|Year : 2019 | Volume
| Issue : 4 | Page : 316-326
Empathy among dental students: A systematic review of literature
Ridhi Narang1, Litik Mittal2, Sonali Saha3, Vikram Pal Aggarwal4, Poonam Sood5, Shyam Mehra6
1 Department of Public Health Dentistry, Adesh Institute of Medical Sciences, Bathinda, Punjab, India
2 Department of Conservative Dentistry and Endodontics, Adesh Institute of Medical Sciences, Bathinda, Punjab, India
3 Department of Pedodontics, SPPGIDMS, Lucknow, Uttar Pradesh, India
4 Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India
5 Department of Public Health Dentistry, HS Judge Dental College, Chandigarh, India
6 Department of SPM, Adesh Institute of Medical Sciences, Bathinda, Punjab, India
|Date of Web Publication||7-Nov-2019|
Dr. Vikram Pal Aggarwal
Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Empathy is just as relevant within dentistry, although research is limited in this field and very less is available in the current literature. The demonstration of empathy by dentists has been correlated with decreased dental fear. The authors systematically reviewed the literature to investigate empathy levels among dental students. Methods: A systematic review of the literature was undertaken concerning dental students' empathy, published from November 2016 to June 2018, using manual methods and the PubMed, PMC, PsycINFO, and other databases. Articles not in English and not concerned with dentistry were excluded, and intervention studies intended to enhance empathy, opinion articles, and reviews or reports of nonoriginal research were excluded. Eligible studies were those published from January 1, 2005, to May 31, 2017, in English language. A total of 34 full-text articles were obtained and assessed. Of these 34 papers, only seven publications were considered to have met the inclusion criteria and were directly related to the aim of literature search. Results: Only seven articles that provided data and evidence describing empathy among dental students were included. Four studies reported that the difference in mean empathy level across the year of study was statistically significant (P < 0.05), and one reported that there was no significant difference in empathy scores between the year levels of study. Three articles reported that males had higher mean empathy score than females, whereas vice versa was found in the remaining four articles. Conclusion: This article demonstrates that there is only a limited evidence to provide the understanding of empathy among dental students. The results indicated that as patient exposure increases, the empathy level decreases among dental students. Furthermore, it is observed that education in behavioral sciences may be effective in increasing self-reported empathy, and further training may be necessary to maintain high levels.
Keywords: Communication, dental, dentist, empathy, patient, relationship, systematic review
|How to cite this article:|
Narang R, Mittal L, Saha S, Aggarwal VP, Sood P, Mehra S. Empathy among dental students: A systematic review of literature. J Indian Soc Pedod Prev Dent 2019;37:316-26
|How to cite this URL:|
Narang R, Mittal L, Saha S, Aggarwal VP, Sood P, Mehra S. Empathy among dental students: A systematic review of literature. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2019 Nov 14];37:316-26. Available from: http://www.jisppd.com/text.asp?2019/37/4/316/270484
| Introduction|| |
Communication with the patient is an essential activity which helps build a good rapport between the doctor and the patient. Communication not only helps capture the patient's past medical history and transmit information, but also has a therapeutic effect and supports the patient's healing process. Patient–physician communication has shown to have a positive effect on psychosocial outcomes (e.g., fear, quality of life, anxiety, and depression) and on objectively measurable outcome parameters (e.g., symptom and pain reduction and reduced recovery time). Thus, it benefits the patient in his/her physical, mental, and social well-being. Furthermore, there is increased patient satisfaction and lesser medical litigations.,,
A basic element of a good patient–physician communication is empathy. Empathy is derived from two Greek terms, “em” and “pathos,” meaning “feeling into” and has its origin from the German word “Einfulung.” It enables health-care providers to identify and understand patient's experiences, concerns, and views. In terms of patient care, empathy is defined as a cognitive attribute that involves an ability to understand the patient's experiences, pain, suffering, and perspective, combined with a capability to communicate this understanding and an intention to help. Sympathy is often misused as empathy as both involve sharing, but sympathy is sharing patient's emotions, whereas empathy is to be in patient's position and understanding it.,
Empathy is just as relevant within dentistry, although research is limited in this field and very less is available in the current literature. The demonstration of empathy by dentists has been correlated with decreased dental fear, adherence to orthodontic treatment, improved treatment success especially in cases of pain and cooperation in pediatric patients, and patient satisfaction. Empathy plays an important role in achieving patient centeredness, which is one of the six main goals of a 21st-century health system. The appreciation of the role of empathy and interpersonal skills in dental settings had led the American Dental Education Association to list empathy as one of the most important clinical competencies for training.
