You’re flipping through the television channels when you hear the familiar beginning strains of a Sarah McLachlan song.
You hastily click to the next channel, before the haunting images of homeless animals appear.
Or you’re scrolling through the news one morning when a headline makes you pause — a mass shooting, perhaps, or a tsunami halfway across the globe that’s left thousands homeless, injured or dead. You keep scrolling, unable to stomach such horrible news first thing in the morning.
Daryl Cameron, assistant professor of psychology and research associate in the Rock Ethics Institute at Penn State, wants to understand when, how and why people choose to avoid empathy in their daily lives.
Often conflated with compassion — sympathy or concern for others’ suffering or misfortune — empathy is the experience of understanding and actually sharing the feelings of someone else. Empathy, Cameron said, can be thought of as feeling with a person, rather than feeling for them.
But aren’t feelings automatic, something that happens without conscious effort?
Sometimes, but Cameron also said that we often make a choice of whether — and toward whom — we’re empathetic.
Across several studies, he and his colleagues have demonstrated that we do indeed opt out of being empathetic, and they’re closer to understanding one reason why.
And while it can seem like a negative thing, Cameron said the fact that we do have the ability to choose has an up-side.
“If our goal is to inspire more empathy to bridge social divides, then maybe knowing how and why people sometimes choose to not feel it could suggest a lever for pushing people in the opposite direction — to choose empathy.”
The question of choice
Cameron’s interest in the science of empathy was piqued in college while earning dual degrees in philosophy and psychology.
In grad school, he came across a paper suggesting that while people may feel immense empathy for an individual undergoing hardship or tragedy, empathy decreases as the number of victims rises.
At the time, Cameron said, some experts suggested that our empathy systems can’t process mass suffering, so they shut down. Others have argued that empathy isn’t even worth cultivating — that it’s biased and unsustainable and doesn’t lead to positive change.
Cameron disagrees with both views.
“It seems a bit fatalistic and defeatist to say that empathy for large numbers [of people] just isn’t how we’re wired,” he said.
“Research on emotion regulation and mindfulness meditation suggests that people do have ways to change how they relate to their own emotions.
Maybe if we further explored such possibilities, new avenues would open up for encouraging empathy.”
With his colleagues at the time, Cameron performed several experiments and found that empathy can be boosted by changing the way people think about it.
In one study, tweaking participants’ expectations — convincing them that empathy would be emotionally rewarding instead of just exhausting — made participants more likely to humanize someone experiencing drug addiction.
In another, earlier study, participants had greater empathy for mass suffering when they were convinced that it would not cost them financially.
Encouraged by the results, Cameron founded the Empathy and Moral Psychology Lab at Penn State.
The lab explores the mechanisms involved in empathy, moral decision-making, and other ethical questions. Most recently, the lab zoomed in on not just whether and when people choose to be empathetic, but also why.
“It’s easy to think that people might avoid empathy because they just don’t want to feel bad,” Cameron said.
“But what if it’s because empathy is effortful, taxing and fatiguing?
It’s hard work to try to get inside someone else’s head and feel what they’re feeling.
One might be afraid of getting it wrong, or not knowing someone well enough to know what they’re feeling.”
What’s in it for me?
As we go about our day, we are constantly weighing our options. You may change the route you take to work to avoid a construction delay, or choose a lunch spot depending on who you may run into there.
Cameron said this weighing of costs and benefits also applies to situations that may trigger empathy.
“If I’m watching TV and see a sad commercial for a charity organization like the SPCA, I may choose to keep watching and feeling that empathy, or I may choose to change the channel,” Cameron said.
“This decision is based on costs and benefits.
I might think it could be too emotionally exhausting to keep watching, or that I’ll be compelled to spend money and help.
There’s all these interesting considerations about why we have these empathy gaps.”
To dig into why people may choose to avoid situations they think will evoke feelings of empathy, Cameron and his fellow researchers conducted several studies using a task they developed to capture these choices in action.
Participants were asked to choose a card from one of two decks: one labeled “feel,” the other, “describe.” They were then shown a photo of a person.
Participants who drew from the description deck were asked to simply describe the person’s appearance. Those who drew from the empathy deck were asked to try to experience and briefly describe the person’s feelings.
“Some people may think the task seems unnatural or different from how we typically think about empathy,” said Eliana Hadjiandreou, a graduate student and co-author on a paper about the work.
