Abstract
Background
Emotional intelligence (EI), empathy, and leadership are essential competencies in medical training, yet evidence from lower-middle-income countries such as Pakistan is limited. This study assessed EI among medical students and examined its association with empathy, authentic leadership, and sociodemographic factors.
Methods
This cross-sectional study included 264 undergraduate medical students (years 2–5). EI was assessed using the Quick EI Scale measuring Emotional Awareness (EA), Emotional Management (EM), Social Emotional Awareness (SEA), and Relationship Management (RM). Empathy was evaluated using the Jefferson Scale of Empathy-Student Version (JSE-S), and leadership was measured using the Authentic Leadership Self-Assessment Questionnaire (ALQ) assessing Self-Awareness (SA), Internalized Moral Perspective (IMP), Balanced Processing (BP), and Relational Transparency (RT). Associations were analyzed using chi-square tests, ANOVA, and Spearman’s correlation (p<0.05).
Results
Participants showed balanced gender representation (male: 49.6%, female: 50.4%) and were predominantly aged 21–23 years. Age and ethnicity demonstrated significant effects across multiple EI domains, with younger students showing higher EA (p=0.05) and SEA (p<0.001), while ethnicity significantly influenced EA (p=0.05), SEA (p=0.01), and RM (p<0.001). Extracurricular participation improved EM (p=0.03) and RM (p=0.03). In leadership domains, age affected SA (p=0.05), and ethnicity significantly predicted SA (p=0.05). Extracurricular involvement strongly enhanced IMP, BP, and RT (all p<0.001). Empathy increased with age (p<0.001), was higher among females (p=0.01), and was associated with autonomous career choice (p<0.001) and extracurricular participation (p<0.001). Academic year affected EA and empathy (p<0.001), with a U-shaped pattern final year students achieved highest scores (106.99±17.19) while fourth year showed lowest (93.89±19.49). EI correlated strongly with leadership, SEA most with empathy, and SA, BP, RT were significantly linked to empathy.
Conclusion
EI, empathy, and leadership are interrelated competencies shaped by demographic, academic, and extracurricular factors. Incorporating structured EI and leadership development into medical curricula may help cultivate compassionate, emotionally intelligent physician-leaders.
1. Introduction
In communal living, variations of personality types and emotions exist to many degrees in the population. People, despite these differences, interact with one another to form important human relationships, indicating a robust association between cultivating affiliations and human emotions. To acknowledge and understand the emotions of oneself and other, along with using these emotions to have effective human interaction is emotional intelligence (EI). 1
This suggests an incorporation of human emotions and intelligence and takes its conceptual roots from the “Theory of Multiple Intelligences” by Dr. Howard Gardner.2,3 Academic success is usually associated with a higher intelligence quotient (IQ); however, studies suggest that a higher IQ may not translate to excelling academically. Thus, this implies that academic performance is a multifaceted aspect of a person translated by the coordinated functioning of multiple personality traits. 4 EI forms the base of interpersonal interactions. Medicine, being centered around human emotions and relations, exponents EI a much significant area of study in medical science. Moreover, leadership, like empathy and EI, plays an equally significant role in doctor-patient interactions. Although leadership skills are being instilled in various other disciplines, they have not received the same importance that they deserve in medical education.5,6 Daily routines of medical students and health care professionals involve a colossal amount of public interactions with all the diversities and variations of a population. Therefore, effective interaction with patients along with efficient leadership skills are crucial to allow effective care and counselling for health and disease. 7
There has been a keen interest in the significance of EI in health education and practice in recent years. An empathic doctor is more successful at taking a good history of a patient and likewise better at reaching a diagnosis and improving the doctor-patient relationship, and hence patient compliance. 8 Medicine is a field where empathy is of great importance, as its core purpose is to serve humanity and alleviate the suffering of people. 9 A study conducted on nursing students showed that female students had higher EI when compared to their male counterparts, while empathy was found to be equal in both genders. 10 EI, along with leadership, is the key to championing medicine as a profession, where students are often engaged in socially and emotionally challenging instances requiring teamwork. 4 EI can thus improve the qualities of effective leadership by developing interpersonal empathy and social skills, as well as intrapersonal awareness and regulation. On the contrary, medical students struggle with academic stress that’s shown to have a potential effect on EI. 11 Literature also highlights leadership qualities being associated with patient satisfaction and lower rates of burnout among physicians. 12 Physician leadership is vital, especially in terms of traits such as humility, humanity, and collaboration, which can make a physician stand out regardless of their stage in their career. 13
