Abstract
Empathy is vital in ensuring the quality of the patient-clinician relationship. Empathy in the health care setting is the ability to understand a patient's experiences and feelings and communicate this understanding for better clinical outcomes in dental treatments. The study aimed to compare levels of empathy in post-graduate dental students across the different years of the master's degree course. Questionnaire forms distributed among post graduate students and awareness, knowledge, attitude, and empathy levels towards their patients were assessed. Responses of all the post-graduate students of all specialties in a dental institute were subjected to statistical analysis to know and compare their empathy towards the patients during their clinical practice and research throughout their three-year master's degree. The mean empathy score was 52.01 (maximum of 100), with a standard deviation of 6.69. The empathy scores decreased slightly from the first to the third year of the master's degree. The participant's age, marital status, place of residence, and specialties of dental post-graduation showed much significant difference in empathy levels. The study found slight significant gender differences in empathy among the participants. The empathy scores declined gradually very slightly as they were promoted to the next level in the course. The increase in empathy levels found in this study is more significant than those reported in similar studies due to the inclusion of educational and orientation programs at the time of admission into post-graduate studies.
Introduction
Empathy toward dental patients is an essential skill for every dental student and clinician to deliver the best care for their dental patients. Empathy is sometimes confused with ‘sympathy.’ Sympathy is defined as experiencing another's emotions, whereas empathy is appreciating or imagining those emotions (1).
Understanding dental patients' feelings, attitudes, and experiences is an essential and crucial step towards a potent and effective and thorough dental examination. The clinician will effectively communicate with the patients and thereby decrease the Patient's anxiety towards dental procedures, which ultimately improves the clinical outcome (2).
According to Sir William Osler, ‘Neutral empathy’ states that physicians need to neutralize their emotions so that they can do what is needed without feeling grief, regret, or other difficult emotions while treating patients (3,4).
Professional empathy’ is on a purely ‘cognitive’ basis. It is defined as ‘the act of correctly acknowledging the emotional state of another without experiencing that state oneself. “Clinical empathy will be the most powerful tool for a successful collaboration between the Patient and the dentist”. Stepien and Bernstein combined the different definitions within the literature to expand an expanded definition of empathy in the clinical context.
Accordingly, empathy in the clinical context is which moral (the physician's internal motivation to empathize), emotive (the ability to know the Patient's emotions and perspectives), cognitive (ability to identify and understand patients’ emotions and perspectives), and behavioral (ability to convey an understanding of those emotions back to the patients) dimensions were included (5,6).
The ultimate objective of the study was to inspect the empathy levels across the entirety of students enrolled at the post-graduate dental institution. Thus, this observational study aimed to compare the scores of empathy in post-graduate dental students across the different years of the master's degree program at Andhra Pradesh dental institution.
This study also examines the differences in empathy levels with age, gender, marital status, year of study, parents' educational background, previous education, and specific education programs within the curriculum.
Methodology
The study described is a cross-sectional study which involves dental post-graduate students enrolled at a post-graduate, 3-year course affiliated to Dr. NTR University of Health Sciences, Andhra Pradesh, India.
Once the Institutional Ethics Committee approved the study, Google forms were created with 20 open-ended questions and distributed to all the post-graduate students via e-mail and Whatsapp. Participation in the survey was voluntary and anonymous. All the post-graduate students enrolled in the master's course in the dental institution during the academic year of 2018 to 2020 were eligible to participate in the study.
The principal investigator invited the eligible students to take part in the study via email and Whatsapp. Inclusion criteria: students in their 1st, 2nd, and 3rd year of post graduation and the post graduates of all the specialties. Exclusion criteria: under graduate students and interns and those who are not willing to participate in the survey.
Participation in the survey was voluntary and anonymous and non-participation had no negative consequences. Students willing to participate contacted the principal investigator and then received oral information about the study before their participation. Participating students received no allowance.
Students were asked to submit the completed surveys online. The principal investigator once receives all the responses, the scores were tabulated in an excel sheet and then subjected to statistical analysis.
The research tool consisted of a survey encompassing an empathy scale in conjunction with questions on demographics, stage of dental education, previous degree(s), and completion of educational programs within the curriculum.
The empathy scale employed in this study was based on the Jefferson Scale of Physician Empathy-Student version. The JSPE-S is a 20-item psychometrically validated questionnaire. The research instrument where respondents are required to indicate their level of agreement to each item on a five-point Likert Scale was included in the study (i.e., 1 = strongly disagree, 5 = strongly agree).The JSPE-S total score should range from 20 to 100, with higher values indicating a higher degree of empathy.