“But it’s not unlike an everyday situation where you choose to change the channel to avoid feeling for someone, or you cross the street to avoid someone who is homeless.”
The researchers found that over several trials, the study participants vastly preferred the description deck, choosing it more often than the empathy deck.
Graduate student Julian Scheffer, also a co-author on a paper about the work, noted that it wasn’t just empathizing with suffering that proved to be hard for people in these studies.
We can choose to put ourselves in situations where we will feel empathy — the experience of understanding and actually sharing the feelings of someone else — or we can choose to avoid such situations.
Penn State psychologist Daryl Cameron is studying how we make that decision, and whether we can be encouraged to be more empathetic
“We also asked participants to empathize with positive targets, maybe someone who is smiling and more joyful,” Scheffer said. “We thought that empathizing with more positive emotions may be easier, but we found it to be just as effortful and difficult.
Participants avoided empathizing with positive emotions as well as negative ones.”
Cameron said their work suggests that people who choose to avoid feeling empathy may do so because it’s just plain hard work.
The current state of empathy
With the rise of social media, it’s easier than ever to see what people choose to be empathetic about.
People may post condolences for the victims of shootings in Paris and Christchurch while staying silent about bombings in Sri Lanka.
The divide between political parties seems wider than ever. And debates rage about whether people in need deserve assistance from the government.
On top of that, some research suggests that empathy is declining.
A 2010 meta-analysis of survey data found a 40% drop in self-reported empathy among college students between the 1970s and the early 2000s.
But Cameron said the empathy forecast isn’t as bleak as it may appear. In the empathy deck work, when participants were randomly assigned to a condition in which they were told they were skilled at empathy, he reports, those individuals were more likely to choose the empathy option.
For another thing, just because empathy is hard work doesn’t mean everyone will avoid it. Cameron said the perceived effort required may make engaging in empathy more rewarding for some people.
“There are plenty of cases in which people like doing effortful things, like charity marathon runners or people who like reading thousand-page Victorian novels,” Cameron said. “For some, it’s the effort itself that makes something worthwhile.”
Additionally, Cameron said because empathy seems to be malleable, there’s always the hope that it can increase. And changing the way we think about empathy may also help break down barriers.
“Part of it may be letting go of inhibitions a little bit,” Cameron said.
“People may see roadblocks to empathy, whether it’s they themselves thinking it’s too hard, or other people telling them it’s not worth it, or thinking it will make them seem weak. Getting past those personal and social inhibitions may be key.
When we do that, maybe we can see more openings for boosting empathy.”
And that is something to be hopeful about.
Over the past 20 years, the patient-physician relationship has been deteriorating in China (Pan et al., 2015; He and Qian, 2016). Many complex reasons contribute to the tense relationship, but the lack of communication skills amongst physicians is an important factor (Blatt et al., 2009).
Empathy is an essential component of communication skills and has increasingly become a crucial element for establishing positive patient-health provider relationships (Winefield and Chur-Hansen, 2000; Veloski et al., 2005; Loh and Sivalingam, 2008; Hojat et al., 2013).
Empathetic physicians experience greater job satisfaction, increased health and well-being, and improved clinical decision making (Kim et al., 2004; West et al., 2006; Hojat et al., 2015). Definitions of empathy are diverse.
Hojat defines empathy as “a predominantly cognitive attribute that involves an understanding of experiences, concerns, and perspectives of the patient” (Hojat et al., 2002b). Morse considers empathy a construct composed of emotional, moral, cognitive and behavioral dimension (Morse et al., 1992).
According to Hemmerdinger et al. (2007), empathy is a personality trait that enables one to identify with another’s situation, thoughts, or condition by placing oneself in their situation. The commonality among these definitions is that empathy is part of a greater psychological domain.
Empathy is a crucial element of effective physician-patient communication (Levinson, 1994; Winefield and Chur-Hansen, 2000). It is critical to study the characteristics of students with greater empathy and to encourage empathy development throughout medical training as studies have shown that empathy is considered a “positive personality attribute” (Hojat et al., 2015) and may better predict clinical competence than pre-admission test scores (Stratton et al., 2008).
Socio-demographic and academic factors including gender (Toussaint and Webb, 2005; Schulte-Ruther et al., 2008), year in school (Coulehan and Williams, 2001), and future career preference (Li et al., 2018) affect medical student empathy.