According to a study, EI, very much unlike IQ, is not fixed and can be developed overtime with relevant training. 14 EI can be improved to make people cope with stress better and even display better academic performance. 15 Yet another study showed that academic performance and leadership share a positive association, while stress and leadership capacity shared a negative association. 11 The same observation is attested by local studies where correlations between EI and academic performance were observed in medical students of Pakistan, implying that emotionally intelligent students performed better academically as well as in other domains. 7 Likewise, leadership qualities can also be acquired and polished via training programs and modules in the undergraduate medical curriculum.6,7
Although abundant literature is present which emphasizes the significance of EI, data remains scattered, isolated and explores only a single construct. Limited to no data is available which evaluates these three constructs, EI, leadership and empathy, together. Moreover, studies measuring the effect of socio-demographic factors on these three constructs are scarce. International studies do identify the relationship between EI, academic performance, leadership qualities and burnout, there is insufficient data on the interaction between these three variables in cultural context of low-middle income countries like Pakistan. Cultural norms, educational structures and stressors vary from other countries and hence can play a significant role in development and expression of emotional intelligence.
Hence a detailed and comprehensive study integrating the three constructs in relation to socio-demographic factors is the need of the day. Furthermore, it is imperative to understand if emotionally intelligent medical students are empathic leaders with strong leadership skills or not and to justify if these attributes are in any way influenced by gender and other background characteristics. Due to this dearth in literature, this study aims to determine the level of EI among medical students and its correlation with empathy, leadership and sociodemographic factors.
2. Methods
2.1. Study Design and Participants
This cross-sectional study by following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement (supplementary files) 16 includes 264 undergraduate medical students from years 2-5 at a private medical college, Bahria University Health Sciences Campus (BUHSC), Karachi, Pakistan, selected through purposive sampling. The study was conducted over six months (October 2023 – March 2024) and included MBBS students in good general health who had appeared in professional examinations. Sample size was calculated to be 235 by using Open Epi Info calculator and population size was taken as 600, hypothesized frequency of 50% with 95% confidence level. Students from year 1 undergraduate medical education, allied health sciences, and those with a history of chronic illness, drug abuse, or use of psychological/psychiatric medications in the past six months were excluded. To minimize response bias, participation was voluntary and responses were collected anonymously. Incomplete questionnaire responses were not included in the analysis.
2.2. Ethical Approval
Data collection started after receiving approval from the Ethical Review Committee of BUHSC (ERC 26/2023). Written informed consent was obtained voluntarily from participants.
2.3. Data Collection Instruments
Emotional Intelligence (EI) was assessed using Quick EI Scale, which has assessed four domains: Emotional Awareness (EA), Emotional Management (EM), Social Emotional Awareness (SEA), and Relationship Management (RM). 17 Each domain was measured using a 5-point Likert scale (1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Often, 5 = Always). Scores were categorized into three levels: 1.00 (high competency), 2.00 (moderate competency), and 3.00 (low competency) based on domain-specific scoring algorithms. The reliability of this scale was calculated in the present study and found to be 0.95, thus demonstrating excellent internal consistency. The Jefferson Scale of Empathy - Student Version (JSE-S) (Cronbach α = 0.82) was used to assess empathy. 18 JSE-S consists of 20 items measuring empathic attitudes and behaviors toward patients. Items are scored on a 7-point Likert scale (1 = Strongly Disagree to 7 = Strongly Agree). Total scores range from 20-140, with higher scores indicating greater empathic orientation. Leadership competency was measured using Authentic Leadership Self-Assessment Questionnaire (ALQ), (Cronbach α ranging from 0.74-0.85 ranging across samples and subscales), which measures four dimensions of authentic leadership using 16 items scored on a 5-point Likert scale (1 = Strongly Disagree to 5 = Strongly Agree). 19 The four domains include: Self-Awareness (SA), Internalized Moral Perspective (IMP), Balanced Processing (BP), and Relational Transparency (RT). Domain scores range from 4-20, with scores ≥16 indicating high competency and ≤15 indicating low competency.