The JSPE-S was chosen because it was explicitly designed to investigate the development of clinician's empathy and its variation and its correlates in different medical or dental education stages and among other groups of dental students and clinicians.
Statistical Analysis
The participants of the study responded to the survey anonymously, and the data stored in the hosted online survey service. Descriptive data analyses conducted using the data analysis tool provided in the online survey site. Independent ‘t’ test, analysis of variance, and Pearson correlation tests were used in statistical data analyses.
Results
Response rates were nearly 90% of participating post-graduates exceeded our target goal. This pattern of high response rates in an institutional study using an online survey is very impressive and probably unique.
Out of 111 post-graduate dental students, 100 students responded to the survey. Among all the responders, 73% were female, and 27% were male students aged 23–33 years through 1st to 3rd MDS course were included in the study. Among the participants, 33% were 3rd-year students, 29% were 2nd-year students, and 38% of I-year students were included in the study.
Participant's Characteristics
All the demographic characteristics like students' age, gender, marital status, the decision to enroll in the dental profession, the reason for selection of dentistry as degree, reason for choosing the subject specialty, year of study, and current residence were assessed and compared for any effect on empathy levels towards their patients during clinical research. The demographic factors and the empathy levels were summarized in Table 1.
Demonstrate the Demographic Characteristics and Empathy Scores.
Descriptive Characteristics of the Scale
Reliability testing showed a Cronbach's Alpha less than 1 for the JSPE-S, indicating the scale items' consistency. The mean, standard deviation, and p-value are reported in Table 2 when compared the mean empathy score among different demographic characteristics. The scores for the entire sample were44.305 and 50.850, respectively, when compared within and between the groups with a mean score of 52.
Comparison of Mean Empathy Score among Different Demographic Characteristics.
Group Comparisons of the Empathy Scores Among Dental Post-Graduate Students
There were no much significant differences as such in the empathy scores when comparing the student populations regarding age, gender, marital status, year of study and prior education/degree, residence, decision to enroll in dentistry, and choosing a specialty. But, there were slightly higher empathy scores among post-graduates who were residing in rural areas and the ones who were married. Interestingly the empathy scores were marginally higher among 1st-year post-graduates compared to 2nd and 3 yr students Figure 1
The bar graph demonstrates the mean scores of the jefferson scale of physician empathy concerning the year of the post-graduate dental program.
First, of its kind, we compared the empathy levels among the specialties of dentistry, and the results showed that there were no many differences in empathy scores with the highest ranking in empathy scores registered among orthodontics, prosthodontics, and conservative dentistry post-graduates, respectively, when compared to the fellow students.
The mean and standard deviation (SD) of empathy levels of post graduate students of dentistry are tabulated in Table 3, with the lowest mean score of 3.5800for question number 3, and the highest mean score of 4.4600for question number 7 with a total mean score of 52 was inspected among post-graduates of dentistry.
Mean and Standard Deviation for Each Question.
The correlation between total empathy score and empathy score per question was calculated with the Pearson correlation test. The statistics were described with Pearson correlation rank, and the p-value for each question is tabulated in Table 4.
Correlation Between Total Empathy Score and Score per Each Question.
*Statistically significant.
**Highlt statistically significant.
Discussion
Compared to other health care professions, the relationship between dentist and Patient has a significant impact on clinical treatment outcome. The Patient's satisfaction levels in dental care depend on the dentist's initial visit communication. (1,7)
In dentistry, empathy is to understand the patients’ inner feelings and needs at the initial visit and helping them to provide a high rate of success in treatment outcomes. (8,9) Thus, empathy remains an integral part in establishing and maintaining the relationship between dentists and patients. This study demonstrated that empathy levels in dental post-graduates resulted in outstanding success in their treatment procedures done by the students because of the trust created in their patients. (10,11)
Our study demonstrated that empathy levels during the first year of post-graduation in the dental institute are slightly high compared to second and third-year post-graduation students. (12,13) These results follow the studies in different medical specialties, but the empathy levels remain very close through the post-graduation training. This may be due to the strict guidelines we follow during their entire clinical practice and research projects. (14,15)
The decline in empathy levels in post-graduate students is very low as they progress in their curriculum compared to other medical profession studies and in undergraduate dental studies on empathy scores. (16–18)
The decline in empathy scores is due to increased technical demands in clinical training, which exhausted the students and neared their course ending. There is no much difference in empathy levels in our post-graduates because of our patient-centric approaches. (8,19)
Patel S et al., in 2019 in his systematic review on curricula for empathy and compassion training in medical education stated that training can enhance physician empathy and compassion. Training curricula should incorporate the specific behaviors identified in their report. (20)
