set at P < 0.05.

Ethical considerations

Ethical clearance was obtained from the Institutional Ethics Review Board of the University of Ibadan/UCH Ibadan, Nigeria. Informed consent was obtained from all the participants who participated in the study. Confidentiality of the participants and data security was ensured.


  Results Top


A total of 188 medical doctors working in the UCH, Ibadan, Nigeria, participated in this study. The majority of the medical doctors were male (60.1%), in their third decade (60.6%) of life, married (60.6%), Christians (91.5%), Yoruba (82.4%) by ethnicity and were raised in a middle social-class (87.8%), monogamous family (92.0), as shown in [Table 1].
Table 1: Sociodemographic and family characteristics of the participants

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[Table 2] shows that many, worked in the internal medicine department (38.3%), were senior-resident doctors (41.0%), attended to an average of 11 patients a day. Most (98.4%) understand the concept of empathy but fewer (28.2%) were ever taught clinical empathy.
Table 2: Work data and overview of the self-assessed perception of empathy by the medical doctors

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[Table 3] showed that Females (118.9, P = 0.051), older doctors ≥50 years (133.0, P = 0.083), Senior residents (120.6, P = 0.007) and Consultants (117.9, P = 0.007) had highest empathy scores. Doctors who are from lower social status family (56.2, P = 0.049) significantly lacked the ability in taking the patient's perspective. The post hoc test within the social classes was insignificant, but the most remarkable mean difference of the “perspective-taking” scores was between the lower class and middle class (df = 2; P = 0.250).
Table 3: Relationship between sociodemographic characteristics and empathy scores

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Medical doctors who are active members of their religious group significantly had higher empathy scores and the post hoc test between the three religious groups was not remarkable.

Post hoc test showed a significant mean difference in the total empathy scores between age groups 20–29 years and 50–69 year (df = 3, P = 0.049) while mean scores are identical between age groups 30–39 years and 40–49 years.

[Table 4] shows that medical doctors in radiology (108.6 ± 14.2) and surgical-related specialities had lower total empathy scores while those in medical-related specialities especially Family Physicians (125.8 ± 7.9) and Psychiatrists (127.1 ± 10.1) had the highest scores (P = 0.034). Family Physicians scored highest in Compassionate care at ([53.6 ± 3.0]; P = 0.005). Post hoc test between the specialities (df = 7) showed that Surgery, Radiology, Peadiatrics and Dental have identical total empathy mean scores. Family Medicine and Psychiatry also have identical total empathy mean scores and the mean difference between these two specialities (P = 0.228 for Family Medicine and P = 0.173 for Psychiatry) and Surgery were most remarkable but not statistically significant.
Table 4: Relationship between work characteristics, perceptions and empathy scores

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The Post hoc test for the total empathy means scores between the cadres (df = 3), showed significant mean difference between the interns and senior residents at P = 0.007.

The medical doctors who thought empathy should be taught had higher total empathy scores (116.1 ± 18.7, P = 0.036) while those who had “never” learnt about empathy had lower score in perspective-taking (50.5 ± 30.4, P = 0.041). The post hoc test for “How did you learn about the concept of empathy?” (df = 4), showed identical total empathy means for those that learnt via “literature” and “personal experience”. The mean difference between “other sources” versus “personal experiences” and “medical carers” was most remarkable at P = 0.052 and P = 0.088 respectively.