In turn, most dental schools acknowledge the importance of empathy and also provide some training in empathy, active listening, and verbal and nonverbal communications, but measurement of the acquisition of these skills remains a challenge. The gold standard for assessment of empathy is behavioral observation by trained observers; however, this can be costly and time-consuming. The dearth of research on the topic has been attributed to the absence of adequate self-report measures. While several self-report measures of empathy have been developed for use in the general population, only one has been developed for use in the health-care setting. The Jefferson Scale of Physician Empathy has been validated in a variety of health-care settings, and also its psychometric properties have been established in the dental setting., Further, little is known about changes in empathy during formal dental education.
By conducting a systematic review of the literature, the authors aimed to describe the current status of empathy scores in students of different years of dental school.
| Methods|| |
Aim of literature review
A systematic review of the literature was undertaken with the following key objective: “To review the empathy among dental students based on previous research.”
A methodical approach based on the Centre for Reviews and Dissemination guidance  for undertaking reviews in health care was adopted using electronic databases to search the literature, supplemented by hand searching and cross-referencing. During November 2016 to June 2018, a systematic review of the literature was performed to identify original articles reporting quantitative investigations of the determinants and changes in empathy among dental students. We searched the PubMed, PMC, and PsycINFO electronic databases using the National Library of Medicine's Medical Subject Heading terms such as empathy, dental, and students. Further research was conducted on the Internet via search engines such as Google Scholar and Index Copernicus. A manual search of reference sections of review articles and other publications was also conducted. Forward citation chasing was also done, which fully justifies our comprehensive approach to the search strategy [Flow Chart 1].
Relevant publications from the generated list were identified by examining publication titles and abstracts and reading the entire article. Inclusion and exclusion criteria were applied to the articles identified from the literature search [Table 1]. The focus of this review was on determining evidence base on changes in empathy among dental students irrespective of geographic area and demographics. Eligible studies were those published from January 01, 2005, to May 31, 2017, in English language. Two-stage screening process was done. In stage 1, titles and abstracts were screened against the inclusion criteria. All the articles were included where any degree of uncertainty existed for its inclusion and then the full text was assessed for final decision., and the full-text article was assessed. Stage 2 involved screening of full-text articles against inclusion criteria, which was absolute and was strictly followed.
Electronic search engines yielded 380 articles. Out of the 380 papers, the initial electronic search accounted for 370 articles, with an additional searching technique identifying the remaining 10 papers. The 380 papers were assessed by the lead author against the predetermined selection criteria based on the information available in the titles and abstract, if available. A total of 346 papers were excluded at this stage as they did not apply directly to the research question. A total of 34 full-text articles were obtained and assessed. Of these 34 papers, only 7 publications were considered to have met the inclusion criteria and were directly related to the aim of literature search. Of the potentially eligible 34 papers, content of 21 papers was not related to dentistry, 2 papers were not linked directly to the key question, 1 publication was a review article, 1 publication was not in English language, 1 study was an intervention study, and 1 paper was on practicing dental surgeons [Table 2].
|Table 2: Details of 27 papers identified from literature review and reason for exclusion|
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First, one author (RN) read all of the relevant studies on empathy during dental school. Second, she analyzed the reasons for changes in empathy that each study investigated and discussed. Third, she evaluated the methodological quality of each study, focusing on the study design and method, response rates, and the validity of the self-assessment measures used. The other authors validated her analysis and conclusions. All the disagreements were discussed and resolved.
Many quality appraisal tools are available according to the research undertaken. One of the suitable tools accepted for qualitative studies is the Critical Appraisal Skills Programme (CASP)., Quality appraisal was done for the seven articles by two authors separately (RN and LM) [Table 3].