2.4. Statistical Analysis
Data analysis was performed using SPSS version 25 and GraphPad Prism version 9. Quantitative variables were expressed as means and standard deviations (SD). Chi-square tests examined associations between categorical variables and emotional intelligence/leadership domains. When expected cell frequencies were less than 5 in more than 20% of cells, Fisher’s exact test was applied, and Monte Carlo simulation was used for larger contingency tables to ensure accurate p-value estimation. One-way analysis of variance (ANOVA) tested associations between continuous empathy scores and demographic variables. Spearman’s correlation analysis assessed relationships between emotional intelligence, leadership, and empathy domains. Scatter plot analyses with R2 values were generated to visualize linear relationships between overall domain scores. Statistical significance was set at p<0.05, and all tests were two-tailed.
3. Results
Demographic Characteristics
3.1. Emotional Intelligence Domains
Association of Demographic and Academic Characteristics With Emotional Intelligence Domains
3.2. Authentic Leadership Domains
Association of Demographic and Academic Characteristics With Authentic Leadership Domains
3.3. Empathy Domain
Empathy Scores by Demographic and Academic Characteristics
3.4. Academic Year
Academic year significantly influenced EA (p<0.001) and empathy development (p<0.001), with distinct patterns (Figure 1). Leadership competencies remained stable across all years (Table 3 and Figure 1B), however empathy followed a U-shaped trajectory (Figure 1C), final-year students achieved the highest empathy levels (106.99±17.19), while fourth-year students showed the lowest scores (93.89±19.49), as shown in (Table 4). Association of academic year with A) emotional intelligence domains, B) leadership domains, and C) empathy scores among medical students
3.5. Emotional Intelligence and Leadership Competencies
Association Between Emotional Intelligence Domains and Authentic Leadership Competencies
3.6. Emotional Intelligence and Empathy
Association Between Emotional Intelligence and Leadership Domains With Empathy Scores
3.7. Leadership and Empathy
SA (p=0.003), BP (p=0.001), and RT (p=0.005) all showed significant associations with empathy, with high-competency students demonstrating superior empathy scores whereas, IMP showed no significant relationship with empathy (p=0.14) (Table 6).
3.8. Correlational Among Emotional Intelligence, Leadership, and Empathy
Significant positive correlations emerged between emotional intelligence and leadership domains (p<0.001), with leadership attributes correlating with empathy (p<0.01). Scatter plot analysis (Figure 2) revealed moderate-to-strong correlation between emotional intelligence and leadership (R2=0.506), with weaker associations between empathy and other domains (R2=0.051-0.081), as shown in Table 7 and Figure 3. Scatter plot analysis of correlations between A) emotional intelligence and leadership, B) leadership and empathy, and C) emotional intelligence and empathy Correlation Matrix of Emotional Intelligence, Leadership, and Empathy Domains Heat Map of Emotional Intelligence, Leadership, and Empathy Domains using Spearman’s Rho
4. Discussion
EI, empathy and leadership are increasingly recognized as essential competencies within modern medical education and healthcare delivery. These have been shown to directly improve patient care, collaboration, professional satisfaction, and overall effectiveness. 20 These traits are also key in defining many international frameworks that outline the qualities of being a better physician beyond medical knowledge such as, the CanMEDS and the ACGME core competencies frameworks under their relevant descriptions.21,22 In addition to improving patient satisfaction and communication, these skills have been seen to allow for better stress management and clinical reasoning. 15 Although multiple studies highlight the significance of EI, leadership and empathy across different educational settings, lower-middle income countries (LMICs) like Pakistan have limited data on this subject. This especially stands true for undergraduate medical students where the curricula is excessively content driven with minimal emphasis on channeling non-academic values. Acknowledging this gap, our study highlights the levels of EI, empathy and authentic leadership among undergraduate medical students at a single intuition that is a private medical college in Pakistan.
