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Psychological Measurement
The Jefferson Scale of Physician Empathy: Development and Preliminary Psychometric Data
Mohammadreza Hojat, Salvatore Mangione, Thomas J. Nasca, Mitchell J. M. Cohen, Joseph S. Gonnella, James B.
Erdmann, Jon Veloski and Mike Magee
Educational and Psychological Measurement 2001 61: 349
DOI: 10.1177/00131640121971158
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The present study was designed to develop a brief instrument to measure empathy in
health care providers in patient care situations. Three groups participated in the study:
Group 1 consisted of 55 physicians, Group 2 was 41 internal medicine residents, and
Group 3 was composed of 193 third-year medical students. A 90-item preliminary version of the Empathy scale was developed based on a review of the literature and distributed to Group 1 for feedback. After pilot testing, a revised and shortened 45-item version
of the instrument was distributed to Groups 2 and 3. A final version of the Jefferson Scale
of Physician Empathy containing 20 items based on statistical analyses was constructed.
Psychometric findings provided support for the construct validity, criterion-related
validity (convergent and discriminant), and internal consistency reliability (coefficient
alpha) of the scale scores.
The secret of the care of the patient is in caring for the patient.
Francis W. Peabody (1927/1984)
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HOJAT ET AL.
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Method
Participants
Three groups participated in the present study. Group 1 consisted of
55 physicians who were either faculty members at Jefferson Medical College
or directors of internal medicine residency programs at other postgraduate
institutions known personally by the investigators. Group 2 consisted of 41
residents in the internal medicine program at Thomas Jefferson University
Hospital and its affiliated institutions. Group 3 consisted of 193 third-year
students at Jefferson Medical College of Thomas Jefferson University.
Instruments
A preliminary version of the Empathy scale was developed based on a
review of literature that included 90 items answered on a 7-point Likert-type
scale ranging from 1 (strongly disagree) to 7 (strongly agree). The final version of this instrument after preliminary psychometric analyses consisted of
20 items.
The following research instruments were also used to examine the validity
of scores on the aforementioned Empathy scale.
1. Empathetic Concern. Defined as being concerned about the feelings of
less fortunate people (Davis, 1983). This is one of the scales from the IRI
(Davis, 1983) consisting of six items answered on a 5-point scale ranging from
1 (does not apply to me) to 5 (describes me very well). A typical item is I often
have tender, concerned feelings for people less fortunate than me [sic].
2. Perspective Taking. Defined as a tendency to spontaneously adopt the
views of the other person. This scale contained seven items from the IRI
(Davis, 1983). A typical item is When I am upset at someone I usually try to
put myself in his [or her] shoes for a while.
3. Fantasy scale. Defined as tendencies to transpose oneself imaginatively
into the feelings of fictitious characters in books, movies, or plays. This is
also a scale from the IRI (Davis, 1983) containing six items. A typical item is
After seeing a play or movie, I have felt as though I were one of the
characters.
4. Warmth. A personality facet from the NEO PI-R containing eight items.
The NEO PI-R is a widely used personality inventory for measuring major
factors and facets of personality (Costa & McCrae, 1992). The NEO PI-R has
been used with samples of physicians in the United States. Physicians have
354
been found to score higher than the general population of the United States on
the Warmth facet (Hojat et al., 1999). Also, female positive role models in
medicine scored higher than the general population on this personality facet
(Magee & Hojat, 1998).
5. Dutifulness. A personality facet from the NEO PI-R containing eight
items. Both male and female positive role models in medicine scored higher
than the general population on this facet of personality (Magee & Hojat,
1998).
6. Faith-in-People scale. This scale was developed by Rosenberg (1957,
1965) and contains five items measuring ones degree of confidence in the
trustworthiness of people (Robinson, 1978). A typical item is Most people
are inclined to help others.
The following measures of personal attributes were obtained from Group 3
participants. All these concepts were defined on the instrument and were
answered on a 100-point scale. Respondents were asked to identify the extent
to which they currently have those personal attributes by placing a P on the
scale and the extent to which they think it is desirable to have the defined
attribute as a physician by placing a D on the scale.
7. Personal attribute of empathy. Defined for the respondents as standing
in the patients shoes in the experience of their illness.
8. Global sympathy. Defined as developing feelings for the patients
sufferings.
9. Personal attribute of compassion. Defined for respondents as sympathy for the patient combined with the intention of doing good and desire to
help.
10. Trust. Defined as belief that patients report their illness experience
honestly.