Psychological factors such as personality traits (Song and Shi, 2017; Abe et al., 2018), sense of power (Garden, 2009; Toto et al., 2015), stress, and burnout (Rosen et al., 2006; Gleichgerrcht and Decety, 2013; Yuguero Torres et al., 2015) are also influential factors. Several studies worldwide have also shown that women have higher empathy levels than men (Kataoka et al., 2009; Costa et al., 2013; Wen et al., 2013).
There has also been evidence suggesting a decline in empathy in medical students in a number of countries as they progress through years of studies, although evidence was mixed (Coulehan and Williams, 2001).
Some studies found a reduction (Colliver et al., 2010) in empathy levels during undergraduate education (Austin et al., 2007), while others found no change (Rahimi-Madiseh et al., 2010; Quince et al., 2011; Costa et al., 2013; Toto et al., 2015), or an increase (Kataoka et al., 2009; Magalhaes et al., 2011).
Additionally, medical students who preferred not to become doctors had lower empathy than students who preferred to become doctors (Li et al., 2018). Physicians in “people oriented” specialties also consistently had higher empathy scores than those in “technology-oriented” specialties (Romero et al., 2016).
There is limited literature on empathy’s role in medical students’ greater psychological makeup. Although expressing empathy is linked to communication (Winefield and Chur-Hansen, 2000), it also involves a cognitive component with an intent to understand and comprehend others (Berg et al., 2011).
In addition to empathy, another psycho-cognitive factor which benefits the patient-healthcare provider relationship is self-esteem (Öhlén and Segesten, 1998), which refers to how favorable an individual’s opinion is of him/herself, positive and negative feelings toward oneself, and his/her personal values (Alkhateeb, 2014).
Self-esteem has been strongly correlated with personality traits, affectivity, and extraversion (Watson et al., 2002) as well as self-efficacy (Lane et al., 2004). Individuals with high self-esteem are more capable of handling stress, reducing anxiety and burnout, and developing better communication skills and interpersonal relationships (Kirkpatrick and Ellis, 2006; Edwards et al., 2010).
Improved coping mechanisms and increased self-efficacy may mediate a positive relationship between self-esteem and academic performance (Lent et al., 1986; Magnano et al., 2014). While self-esteem and empathy are both influential psychological factors in medical student performance, there have been few studies on the relationship between self-esteem and empathy in medical students.
One study by Liu showed a negative relationship between empathy and self-esteem in Chinese medical students (Hanlong, 2012).
Another study found that healthcare professionals with higher self-esteem and empathy levels had lower burnout rates (Molero Jurado et al., 2018).
This research study hypothesizes that self-esteem influences medical student empathy. Improving medical students’ self-esteem or discovering mediating factors between self-esteem and empathy may enhance medical students’ empathy.
To our knowledge, the correlation between empathy and self-esteem in medical students has not been fully interpreted. Inconsistent past study results may have occurred from study participants spanning across different specialties and from a limited sample size.
This research study consequently examines the relationship between self-esteem and empathy in medical students in China, in addition to assessing the differences in empathy scores by gender, year of study, and other academic factors via a multi-institutional design.
Empathy has been considered the royal road to an optimal physician-patient relationship and overall physician competence in China (Blatt et al., 2009). In this study, the mean score for medical students in Shanghai (M = 102.73) was similar to previous studies on medical students of one institution in Shanghai (M = 104.2) (Li et al., 2018). However, scores were slightly lower than a study by Wen from Liaoning province (M = 109.60) (Wen et al., 2013).
This may be explained by the study participants’ differences in academic year. In Wen’s study, participants were in their first to fourth years in medical school, and the study excluded internship medical students, which may have influenced mean empathy scores. Nonetheless, the overall empathy level of Chinese medical students was significantly lower than that of American medical students (Hojat et al., 2002a).
This may be due to cultural differences. It has been suggested that factors such as decreased physician to patient ratios or an overabundance of patients may result in increased burnout and decrease empathy (Diez-Goni and Rodriguez-Diez, 2017). With China’s immense patient population, Chinese medical students may feel overwhelmed and forced to rush through clinical diagnoses and patient visits, leading to distress and lower empathy levels. Furthermore, the increasing use of technology in medicine in China may dehumanize health care providers from empathizing with patients (Li et al., 2018).