In our study, EI was seen as a strong predictor of leadership. This finding underscores the concept that emotional skills serve as the foundation for leadership in our students. It is also important to note that both SEA and RM were particularly associated with higher empathy suggesting that the ability to understand and manage interpersonal relationships translate directly into more empathetic attitudes towards patients. Similarly, self-awareness, balanced processing, and relational transparency within leadership were significantly related to empathy, highlighting leadership’s overlap with compassionate care. By comparison, EA and IMP showed no clear association with empathy, which may reflect the distinction between cognitive recognition of emotions or values and their translation into behavioural relations. Altogether, these results suggest that empathy and leadership function together, supporting the integration of these into medical curricula rather than teaching them separately. These findings support the theoretical assumption that EI acts as a foundational socio-emotional competency from which leadership and empathetic behaviours emerge. 23 Previous literature suggests that emotionally intelligent individuals demonstrate superior interpersonal regulation and social perception, which are essential elements of authentic leadership and patient-centered communication. 24 Therefore, the observed association between EI, leadership and empathy in our sample may reflect the shared psychological mechanisms underlying these competencies, particularly emotional regulation, perspective taking and social awareness.
Our study concluded that EI and its domains were influenced by several factors including age, parental education, ethnicity, and residential status. We found that younger students were found to show higher levels of EA, while hostel residents appeared to have more SEA and RM. This is supported by findings reported in other studies as well. Some studies conducted to assess the developmental association of EI in adulthood showed an increase signified by greater emotional stability, self-control and adaptability, displaying consistency with the maturity principle it was initially compared to.25,26 The age-related differences we found likely also reflect developmental maturation during medical training as students progress through the medical curriculum. Across the years, students encounter emotionally challenging clinical environments that need adaptive coping and interpersonal communication. Exposure to such experiences may contribute to the gradual honing of emotional regulation and social awareness. On the contrary, younger students demonstrating higher emotional awareness in this study may represent greater sensitivity to emotional cues during early training before the onset of clinical fatigue or academic pressure.27,28 In addition to this, parental literacy and involvement with their children have also been linked to higher EI levels, suggesting that emotionally supportive environments improve EA and its regulation. 29 Moreover, literature suggest that environments, such as hostel residence, allow for regular social interactions that require empathy, conflict resolution skills and EI. Research shows that students engage more in regular human interactions than purely academically stimulating ones and thus, suggest that living in shared spaces enhances EI related skills. 30 This supports our finding that hostel residents demonstrated higher SEA and RM. Furthermore, living and working in multicultural and group based settings like shared accommodations, can help students develop cultural sensitivity, self awareness, and emotional resilience. 31 Our study shows that students of Punjabi descent have better EI outcomes than other ethnicities and cultures. However, these findings should be interpreted cautiously as cultural differences in emotional expression, communication styles, and social upbringing may influence how people perceive and report their competencies. 32 Cultural norms often shape emotional regulation and interpersonal skills, which may partially explain variability in EI across ethnic groups. Future multicentred studies including diverse institutional settings would help determine whether these differences reflect broader patterns or are unique to our sample. 33 Lastly, we found that EI was also associated with leadership skills which is consistent with prior findings demonstrating that EI predicts transformational and authentic leadership through better regulation of emotions, interpersonal skills and self-awareness. 34
Our study concluded that self-awareness, balanced processing and rational transparency were positively associated with age, hostel residence and extracurricular engagement. This suggests that self-sufficiency and social exposure contribute greatly to leadership development. These findings align with contemporary leadership theories that emphasize emotional competencies as core determinants of effective leadership. 35 Authentic leadership, in particular, is rooted in self-awareness, transparency, and decision making, all of which are closely related to EI. Therefore, the strong association between EI domains and leadership competencies observed in this study further supports the argument that cultivating emotional skills during medical education may facilitate the development of competent physician leaders. 36 In addition to this, some longitudinal studies indicate that mentorship can improve overall leader identity, self-efficacy, and performance especially with a targeted goal to achieve.37,38 Mentorship opportunities also provide a ground for role modelling, seeking personal feedback, and the development of critical skills, which are imperative in creating the leaders of tomorrow. 