Minimization of bias
The studies included in the present study had to have adequate random allocation concealment, comparable intervention and control groups, and complete information on dropouts by study groups, where the dropout rate also had to be <25% at 12-month follow-up and <30% at 24- or 36-month follow-up. This was done to minimize the risk of bias. The overall bias rating was based on the scale reported in the Cochrane Handbook for Systematic Reviews of Interventions 5.0.0 (Higgins 2008) for the three characteristics outlined in the previous paragraphs (allocation concealment, dropout rates, and the comparability of the intervention and control groups).
| Results|| |
Only seven articles provided data and evidence describing empathy among dental students. These eligible papers used qualitative research and were of acceptable quality as per CASP guidelines. A summary sheet providing an overview is shown in [Table 4]. Majority of the studies were conducted in India (4 out of 7),,,, with the exception of 1 study conducted in Malaysia  and 2 in the United States of America.,
|Table 4: Overview of seven articles finally selected for systematic review|
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All the seven studies were cross-sectional in nature and were based on standardized questionnaires (Jefferson Scale of Empathy) with students and exclusively used tools for self-assessment of empathy. Out of these, two studies by Datta et al. in 2016 and Sherman and Cramer in 2005 used Jefferson Scale of Physician Empathy-Health Professionals Version (JSPE-HP) and five studies used Jefferson Scale of Physician Empathy-Health Professionals student Version (JSPE-HPS). The study done by Datta et al. in 2016 used a 5-point Likert scale, whereas the remaining six studies used a 7-point Likert scale. The literature review suggests that very few studies have been done regarding empathy among dental students.
Only one paper  conducted the study on 3rd-year and final–year students and interns of dental colleges as patient exposure starts in the 3rd year, whereas other studies included first- to final–year students ,,,,, and also interns.,,,, One study  also included postgraduate students in the study population. Three of the studies had mentioned time period of training in particular year as inclusion criteria. This was reflected in the study conducted by Aggarwal et al. in 2016 who assessed students who had completed 6 months following admission. Sherman and Cramer  included students at the end of their spring quarter and Diaz-Narvaez et al. included those attending the last section of the first semester of each course.
Empathy among dental students
There are a number of similarities between the seven papers in terms of research topic, tool used for data collection, sample population, and sampling methods. However, three studies were single centered,,, whereas four were multicentered.,,, Four papers did not study the psychometric properties of a measure of empathy to the dental setting, whereas the remaining three studies concluded that the JSE-HPS demonstrated good internal consistency (Cronbach's α >0.70).,,
Three articles reported that males had higher mean empathy score than females,,, whereas vice versa was found in the remaining four articles.,,, Four studies ,,, reported that the difference in mean empathy level across the year of study was statistically significant (P < 0.05), and one reported that there was no significant difference in empathy scores between the year levels of study. Two studies showed the highest mean empathy score among 1st-year dental students,, whereas one study  showed the lowest mean empathy score among 1st years. Three studies showed that the mean empathy scores were found to be minimum among 3rd-year students.,, Three studies ,, reported final-year dental students' mean empathy score to be minimum when compared to that of other years of study, whereas only one study found maximum mean empathy score in final-year students. In three of the studies, interns were found to have higher mean empathy scores,,, whereas other three had lower mean empathy score.,,
| Discussion|| |
Mean empathy score across gender
Comparison of mean empathy score across gender in the present systematic review showed that three studies found that females had statistically higher mean empathy scores than males,,, whereas only one study did not have statistical difference even if females had higher score. This might be because female brain probably shows more empathy than male brain. When females are put in a situation where they consider themselves standing in patient's shoes, their brain action shows that they themselves feel the same sentiments as well, while in contrary, male's brain action shows judgmental/noetic assessment – a more objective position. Women show a greater understanding of the emotional support that the patient may need and generally tend to give a higher significance to developing interpersonal relationships with patients, whereas men tend to assign greater significance to authority, independence, and control.
