To examine the relationship between stress, social support, and empathy among medical students.
We evaluated the relationships between stress and empathy, and social support and empathy among medical students. The respondents completed a question-naire including demographic information, the Jefferson Scale of Empathy, the Perceived Stress Scale, and the Multidimensional Scale of Perceived Social Support. Corre-lation and linear regression analyses were conducted, along with sub-analyses according to gender, admission system, and study year.
In total, 2,692 questionnaires were analysed. Empathy and social support positively correlated, and empathy and stress negatively correlated. Similar correla-tion patterns were detected in the sub-analyses; the correla-tion between empathy and stress among female students was negligible. In the regression model, stress and social support predicted empathy among all the samples. In the sub-analysis, stress was not a significant predictor among female and first-year students.
Stress and social support were significant predictors of empathy among all the students. Medical educators should provide means to foster resilience against stress or stress alleviation, and to ameliorate social support, so as to increase or maintain empathy in the long term. Furthermore, stress management should be emphasised, particularly among female and first-year students.
Empathy in medical practice is related to clinical competence.
Social support is one of the coping mechanisms for stress. Medical students satisfied with their own lives have been found to have low perceived stress and high resilience, and to seek social support.
We assume that high stress levels and low social support are some of the important contributing factors towards low empathy levels among medical students. However, little is known about the relationships between stress, social support, and empathy, particularly as determined through use of the Jefferson Scale of Empathy (JSE). Most previous studies on stress and empathy did not use the JSE, an instrument designed to measure empathy in relation to a patient-caregiver situation.
This cross-sectional study was approved by the institutional review board for human research at Inje University Busan Paik Hospital, South Korea. The questionnaires were distributed to all first- to fourth-year medical students at 20 medical schools in South Korea, in October 2014. The following data were also collected, forming part of demographic data: gender, age, medical school admission systems, and study-year level.
The student version of the JSE was used. The JSE was developed so as to measure physician empathy,
The Perceived Stress Scale (PSS) is as self-report instrument used to evaluate the degree of perceived stress in daily life within the past month. It was developed by Cohen et al. in 1983, who at the time, reported good reliability and validity.
The Multidimensional Scale of Perceived Social Support (MSPSS) was developed by Zimet
The differences in the levels of empathy, social support, and stress according to gender and medical education system were evaluated using the t-test, whereas analysis of variance (ANOVA) was used to analyse those differences according to study-year level, with Dunnett’s T3 test used for post-hoc analysis. Pearson’s correlation analysis was performed to assess the relationship between empathy and social support, and between empathy and stress. Multiple linear regression analysis (enter method) was used to identify predictors of empathy. The Statistical Package for the Social Sciences (ver. 20.0, SPSS Inc., Chicago, IL, USA) was used for the analyses, and significance was declared at p < 0.05.
In total, 2,702 questionnaires were received from 20 medical schools. Questionnaires with incomplete data were excluded and, consequently, 2,692 questionnaires were used for analysis. The sample comprised 1,675 male (62.2%) and 1,017 female students (37.8%). The mean age of the respondents was 24.73 years (range: 20–40). In addition, 1,353 students were enrolled in undergraduate programmes (50.3%) and 1,339 enrolled in post-baccalaureate programmes (49.7%). There were 929 (34.5%) first-year students, 971 (36.1%) second-year students, 559 (20.8%) third-year students, and 233 (8.7%) fourth-year students (
Variables | No. (%) | |
---|---|---|
Gender | ||
Male | 1,675 (62) | |
Female | 1,017 (38) | |
Age | ||
Years (Mean, SD) | 24.73 (3.004) | |
Medical school admission system | ||