At the same time, with the wide range of Chinese socioeconomic classes (Bian et al., 2005), Chinese medical students may feel superior to some of their patients, leading to mechanized, emotionally detached medicine (Li et al., 2018).
This is concerning because the developmental course of empathy in Chinese medical students across their careers is poorly understood. There may be a possible decrement in empathy across Chinese medical education. A more sophisticated understanding of empathy in medical students is needed, with attention to issues that may adversely impact this crucial aspect of their development (Mahoney et al., 2016).
“Self-esteem” was the second most important predictor of empathy in our study, which was consistent with a study on Chinese nursing students (Hongrui et al., 2016) and college students (Hui, 2002) which revealed that participants with higher RSES scores received higher JSPE-S scores. However, this study contradicted Liu’s study on Chinese medical students (Hanlong, 2012), which showed that self-esteem was negatively correlated with medical students’ empathy.
In Liu’s study, individuals with higher self-esteem tended to identify with individuals with their own values and could not accept others’ opinions and feelings. Research has indicated that empathy has been linked, theoretically and empirically, to several psychological attributes, such as personality, stress, anxiety, and burnout.
Similarly, self-esteem may affect empathy by these same attributes as self-esteem is correlated with personality and one’s value system (Iacobucci et al., 2013). Previous studies have shown that self-esteem was strongly negatively correlated with neuroticism/negative affectivity and moderately to strongly related to extraversion/positive affectivity (Watson et al., 2002).
Individuals with high self-esteem may be more positive and optimistic and have a good sense of security, self-control, and motivation. These feelings and personality traits may consequently help stress management and reduce anxiety or dissatisfaction with life (Xiangkui and Lumei, 2005; Fangsong, 2006). Healthier mentality and positive emotion may also improve the development of better interpersonal relationships (Kirkpatrick and Ellis, 2006), while low self-esteem may lead to emotional problems such as anxiety and sociophobia, which negatively influence interpersonal relationships (Edwards et al., 2010).
Furthermore, stress and anxiety have been shown to lead to occupational burnout (Cass et al., 2016; Youssef, 2016; Zhou et al., 2016; Patel et al., 2017), which may significantly reduce medical students’ empathy (Thomas et al., 2007; Gleichgerrcht and Decety, 2013; Yuguero Torres et al., 2015). According to Alvaro’s conservation of resources theory, accumulating condition resources such as increased well-being and lower rates of burnout may allow greater access to other personal resources. Self-esteem was defined as one of these personal resources which alleviated burnout (Alvaro et al., 2010).
Additionally, initial levels of empathy for patients may lead to increased patient satisfaction and positive feedback from patients. This may create a self-perpetuating positive reinforcement cycle, which continues to increase health care providers’ empathy levels (Pollak et al., 2011).
In addition to higher patient satisfaction, an additional explanation for positive reinforcement of patient empathy levels is the association between empathy, higher communication, and interpersonal skills, which allow physicians to easily express empathy, create better physician-patient relationships, and receive positive reinforcement to continue expressing empathy (Winefield and Chur-Hansen, 2000; Pollak et al., 2011). It has been suggested that self-esteem is linked with skilled communication (Carson et al., 2001).
Individuals with better communication skills and higher self-esteem may be more adept at expressing empathy, leading to greater patient satisfaction and subsequently, an increased desire to continue expressing empathy in the future. This suggests that medical students with greater communication and interpersonal relationship training may be more comfortable expressing empathy (Winefield and Chur-Hansen, 2000; Pollak et al., 2011).
In the final model of regression, “perception of the importance of empathy” was the most significant predictor of empathy. “Academic pressure” as well as “desire to be a doctor after graduation” were also positive but weak contributors of medical students’ empathy.
These results suggest that medical students who had a positive attitude toward empathy and future career had higher empathy scores, which echoes a study by Li et al. (2018) which found that medical students who did not want to become physicians had lower empathy scores than medical students who were still unsure of their passion to become physicians. This may be explained by differences in Chinese vs. American medical education. Chinese medical students choose their specialty after senior middle school graduation. Some students do not choose medicine as their career voluntarily, and they may have little interest in medicine and low motivation to become a doctor after their studies (Wang et al., 2014).