11. Tolerance. Defined as the ability to evaluate a patient who shows
offensive and self-destructive behavior without becoming judgmental or losing interest in helping.
12. Personal growth (through patient interaction). Defined as learning
and gaining reward through emotionally intense (either positive or negative)
interactions with patients.
HOJAT ET AL.
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Respondents were asked to cross out any item that they considered irrelevant to measuring empathy as defined. In addition, they were asked to edit the
remaining items for simplicity and clarity and add any new items that they felt
should have been included in a scale of physicians empathy. Fifty-five physicians responded by making editorial and conceptual comments, as well as
suggestions about revisions, additions, or deletions.
Modified Version
We excluded items from the preliminary version that were deleted by at
least 5 physicians in the pilot study. In addition, we incorporated appropriate
editorial suggestions in revising the instrument. The modified version of the
Empathy scale consisted of 45 items. This modified version, plus the IRI
scales, was completed by 41 resident physicians (Group 2 participants).
Also, the modified 45-item Sympathy scale and other research instruments
(IRI scales, personality facets of the NEO PI-R, Faith-in-People scale, and
Personal Attributes) were distributed to 223 medical students for
psychometric analysis; 193 responded (86%).
Final Version of the Physician Empathy Scale
To screen for the best conceptually relevant items for inclusion in the final
version of the Physician Empathy scale, we employed factor analysis by
using data collected on the 45-item Sympathy scale for medical students
(principal component factoring followed by varimax rotation). Based on the
results of factor analysis, 20 items with the highest factor structure coefficients (all above .40) on the grand factor were retained. The obtained
eigenvalue for the grand (first) factor was 10.64, with an eigenvalue 3.45 for
the second factor. A relatively large magnitude of eigenvalue for the first
extracted factor is indicative of the strength of this grand factor, and a significant drop of the eigenvalues indicates minimal contribution of the other
factors.
The following conceptually relevant item was among those with the highest factor structure coefficient on grand factor: Empathy is an important
therapeutic factor in medical treatment. Because of insufficient sample size,
factor analysis was not performed on data for the residents, but the examinations of the patterns of inter-item correlations for medical students and residents showed considerable similarities.
Scoring of the Physician Empathy Scale
Among the 20 retained items, 17 with positive factor structure coefficients
(and positive correlation with aforementioned item) were directly scored on a
HOJAT ET AL.
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Table 1
Rotated Factor Matrix of the Jefferson Scale of Physician Empathy
Factor
Item
A physician who is able to view things from another persons perspective can render better care.
Physicians sense of humor contributes to a better clinical outcome.
Physicians understanding of their patients feelings and the feelings of their patients families is a positive treatment factor.
For more effective treatment, physicians must be attentive to their patients personal experiences.
Understanding body language is as important as verbal communication in physician-patient relationships.
Empathy is an important therapeutic factor in medical treatment.
Patients feel better when their feelings are understood by their physicians.
Physicians demonstration of understanding their patients emotions is an important factor in interviewing and history taking.
Willingness to imagine oneself in another persons place contributes to providing quality care.
Patients illness can be cured only by medical treatment; physicians affectional ties with their patients do not have a significant
place in this endeavor.a
What is going on in a patients mind can often be expressed by nonverbal cues such as facial expressions or body language that
must be carefully observed by physicians.
A patient who feels understood can experience a sense of validation that is therapeutic in its own right.
One important component of the successful physician-patient relationship is the physicians ability to understand the emotional
status of his or her patients and their families.
It is as important to ask patients about what is happening in their lives as it is to ask about their physical complaints.
It is acceptable for a physician to be touched by intense emotional relationships between patients and their families.
Reading nonmedical literature and enjoying the arts can enhance physicians ability to render better care.
Because people are different, it is almost impossible for physicians to see things from their patients perspectives.a
Emotion has no place in the treatment of medical illness.a
Empathy is a therapeutic skill without which the physicians success will be limited.
The best way to take care of a patient is to think like a patient.
Note. Items are listed based on the magnitude of rotated factor structure coefficients within each factor. Values greater than |.40| are in boldface.
a. Responses were reverse scored (1 = strongly agree, 7 = strongly disagree); otherwise, items were directly scored (7 = strongly agree, 1 = strongly disagree).
II
III
IV
.82 .06
.74 .12
.68 .44
.67 .32
.64 .40
.63 .32
.58 .45
.56 .33
.56 .19
.14
.08
.18
.12
.06
.16
.11
.03
.39
.03
.10
.08
.10
.9
.19
.01
.08
.08
.47
.22
.32 .31
.24
.23
.20
.33
.16
.28
.17
.33
.39
.20
.63
.59
.48
.47
.13
.32
.28
.19
.32
.00
.10
.37
.79
.54
.18
.03
.06
.07
.51
.10
.04
.24
.04
.82
HOJAT ET AL.