Undergraduate programme | 1,353 (50) | |
Post-baccalaureate programme | 1,339 (50) | |
Medical school admission system and sex | ||
Males in undergraduate programme | 912 (67) | |
Females in undergraduate programme | 441 (33) | |
Males in post-baccalaureate programme | 763 (57) | |
Females in post-baccalaureate programme | 576 (43) | |
Study year | ||
First-year | 929 (35) | |
Second-year | 971 (36) | |
Third-year | 559 (21) | |
Fourth-year | 233 (9) | |
Total | 2,692 (100) |
The mean total score on the JSE was 105.48 ± 14.67 (
Variables | JSEaMean (SD) | PSSbMean (SD) | MSPSScMean (SD) | |
---|---|---|---|---|
Total students | 105.47(14.67) | 28.65(6.22) | 68.02(11.79) | |
Gender | ||||
Male | 104.76(15.44) | 28.26(6.25) | 68.34(12.26) | |
Female | 106.63(13.25)* | 29.29(6.12)* | 70.14(10.90)* | |
Medical school admission system | ||||
Undergraduate programme | 104.77(14.86) | 28.85(6.28) | 67.72(12.40) | |
Post-baccalaureate programme | 106.17(14.46)† | 28.45(6.15) | 70.35(10.99)† | |
Medical school admission system and sex | ||||
Males in undergraduate programme | 103.58(15.36) | 28.54(6.22) | 66.89(12.70) | |
Females in undergraduate programme | 107.24(13.44)* | 29.49(6.37)* | 69.42(11.58)* | |
Males in post-baccalaureate programme | 106.17(15.42) | 27.93(6.28) | 70.08(11.47) | |
Females in post-baccalaureate programme | 106.16(13.09) | 29.14(5.92)* | 70.69(10.32) | |
Study years | ||||
First-year | 106.80(13.92) | 29.55(6.11) | 69.66(11.07) | |
Second-year | 104.46(15.52)ǂ | 28.60(6.05)ǂ | 68.15(12.61)ǂ | |
Third-year | 105.32(14.49) | 27.75(6.58) | 69.37(11.84)ǂ | |
Fourth-year | 104.70(14.12) | 27.47(5.96) | 69.25(10.72)ǂ |
aJSE: Jefferson Scale of Empathy; bPSS: Perceived Stress Scale; cMSPSS: Multidimensional Scale of Perceived Social Support.*p<0.05 when compared to male participants; †p<0.05 when compared to the undergraduate programme; ǂp<0.05 when compared to first-year level
The mean total score on the PSS was 28.65 ± 6.22 (
The mean total score on the MSPSS was 68.02 ± 11.79 (
The JSE score and the PSS score showed a weak, negative correlation (r=-0.14, p<0.001). In the sub-analyses comprising the medical school admission system and study-year level, correlations between empathy and stress were similar to those obtained for all of the students. However, a negligible correlation between empathy and stress was detected among female students (r = -0.07, p = 0.021) (
The JSE score and the MSPSS score showed a moderate, positive correlation (r = 0.33, p < 0.001). In the sub-analyses comprising gender, the medical school admission system, and study-year level, correlations between empathy and social support were similar to those obtained by all of the students (
Variables | JSEa and PSSb | JSEa and MSPSSc | |
---|---|---|---|
Total students | -0.14* | 0.33* | |
Gender | |||
Male | -0.19* | 0.34* | |
Female | -0.07† | 0.29* | |
Medical school admission system | |||
Undergraduate programme | -0.14* | 0.32* | |
Post-baccalaureate programme | -0.15* | 0.32* | |
Study year | |||
First-year | -0.13* | 0.33* | |
Second-year | -0.14* | 0.35* | |
Third-year | -0.18* | 0.29* | |
Fourth-year | -0.21† | 0.25* |
aJSE: Jefferson Scale of Empathy; bPSS: Perceived Stress Scale; cMSPSS: Multidimensional Scale of Perceived Social Support.*p<0.001, †p<0.05
In the regression model, stress and social support were found to be moderate, significant predictors of empathy among all of the students. Social support and stress showed similar patterns of moderate, significant prediction of empathy in the sub-analysis. However, in the sub-analysis, stress did not significantly predict empathy among female and first-year students, respectively (
Variable | PSSa | MSPSSb | ||||
---|---|---|---|---|---|---|
B | SE | β | B | SE | β | |
Total students (R2 = 0.109) | -0.144* | 0.044 | -0.061 | 0.385† | 0.023 | 0.309 |
Gender | ||||||
Male (R2 = 0.122) | -0.246† | 0.059 | -0.100 | 0.387† | 0.030 | 0.308 |
Female (R2 = 0.086) | -0.002 | 0.067 | -0.001 | 0.356† | 0.038 | 0.293 |
Admission system | ||||||
Undergraduate programme (R2 = 0.108) | -0.154ǂ | 0.062 | -0.065 | 0.368† | 0.032 | 0.307 |
Post-baccalaureate programme (R2 = 0.107) | -0.129ǂ | 0.064 | -0.055 | 0.404† | 0.036 | 0.307 |
Study year | ||||||
First-year (R2 = 0.108) | -0.106 | 0.073 | -0.046 | 0.398† | 0.040 | 0.316 |
Second-year (R2 = 0.127) | -0.166ǂ | 0.079 | -0.065 | 0.415† | 0.038 | 0.337 |
Third-year (R2 = 0.090) | -0.198ǂ | 0.095 | -0.090 | 0.313† | 0.053 | 0.256 |
Fourth-year (R2 = 0.081) | -0.349ǂ | 0.156 | -0.147 | 0.269* | 0.087 | 0.205 |
