Sunday, October 1, 2023

Empathy competence and future specialty among medical residents in Japan: a nationwide cross-sectional study – Scientific Reports

This study used a nationwide cross-sectional survey across Japan to assess variations in empathy levels among residents (PGY-1 and PGY-2) based on their intended future specialty. The findings, measured using the JSE, revealed disparities in empathy levels correlated with future specialty choices before residents’ specialty training, with the highest levels observed in those leaning toward the choice of general medicine. In addition, after adjusting for the training environment and resident level, general medicine was associated with significantly higher empathy scores among the 19 primary medical specialties as well as with a higher number of women majoring in the field. The Cronbach’s alpha of the JSE was high for medical students (0.80) and physicians (0.80) in the US (0.84), which is comparable to the level reported for medical students (0.80) and physicians (0.81) in Japan; this study demonstrated similar results (0.84)20,21. Our discussion focuses on three areas to help frame our results: (1) differences in empathy by specialty, (2) potential explanations for high empathy levels among general medicine candidates, and (3) potential explanations for high empathy among women.

Differences in empathy among each specialty

Previous research indicates that physicians employed in patient-centered specialties, such as general medicine, internal medicine, psychiatry, and pediatrics, exhibit notably higher levels of empathy compared to those in procedure- and technology-centered specialties, such as surgery, anesthesiology, plastic surgery, orthopedics, and neurosurgery3,21,32. The findings of a Polish study are particularly noteworthy as it highlights that family physicians display the highest levels of empathy, which aligns with the current study’s observation of high empathy among Japanese generalists32. Although not directly comparable numerically to our study, as shown in Table 2, the empathy of residents who sought to train in procedure- and technology-oriented departments tended to be lower. This trend was similar to previous studies16,22,24. Other studies have suggested that a patient-centered communication style predicts medical error outcomes in primary care physicians but not in surgeons, proceduralists, and technique-centered practice, and the reasons are still unknown33. It remains unclear whether these disparate levels of empathy are due to self-selection into a specialty or the result of their unique training effects and experiences17,24,34,35. In this study, the evidence highlights the differences in empathy levels depending on the specialty of interest that exist even before residents begin specialty training. Several other studies have suggested that empathy may decrease after surgical training23,24. This may be due to the unique empathic characteristics of surgeons, which differ from those in general medicine and internal medicine24. Therefore, some training for personnel in specialties where empathy tends to be low may be helpful, and numerous educational studies have been reported19,20,36,37.

Potential explanations for high empathy levels among general medicine physicians

Several previous studies have consistently demonstrated that physicians practicing in environments that prioritize patient-centered principles exhibit elevated empathy levels3,21. Notably, the prospective general medicine physicians in our study displayed significantly higher empathy levels than the average residents. Since they were residents before embarking on their specialized training in general medicine, it is improbable that the influence of their major program accounts for this difference. Instead, it is plausible that residents who initially chose to pursue a career in general medicine may have prioritized empathy as a crucial factor in their decision-making process. Thus, we must carefully consider the potential impact of the general internal medicine specialty certification program, which commenced in 2018, and its stated competencies38, as it may further illuminate the observed higher empathy levels among general internists. The General Medicine Board-Certified Programs include human-centered medicine and care (patient-centered medicine, family-oriented medicine and care, and communication to facilitate collaboration with patients and families) as the first of six competencies25,38,39. That is, residents who agree with the importance of these competencies are likely to further increase their empathy scores by applying them to general medicine. In Japan, there is only a slight disparity in salaries among medical specialties, and the lack of competition allows residents to choose their specialty according to their medical interests and aptitude21. While this situation may be unique and different from that in North America40, the apparent high level of empathy among residents who wish to pursue general medicine adds new evidence to previous studies.

Potential explanations for high empathy among women

Numerous studies have consistently suggested a higher level of empathy among women physicians and medical students3,17,21,41,42. This finding has historically been attributed to intrinsic factors (e.g. biological and evolutionary sex differences) and extrinsic factors (e.g. socialization, sex [gender] role norms, and societal expectations)21,42. In our study of medical residents, the average JSE scores were higher among women, which is consistent with previous studies. At least one study from Japan also noted that among women residents, the medical specialty choice is influenced by work-life integration (e.g. perceived balance between work and childcare)21. However, we were unable to correlate the choice of specialty among women physicians with levels of empathy found among physicians in various specialties, primarily because of the relatively low representation of women among the residents in our study.

This study has additional limitations. First, as this was a cross-sectional study, we cannot know whether PGY-1 residents will, in fact, enter their identified future specialty as they reported in our questionnaire. The percentage of PGY-2 residents that aspired to become general medicine physicians was slightly lower compared to PGY-1 residents. However, the data from PGY-2 residents are more reliable because the career paths of almost all residents are already determined at the time of the end-of-year examinations. Second, we excluded respondents that chose more than one specialty. The results would likely have been slightly different if they had been included. Third, general medicine in Japan is a relatively new specialty, and the fields of general internal medicine, hospital medicine, and family medicine overlap; hence, some residents of internal medicine might pursue hospital medicine or general internal medicine. Fourth, the current distribution of training facilities in Japan consists of approximately 45% university hospitals and 55% city hospitals. Notably, this study’s data are significantly well represented by the participation of the city hospitals. This can be attributed to the pronounced popularity of the GM-ITE among city hospitals, contributing approximately 80% of the participants, despite the involvement of over 630 training facilities annually. However, while there exists a disparity in the participant ratio between university hospitals and city hospitals, the ratio of affiliations between examinees and training participants remains nearly identical. Fifth, this study lacks specific details on the training departments chosen by each resident. The Japanese postgraduate clinical training requirements entail a minimum of 24 weeks in internal medicine, 12 weeks in emergency medicine, and 4 weeks each in surgery, pediatrics, obstetrics and gynecology, psychiatry, and community medicine. However, it is essential to consider that if the residents receive additional training in certain technology-oriented departments during the selection period, such as surgery or anesthesiology, it could potentially impact empathy levels and, consequently, lead to different study results24.

Our survey is the first to be used nationally to reveal differences in empathy among Japanese medical residents according to their future specialties. Our study confirms a high degree of empathy among physicians who aspire to be general medicine physicians, a specialty that values patient-centeredness. Empathy tended to be higher in more human-centered departments and lower in more procedure- and technology-oriented departments. However, in multivariate analysis, only aspirations for general medicine and being a woman were linked with significantly higher levels of empathy. No differences were found after adjustment for other medical specialties, training, working environment, or other factors. The findings of this study strengthen the evidence from previous studies conducted outside of Japan. Our results may have implications of postgraduate education; for example, empathy training strategies may be created for use in specialties wherein physicians tend to have lower empathy scores. However, further research is needed to determine why there are differences in the levels of empathy among applicants and to what extent these differences affect clinical practice.

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