Ferreira-Valente A et al., in 2016 conducted a study on psychometric properties of the Spanish version of the Jefferson Scale of Empathy. A sample of 1104 medical students of two Spanish medical schools completed a socio-demographic and the Spanish JSE-S. The findings provided acceptable to good sensitivity, construct validity and reliability of the adapted Spanish JSE-S with Spanish medical students. (21)
Narang R et al., in 2019 conducted a systematic review on empathy among dental students and stated that as patient exposure increases, the empathy level decreased among dental students. Their observed that education in behavioral sciences may be effective in increasing self-reported empathy, and further training may be necessary for all dental students. (22)
Lee M, and Ihm J in 2021 conducted a cross-sectional study among dental students in Korea on empathy and attitude toward communication skill learning as a predictor of patient-centered attitude. A sample of 312 dental students included in the analyses and they completed the Patient-Practitioner Orientation Scale (PPOS), the Interpersonal Reactivity Index (IRI), and the Communication Skills Attitude Scale (CSAS). The students tend to be moderately patient-oriented and slightly more patient-centered and concluded that conducting follow-up educational sessions will prevent students from becoming less patient-centered. (23)
Nourein AA et al., in 2019 compared the attitudes towards communication skills learning between medical and dental students in Saudi Arabia. The cross-sectional study included 260 conveniently sampled medical and dental undergraduate students where data was collected on socio-demographic characteristics, education-related factors, and CS using Communication Skills Attitude Scale (CSAS) that assess positive and negative attitudes (PAS, NAS). The study concluded that Demographic and education-related characteristics underpinned medical student positive attitude towards CS compared to dental students. (24)
All the above discussed cross-sectional comparative studies, surveys and systematic reviews concluded that promoting early patient-student communication, improving clinical skills and communication through educational courses should be included in the curricula of both medical and dental profession seem to promote empathy in medical and dental students.
Students who received training in ethics and practice management or any educational programs related to research ethics/clinical practice helped the students of our institute maintain empathy levels through the three-year course of post-graduation.
In this study, we compared the empathy levels among the different specialties. We found the highest empathy scores among orthodontics, prosthodontics, and conservative dentistry post-graduates, respectively, compared to fellow students from other specialties.
Significance of This Observational Study
Our study on comparing the empathy levels among the post-graduate students in the dental institute is different from other research studies because the educational programs conducted at the beginning of the course and the ethical standards and guidelines followed by the students during their clinical practice not only increased the communication skills with their patients but also helped in obtaining the outstanding success rates in treating patients in all the specialties of dentistry in our institute.
Conclusion
Educational programs on research ethics and clinical practice will further increase empathy levels among budding dentists. Empathy among dental professionals is much more critical than in other healthcare settings because the relationship between dentists and patients is vital to achieve higher success in clinical treatments of all specialties.
Supplemental Material
sj-docx-1-jpx-10.1177_23743735211056521 - Supplemental material for Awareness, Knowledge, Attitude and Empathy Levels of Dental Postgraduates Towards Their Patients During Practice and Research—A Questionnaire Based Survey
Supplemental material, sj-docx-1-jpx-10.1177_23743735211056521 for Awareness, Knowledge, Attitude and Empathy Levels of Dental Postgraduates Towards Their Patients During Practice and Research—A Questionnaire Based Survey by P Mohan Kumar, D Praveen, G Praveen and P Arun Bhupathi, M Ravi Kanth, KS Uloopi in Journal of Patient Experience
Footnotes
Acknowledgments
We acknowledge the whole team of Institutional Ethics Committee (IEC) who actively conducted the study according to the guidelines. We also appreciate all the post-graduate students of the institution for their active participation in the study. Last but not least, we acknowledge our management for providing all the necessary aspects in all the stages of the research.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
Ethical & consent statements
The institutional review board of our dental institute approved this study with IRB number as VDC/RP/2021/78. The study aims; objectives, information confidentiality, and their right to respond to the survey were explained by the investigator's team for all the participants. Oral informed consent was taken from all the participants prior launch of the study.
Statement of Human and Animal Rights
The procedures followed while collecting the data from the participants were in accordance with the ethical standards of the institutional committee on human experimentation. The institutional review board of our dental institute approved this study with IRN number as VDC/RP/2021/78.
The study participants involved were post graduate students of dental institute and they were assessed for empathy levels towards their patients during practice and research. The factors affecting empathy scores were also assessed through questionnaire form after taking written information consent from all post-graduates about the entire study.
Supplemental material
Supplemental material for this article is available online.
References
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