In contrast, American students must finish their relative undergraduate degree (biology, etc.) before entering medical school and may pursue medicine as a future career with more mature, intentional thought. Additionally, only students with distinct, desirable personality traits such as high empathy may garner acceptance into such competitive American medical schools (Lumsden et al., 2005). Furthermore, medical school curriculum is quite different between China and the United States. While empathy has been recognized as an important ability for medical students, it is still not integrated into most Chinese medical school curriculum (Wen et al., 2013).
On the other hand, empathy is objectively assessed on the United States USMLE, which may increase medical students’ emphasis on empathy (Hojat et al., 2002a) and may pressure students to be more empathetic.
Bivariate analysis showed that empathy scores of participants decreased with increasing years of medical training and were lowest during the final clerkship year. Female medical students had greater empathy scores than male participants.
However, after controlling for gender and age in the regression analysis, gender and “year of school” did not significantly affect empathy. This hinted that the significant effects seen in the bivariate analysis may be because of other factors which were not controlled for in the multivariate analyses.
Although the associations between gender and “year of school” were insignificant after adjusting for some covariates, previous studies illustrated that factors such as gender and “year of school” may affect empathy (Coulehan and Williams, 2001). Therefore, future investigations should include surveys with larger sample sizes and more detailed participant information.
Age was a weak negative predictor of empathy in this study which may be because younger age is associated with increased empathy from less burnout and fatigue in the medical profession (DiLalla et al., 2004). Another explanation may be that older age is correlated with years of clinical training in medical school. United States medical students often take gap years between undergraduate education and medical school and maybe of various ages at medical school admission. On the other hand, it is common in China to matriculate into medical school immediately after high school.
As such, Chinese first year medical students are typically younger than second and third year medical students (Chen et al., 2010). As older students gain clinical experience in medical school, they may emotionally harden to being exposed to pain, death, and hardships to mentally protect themselves (Coulehan and Williams, 2001). Likewise, even in the United States, where medical student age may not correlate as well with years of clinical training as in China, older individuals may have accumulated more life experience regarding suffering and may become jaded more easily than younger individuals (Eysenck et al., 1985).
Empathy education is a vital part of medical students’ empathy development. Chinese medical students’ low empathy in this study suggests that current education patterns need improvement. Furthermore, our research found a positive relationship between self-esteem and empathy, as well as academic attitude and empathy.
These results suggest that factors decreasing self-esteem or mediating factors such as personality, stress or burnout may subsequently negatively affect empathy levels. Improving medical students’ professional identity as well as increasing educational emphasis on empathy may help increase medical students’ self-esteem and empathy.
Strengths and Limitations
To our knowledge, this is the first multi-institutional study on Chinese medical students’ self-esteem and empathy. However, we also acknowledge that participants were medical students solely from Shanghai, who were unmarried, mainly from single-child families, and ranged from ages 16–27. This sample is not necessarily representative of empathy levels among medical undergraduates nationwide.
Furthermore, participants responded via self-report questionnaires. While these instruments have been validated for the Chinese population, the use of self-reported assessments and the retrospective study design may decrease data validity.
Additionally, as this study is cross-sectional and descriptive, future research should confirm our findings via a longitudinal and prospective study.
Finally, although the relationship between self-esteem and empathy was positively correlated in this study, there is still a need for further investigation of possible mediating factors such as stress, anxiety, burnout, or wellness.
Empathy is a particularly important disposition for medical students and toward their future careers as doctors. Self-esteem is one of many influential factors toward medical students’ empathy. This study revealed that there is a positive association between self-esteem and empathy. School year, academic pressure, attitude toward empathy, and desire to be a doctor after graduation are also positively correlated with empathy level while age is indirectly related to empathy.
By increasing self-esteem and empathy in medical students and physicians, the quality of the patient-physician relationship may be improved, resulting in reciprocally beneficial outcomes. Patients may become more trusting of physicians and be more open to disclosing their concerns to empathetic physicians. Likewise, empathetic, high self-esteem physicians may be more adept at handling sensitive, emotional patient situations. As such, improving self-esteem and empathy in medical students and physicians is a critical component of providing quality health care.
Further research may explore additional mediating factors between self-esteem and empathy. Future studies may also investigate the relationship between self-esteem and empathy in medical students outside of Shanghai such as in more rural cities or in different regions of China. This study may also be replicated outside of China to investigate if there is a cultural influence on self-esteem and empathy.
Katie Bohn – Penn State
The image is adapted from the Penn State news release.