[Table 5] shows that the duration of practice correlated positively with all empathy scores (rs = 0.174, P = 0.018). Heavy work burden, measured by work-hours (rs = −0.206, P = 0.005) and the number of patients seen per day (rs = −0.056, P = 0.469) correlated negatively with total empathy scores.
Table 5: Correlation of empathy scores with work and family variables

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  Discussions Top


Medical doctors with different sociodemographic and job characteristics, working in the UCH Ibadan, Nigeria participated in this study. The majority of the medical doctors who participated in this study were married men in their third decade of life, Christians and of Yoruba ethnicity. Many of them were from a middle social-class family of origin, whose parents had a monogamous marriage and raised a maximum of 4 children in the family. These sociodemography characteristics and family background is expected and typical of a medical doctor living and practicing in southwest Nigeria.[12],[19]

The female medical doctors in this study seemingly had better empathy scores. Although this was not a statistically significant finding, research has shown that women have better care-oriented qualities and are more sensitive to social stimuli and emotional signals.[3],[20],[21] Likewise, female medical doctors are known to be compassionate and better at taking patients' perspective.[3],[20]

The empathy scores observed in medical doctors raised in a polygamous family can be attributed to the chaotic and hostile interpersonal relationships that may exist in polygamous African families.[19],[22],[23] This may be exaggerated for the children raised in a polygamous and large-sized family setting, with the consequent narrow emotional rapporteur and struggles for empathic connections.[3],[22],[23] The number of siblings in the family of origin correlated negatively with empathy scores in this study, although, the association between a polygamous family of origin and lack of empathy skill is statistically insignificant. It is noteworthy that a child from this family setting may grow up with an unconscious motivational force that negatively influences adulthood capacity for empathic engagement.[3],[22] Bauer and Hobart's hypothesis explained that early childhood socio-emotional exchange and mental script guides primary empathy which will predict secondary empathy in adulthood.[3]

Medical doctors who were from families of lower social status in this study significantly lacked the ability in taking a patient's perspective. How people perceive and express emotion during social interaction is influenced by their current socioeconomic status and that of their family of origin, more importantly.[24],[25] There is conflicting evidence regarding the effect of social class on empathy and a study reported a contextual influence of social status on empathy.[25] Another study reported that childhood subjective socioeconomic status and current subjective socioeconomic status both correlated negatively correlated with neural empathic response.[24] However, it is generally agreed that higher socioeconomic status correlates positively with prosocial traits and self-reported empathy, as buttressed by the result of this study.[24],[25]

Medical doctors in this study who perceived themselves as actively involved in their religious group, have higher empathy scores. Corroborating this result, are publications that had reported that religious belief and practices have a significant impact on altruism and positively shapes clinical empathy and practice of medical doctors.[26],[27]

The en-espoused medical doctors in this study seemingly lacked empathic skills. Plausibly because empathic concern, perspective taking and compassionate care are necessary attributes of persons engaged or married.[7] A failed marriage or marital disharmony may induce disempathetic behaviour and limit the ability to empathize with patients.[7] According to Bauer, an already developed adulthood secondary empathy can be damage by heartbreak.[3] This may be another explanation for the observation among the unmarried medical doctors in this study, especially those divorced and separated.

The medical doctors who were in their 5th decade of life upwards had the most scores across all domains of empathy. Expectedly, the knowledge of social norms, interactive competency, ability to take the perspective of others, recognize patients cues and be compassionate increases with age.[3],[21] The younger medical doctors in their 2nd decade of life, in this study, significantly had lower total empathy scores compared to those 50 years and older. Understandably, modern-day medical training and the younger generation of medical doctors are more oriented to “evidence-based” practice where statistics matters more.[6] This trend has put the younger generation of medical doctors at risk of losing their humanity with inadvertent lowering of empathic competency.[6] Additionally, increased life experience such as experiences of ailments and losses tend to increase empathy levels in older individuals.[21] Therefore, older medical practitioners with vast life experience will be more empathic towards patients, as observed in this study.[21]