B: unstandardized coefficient; SE: standard error; β: standardized coefficient. aPSS: Perceived Stress Scale;bMSPSS: Multidimensional Scale of Perceived Social Support.*p<0.01, †p<0.001; ǂp<0.05
In our study, we demonstrated the association between empathy and stress, and between empathy and social support in a large sample of Korean medical students. However, we found a negligible correlation between empathy and stress among female students and no significant prediction of empathy by stress among female students and first-year students, respectively.
The mean total score on the PSS in our study was surprisingly higher than that previously obtained by medical students in the United States (16.6 ± 7.49) and Chinese university students (18.44 ± 7.35).
In this study, first-year medical students showed the highest stress levels; a decline in stress levels among students in the higher study-year levels was also observed. In a previous longitudinal study, first-year students had the highest levels of depression and anxiety, contrary to fourth-year students, who had the lowest depression and anxiety levels.
In our study, a negative correlation was found between scores on stress and empathy levels. This finding is consistent with previous studies, wherein empathy negatively correlated with burnout among medical students.
In the regression analysis, stress did not correlate significantly with empathy among female and first-year students, respectively. This might be because women are biologically emotional, have high levels of empathy, and are sensitive to stress, as previously mentioned. Furthermore, first-year students might experience high levels of stress due to excessive competition and a new environment, though retaining sufficient levels of empathy. Senior students seem to become insensitive to stress and less empathetic, due to depersonalization.
In our study, the total mean score on the MSPSS was 68.02 ± 11.79, which is similar to the score previously obtained by Chinese university students (69.12 ± 10.14).
Weak social support, measured through the Medical Outcome Study, is commonly associated with mental problems among medical students.
We have made several suggestions for medical education on the basis of the above results. It is almost impossible to remove or reduce all the stressors affecting medical students. However, medical students should be provided with tools that aid the development of resilience against stress and the means to modify or decrease the impact of stressors, as part of the curriculum. For example, students with problem-based learning felt more socially supported at university than did those on the traditional curriculum tracks.
The present study has a few limitations. The response rate was 48%, due to the low response rate of third- and fourth-year students. There was limited access to third- and fourth-year students during the course of our survey. Third-year students were conducting clinical work and fourth-year students were preparing for the medical licensing examination. Furthermore, in addition to stress and social support, various other factors may be influencing empathy among medical students. This limitation could be the reason for the low correlation coefficient or weak prediction yielded by the regression analysis. Finally, our result regarding stress might be temporary, as PSS is used to measure stress levels relating to the previous month. However, our study might be representative of the typical Korean medical student, as it included multiple schools and students in various medical fields.
Stress and social support were significant predictors of empathy among all the students. In the sub-analyses conducted according to gender, the medical school admission system, and study-year level, similar patterns were demonstrated; however, stress was not a significant predictor among female students and first-year students. Medical educators should construct measures aimed at developing resilience against stress or decreasing stress, and at improving social support; examples of these are the restructuring of the curriculum and the mental health support system. These would lead to the maintenance of or an increase in empathy in the long term. Furthermore, stress management should be emphasised, particularly among female and first-year students.
This work was supported by the Inje University College of Medicine, in 2014.
The authors declare that they have no conflict of interest.