39 In medical education settings, structured mentorship and leadership training programs have been shown to enhance leadership identity formation among students. Such programs not only promote professional development but improve practice and team-based decision making which are essential attributes in modern healthcare. 40 Furthermore, literature suggests that leadership that makes use of clear communication and is guided by autonomy creates opportunities where individuals develop essential life and professional skills. An observational study on leadership emergence in work environments found that qualities such as cognitive ability, conscientiousness, and openness to experience were associated with the leadership qualities. 41 This has also been supported by other existing studies which propose that participating in activities that are autonomy-based are associated with better autonomous behaviour, proactiveness, and leads to greater self-leadership awareness, improved cooperation, and problem solving.42,43
We deduced that levels of empathy varied significantly with demographic factors such as age, gender and extracurricular activities (ECAs). In our sample, older students demonstrated higher empathy scores, while females consistently outperformed their male peers. Participation in ECAs also showed to have a stronger association with empathetic orientation. Interestingly, empathy followed a U-shaped trajectory across academic years, where final-year students achieved the highest scores and fourth-year students achieved the lowest scores. The temporary decline observed during fourth year may reflect the transitional phase in which medical students shift from preclinical to more advanced clinically demanding environments. Increased workload, emotional exhaustion, and exposure to patient suffering may initially overwhelm their coping mechanisms, leading to reduced empathetic responsiveness. However, the subsequent increase in final-year students suggests that greater clinical familiarity and professional identity formation may enable students to regain empathetic engagement with patients. Our results echo prior reports where multiple studies have documented gender differences in empathy with females outperforming males on measures of empathetic concern.44,45 Some longitudinal studies also suggest that with subsequent increase in exposure, empathy scored increase. This is also associated with the establishment/exposure of students to humanities curricula therefore, allowing them to think and challenge social norms and stepping out of their comfort zones to critically think and provide holistic care. 46 Multiple studies show that establishing supportive relationships with peers in ECAs are also positively linked to increasing empathy, which in turn promotes behaviours like caring and helping. 47 Social and arts related ECAs are shown to be more effective in promoting compassion and empathy than others. 48 Extracurricular engagement may provide opportunities for experiential learning that are not always available within traditional classroom settings. Most medical students also engage in patient related societies which aim to elevate their way of living. Such groups often interact with patients and allow students to see what patients go through via more personal experiences and encounters. 49 Such volunteering activities and community outreach programs encourage perspective taking and social interaction, which can foster empathy and reinforce professional values. However, our study’s U-shapes trajectory is comparable to the steady decline reported in multiple articles.50,51 Stressors such as patient overload, time pressure, and reliance on technology are usually considered contributing factors to such declines. In our setting, one such reason may be the more clinical presentation and exposure to diverse fields in addition to participating in multiple electives which may foster empathetic responses from students.
Together, our findings illustrate that EI, empathy and leadership are not fundamentally isolated traits, but interdependent ones shaped by multiple demographic, academic and social factors. The principles of EI provide the foundation for leadership skills, while empathy interacts with both to enhance patient-centered care. This is a triangular relationship showing that strengthening one domain may positively influence the other. From an educational perspective, this relationship highlights the importance of integrating EI training within undergraduate medical curricula. Programs focusing on reflective practice, communication and mentorship may simultaneously enhance empathy and leadership traits.37,52 Such approaches are particularly important in LMIC contexts, where healthcare increasingly requires not only clinically competent physicians but those capable of leading multidisciplinary teams and delivering compassionate care.6,20
This study is one of the few from Pakistan to examine the roles of EI, empathy, and leadership in undergraduate medical education.2,5,7,53 Including medical students across four years allowed us to visualize and predict patterns overtime. The use of validated scales for each measure enhanced the study’s reliability, while the approximately equal gender distribution reduced confounding. On the contrary, the cross-sectional design prevents causal inference. As a single-center study relying on self-reported questionnaires, findings may be influenced by recall or social desirability bias and may not be generalizable. Although there was almost equal gender distribution, demographic variables such as ethnicity and year of enrolment, which showed variations, may have affected the derived results. Although the Quick Emotional Intelligence Self-Assessment is widely used as a brief screening tool, published psychometric properties are not available. This represents a limitation of the study. Finally, the quantitative design did not capture qualitative insights from students, which could have added contextual depth to this project.