Similarly, the senior resident doctors and consultants had higher empathy scores and a longer duration of medical practice correlated positively with empathy scores in this study. Junior medical doctors readily burn out and get distressed by long work hours and high work burden, plus the fact they are still in training and deficient in medical problem-solving skills.[12],[13],[28] Literature on clinical empathy had reported that heavy work burden and distress correlate negatively and significantly with empathy scores in a medical trainee, as observed in this study.[29] It is known also that younger residents doctor experiences distinct challenges relative to their stage of training extended duty hours and lack of time for personal life.[12],[13],[28] It had been reported that the personal distress during the early phase of residency training harm patients' care and may be parallel to the decline in empathic skills.[28] Another publication reported that an overworked medical doctor is physically and psychologically overstretched and unable to muster the cognitive and emotional efforts involved in empathy skills.[7] Contrarily, advanced age, a higher level of personal and clinical experiences and a longer duration of practices can positively influence empathic competence as revealed by this study.[3],[21]

This study revealed that medical doctors working and training in the department of Psychiatry and Family Medicine significantly has the highest and comparable empathy scores. It had been reported that medical doctors training and specialized in Psychiatry significantly had the highest empathy scores compared to surgical related specialities while there was no significant difference between Psychiatrists and Family Physicians, as observed in this study.[4] The medical doctors training and specialized in Family Medicine significantly had the highest score in compassionate care, in this study. Family Medicine is the prototype speciality that utilizes patient centered clinical methods.[4],[14],[30] Therefore, medical doctors in Family Medicine department are expected to possess rich empathic orientations particularly in the domain of compassionate care.[30] This study found that medical doctors in Internal Medicine and Pediatrics had more empathy scores compared to medical doctors in “technology-oriented” Radiology and “procedure-oriented” Dentistry and Surgery, as previously reported.[14],[30] A publication reported that only 21% of Orthopeadic patients attested to satisfactory communication with their Surgeons, the patients perceived the surgeons as poor listeners, who could not take their perspective and rarely use empathic statements.[31] However, the publication and a similar one emphasized the need for communications and empathic skills training for all physicians especially surgeons and cited a quote by Terry Canale which stated that the patient will never care how much you know until they know how much you care.[29],[31]

The personal illness narrative can engender empathy in medical doctors.[20] The medical doctors in the study who had been previously hospitalized seemingly had more empathy scores and those who understands the concept of empathy were more able to take perspectives of their patients. This is because these medical doctors can juxtapose their own illness experiences to their patients' and take the perspective of the patients' health-related situation.[20]

The medical doctors in this study, who had been taught about empathy and particularly those who agreed that empathy should be taught had higher empathy scores. This is congruent with publications that cited the possibility of acquisition of clinical empathy and the positive influence training on empathy has on childhood empathy, despite adverse life events.[1],[3],[6],[10] The authenticity of a solely learned empathic ability is queried, therefore a cohort follow-up studies of medical trainees who will receive training and evaluation of empathy especially from patients perspective is proffered.[3] It is important to consider that empathic responses result from interactions between upbringing, culture, emotional, behavioural, prevailing social factors, life choices and education.[1],[6],[10] Therefore it is possible that learning and training can improve the empathic response of medical doctors.[1],[6],[10] Teachings about clinical empathy enhances the observation skills and communication skills of medical doctors and makes it easier to detect a patient's emotional state and understand the patient's perspective.[1],[6],[10] This study buttressed that medical doctors who never learnt about empathy significantly had the lowest score in taking the perspective of their patients.

Study implication and limitation

This study provided some information on empathy assessment and its correlates among doctors working at the UCH Ibadan. This has filled a research gap in the study of clinical empathy at the premier teaching hospital and serves as preliminary information for further research and training needs. A total sampling was desirable for this study but a convenient sampling method was utilized because of the high mobility of the study population. Potential response bias from the participants and the convenient sampling method used for this study can be considered a limitation. Likewise, the multiple hypothesis testing could have inflated the possibility of Type 1 error.


  Conclusions Top


Finally, it has been suggested that physicians who act empathically may be perceived by the patient as being genuinely empathic.[1],[6],[10],[20] Therefore training on clinical empathy for the medical doctors and medical students shouldn't be underestimated, as this can ingrain empathic skills in them, which can be beneficial to patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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