Furthermore, some suggest that women have evolved to be more gentle and compassionate toward their offspring than their male counterparts, and hence demonstrate better communication skills and a higher level of understanding toward their offspring. A possible connection can be drawn here, as offspring and patients both require care. This finding is consistent with many international studies on medical students.,,
Datta et al. reported statistically higher mean empathy score in males, which could be attributed to the higher proportion of female students compared to male students in the present study. There has been a demographic shift in the selection of dental degree course, and recent trends had shown that dentistry is commonly chosen by female students than male students. The remaining two studies showed higher values for males than females, but the difference was not statistically significant.,
Mean empathy scores across years
Sherman and Cramer  found the highest mean empathy score among 1st-year dental students as their curriculum had considerable emphasis on behavioral science with courses in communication skills, cultural competence, and history taking. These classes emphasize the use of nonverbal behaviors (e.g., nodding consent, eye contact, and body posture) and verbal behaviors such as reflection, validation, support, partnership, and respect that are demonstrative of empathetic communication. Contrary to this, Diaz-Narvaez et al. found least mean empathy scores among 1st years. The probable reason for the same could be that initially when students join dental school, they are not aware of the responsibilities. Gradually, when they come in contact with the patients, they develop empathy.
Among the seven studies, three studies showed that the mean empathy scores were found to be minimum among 3rd-year students,,, another set of three studies reported mean empathy score to be minimum among final year BDS students ,, and also few reported to be lower among interns.,, Empathy appears to drop when patient contact increases. Low levels of empathy may reflect the teaching style at various academic institutions. The education and training of dental students may be stressful and include extensive work hours and a lack of sleep. Chair-side communication may also become reduced due to time constraints, leading to a decrease in empathy. The increasingly emotionally demanding and harsh conditions of their academic career could negatively affect feelings of compassion among students. Furthermore, certain humanities topics are not included in most curricula; these subjects may help improve students' empathetic abilities.
Another possible explanation for the observed decrease in empathy among dental students is the sense of privilege that grows throughout a doctor's training; being part of an advantaged group has been suggested to contribute to changes in an individual's capacity for empathy. Reports on students of medicine paint a similar picture. When students begin working with patients, they may come to realize that patients are not always willing to change their high-risk behaviors in the face of adverse health outcomes. This noncompliance to the instructions given by doctor to patients further makes it difficult for them to feel empathetic towards patient.,,
In one of the studies, empathy levels increased in final year, which could be attributed to lectures, role playing, or communication skills completed recently. Studies have shown an increase in empathy level measured before and after an early analytical exposure to behavioral sciences and clinical encounter. It is possible and hopeful to consider that a gradual increase in empathy follows this final year of dental school training and continues beyond into practice or graduate education. In any case, these data suggest that education in behavioral science may be effective. Interns were found to have higher mean empathy scores,,, which is a virtue to the responsibilities given for the interns toward patient care and their desire to start their clinical practice, which makes them to understand the necessity for a successful dental practice.
In all the seven selected articles, the nature of the study was cross-sectional, and it is possible that cohort effects could account for the observed differences across dental school classes. Although the classes were similar on other variables, they may be dissimilar in empathy levels. Comparisons were performed between different groups of students. The scores would have been more comparable had the same population been followed from 1st year till they became interns. A longitudinal study tracking changes in a single cohort through dental school and potentially beyond might offer considerably more insight into the stability of characteristics such as empathy in practice. Socioeconomic status was not considered in any of the selected article.
A commonly used scale by the seven articles was the JSPE which relies solely on the self-reported measurement of empathy. Although the JSPE has been shown to be a reliable and valid indicator of the construct of empathy, it is limited to reflecting students' orientation to empathy and not actual behaviors. Behavioral observation of activities during a practitioner and patient interaction as an adjunct to self-report would be a valuable addition to future research in the area. Observational methods such as the History-taking Rating Scale could be used with the JSE-HPS to measure empathy level in dental students.
Three of the studies were single centered, i.e., data are limited to one dental school, and hence, findings may not generalize to all dental students.,, Future research may focus on multiple sites and larger samples. In few studies, the students responded to the survey based on their experience in the previous years in the dental school.,,,
| Conclusion|| |
Empathy is an important aspect of providing quality dentistry, but there appears to be poor understanding of the term within the existing literature. This paper demonstrates that there is only a limited evidence to provide the understanding of empathy among dental students. The results of this review, albeit from a little evidence base, would appear to indicate that, as patient exposure increases, the empathy level decreases among dental students. Furthermore, it is observed that education in behavioral sciences may be effective in increasing self-reported empathy, and further training may be necessary to maintain high levels.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]