Medical education in Pakistan and other similar structures must realize the importance of developing structured programs targeted to improve EI and leadership within the academic curricula. These combined with early patient contact, reflective practice, and extracurricular engagement, may strengthen empathy and interpersonal effectiveness. Moreover, incorporating globally accredited frameworks such as the ACGME Core Competencies and the CanMEDS in schooling objectives can highly enhance such outcome scores. These changes could foster physicians who are not only clinically competent but also emotionally intelligent leaders with the ability to deliver compassionate, patient-centered care. We believe that longitudinal and multicentre studies are required to explore how these traits evolve over time and to evaluate the impact of targeted interventions.
5. Conclusion
EI, empathy, and leadership share an interconnection, influenced by demographic, environmental, and academic factors. Age, living status, and parental education emerged as important factors contributing to empathy and various components of leadership. Our findings conclude that these are not fixed traits but attributes that can be strengthened through exposure, to supportive and stimulating environments that challenge the individual to hone these skills. Integrating structured training in EI and leadership within medical schools may therefore improve not only empathy but also the professional grooming of physicians.
Supplemental Material
Supplemental Material - Emotional Intelligence, a Step Further on Empathy and Leadership Skills of Future Doctors: A Cross-Sectional Study on Undergraduate Medical Students of Pakistan
Supplemental Material for Emotional Intelligence, a Step Further on Empathy and Leadership Skills of Future Doctors: A Cross-Sectional Study on Undergraduate Medical Students of Pakistan by Ambreen Surti, Muhammad Raza Sarfraz, Ambreen Usmani, Abdul Rehman, Maryam Tariq and Hiya Huq in Journal of Medical Education and Curricular Development
Footnotes
Acknowledgments
We thank Professor Mohammad Reza Hojat and Thomas Jefferson University, Philadelphia, PA, USA, for granting permission to use the Jefferson Scale of Empathy, and the undergraduate medical students for their participation.
Ethical Considerations
The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethical Review Board of Bahria University Health Sciences Campus, Karachi (ERC 26/2023). Informed consent was obtained from all participants prior to enrollment.
Consent to Participate
Written informed consent was obtained from all participants prior to their inclusion in the study, in accordance with Committee on Publication Ethics (COPE) guidelines. Participants were informed about the study objectives, the voluntary nature of participation, confidentiality of data, and their right to withdraw at any time without academic consequences. No data were collected from minors, deceased, or mentally incapable individuals. Therefore, consent from legally authorized representatives was not required.
Author Contributions
AS and MRS contributed equally to this work. They conceptualized and designed the study, supervised project execution, coordinated data collection, validated and analyzed the data, interpreted results, drafted the original manuscript, and managed overall study coordination. AU provided supervision and expert input in medical education. AR conducted the literature review and contributed to manuscript drafting and final editing. MT contributed to draft preparation, review, validation, and coordination of the research team. HH contributed to manuscript review and editing. All authors critically revised the manuscript and approved the final version.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
De-identified data supporting the findings of this study are available from the corresponding author upon reasonable request.
Institutional Review Board Statement
The Study was Conducted in Accordance with the Ethical Principles of the Declaration of Helsinki and Relevant International Research Guidelines. Ethical Approval was Obtained from the Ethical Review Committee of Bahria University Health Sciences Campus, Karachi (Approval No. ERC 26/2023) prior to commencement of the study.
Supplemental Material
Supplemental material for this article is available online.
Appendix
References
Supplementary Material
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