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Table 2
Descriptive Statistics and Preliminary Norms for the
Jefferson Scale of Physician Empathy (20 items)
M
SD
Median (50th percentile)
Mode
25th percentile
75th percentile
a
Possible range
b
Actual range
Alpha reliability estimate
Residents (n = 41)
118
12
119
119
110
126
20 to 140
88 to 140
.87
118
11
117
112
111
126
20 to 140
87 to 139
.89
butes of Self-Protection (r = .11), Sense of Humor (r = .05), and Clinical Neutrality (r = .05).
Correlations between scores of the Empathy scale and desirable attributes
of physicians are also reported in Table 3. Desirability of the following attributes were associated with higher empathy scores: Empathy attribute (r = .37),
Tolerance (r = .26), Personal Growth (r = . 25), Sense of Humor (r = .20),
Communication (r = .18), Compassion (r = .17), and Trust (r = .16).
The findings that the Empathy scale scores yielded a higher correlation
with the external criterion measures that were more conceptually related to
physician empathy (e.g., Empathic Concern, Sympathy, Compassion,
Warmth) than other less relevant criterion measures (e.g., Self-Protection,
Clinical Neutrality) provided evidence in support of the criterion-related
validity of the Physician Empathy scale (convergent and discriminant validity, respectively; Campbell & Fiske, 1959).
Gender Comparison
The scores of the Physician Empathy scale for 115 male and 78 female
medical students were compared. Women scored higher (M = 119.8, SD =
10.5) than men (M = 115.9, SD = 11.0), t = 2.41, p < .05. The gender difference in empathy score is consistent with the notion that women are more
empathic than men. This may be related to the womens greater capacity for
empathic communication (Davis, 1983; Hatcher et al., 1994). In Hogans
study (1969), not only did female subjects (high school and college students)
score higher on empathy than their male counterparts, but substantial differences were also observed on empathy scores between delinquents and prison
inmates and psychology, medical, and education students in the favor of the
students. Men, according to Zinn (1993), are more often inclined to offer
HOJAT ET AL.
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Table 3
Correlations of Scores on the Jefferson Scale of Physician Empathy (20 items) With External
Criterion Measures for Residents and Medical Students
Residents
(n = 41)
Criterion Measure
Interpersonal Reactivity Index (IRI) scalesa
Empathic Concern
Perspective Taking
Fantasy
b
Self-Reported (7-point scale)
Compassion
Sympathy
c
NEO PI-R personality facets
Warmth
Dutifulness
d
Faith-in-People (misanthropy)
Medical Students
(n = 193)
.40*
.27***
.32*
.41*
.29*
.24*
.56*
.27***
.48*
.33*
.33*
.24*
.12***
Personal
Desirable
.45*
.31*
.27*
.26*
.25*
.15**
.13***
.11
.05
.05
.37*
.17**
.16**
.13***
.26*
.25*
.10
.19*
.20*
.01
rational solutions, whereas women are more likely to offer measures of emotional support and understanding.
Conclusions
Training humane physicians has long been a concern of the medical profession but has become even more timely in the past few decades. The rapid
rise of technology and the resulting shift away from the bedside and into the
labs have probably contributed to the public perception that physicians have
become too detached to care (Kaufman, 1991; Verres, 1996). Many studies
have actually supported this view, showing that students and residents alike
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that empathy should be considered as a distinct personal trait that has a limited
overlap with other concepts, such as compassion, concern, sympathy, perspective taking, imagination, warmth, dutifulness, tolerance, personal
growth, trusting others, and communication. These findings support the
notion that empathy is a unique personal trait that is multidimensional
(Davis, 1983).
The observed gender differences in the scores of the Physician Empathy
scale in the expected direction provided further support for the construct
validity of the scale scores. In addition, the magnitude of the alpha reliability
estimates indicated that the scores are internally consistent. Although these
preliminary psychometric findings are encouraging, further psychometric
research is needed to investigate underlying factors, correlates, stability of
empathy scores over time, and group differences using a larger, more representative sample of physicians and other health professionals.
The present scale of physician empathy was primarily developed to measure empathetic qualities and tendencies among health care students and professionals. We are conducting a study to slightly modify this scale by placing
more emphasis on behavioral manifestations of empathy among practicing
physicians with regard to their interpersonal relationships with their patients.
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