Introducción

Una relación médico-paciente positiva es un elemento crítico en la práctica médica y en el arte de curar. A pesar de las recomendaciones, la empatía médica sigue siendo un área de investigación inexplorada en la educación médica por dos posibles razones. Primero, la investigación teórica de la empatía médica se dificulta por una falta de claridad en su conceptualización y una ambigüedad en su definición. Segundo, la investigación empírica en el tema es limitada debido a la falta de un instrumento que mida operacionalmente la empatía en estudiantes de medicina. El grupo de Jefferson desarrolló una Escala de Empatía Médica (EEMJ). En su versión en inglés ha mostrado validez de construcción, convergente y discriminante, además de una confiabilidad aceptable. Sin embargo, es imprescindible proveer pruebas de las propiedades psicométricas de este instrumento una vez que ha sido culturalmente adaptado. El presente estudio evalúa la validez y confiabilidad de la EEMJ en estudiantes de medicina mexicanos.

Material y métodos

Sujetos: Participaron 1022 estudiantes de medicina con un promedio de edad de 21±2.7 años (494 mujeres y 528 hombres) de la Facultad de Medicina de la Universidad Autónoma de Nuevo León, en Monterrey, México.

Instrumento: Se utilizó la versión “S” de la EEMJ, diseñada para medir empatía en estudiantes de medicina, la cual contiene 20 reactivos tipo Likert en una escala de siete puntos (1=fuertemente en desacuerdo, 7= fuertemente de acuerdo).

Procedimientos: La EEMJ se tradujo del inglés al español y se retradujo, siguiendo la guía para adaptación de instrumentos de evaluación psicológica y asegurando una estricta confidencialidad. Se realizaron un análisis de factores usando el método de extracción de componentes principales y una rotación ortogonal, y se estimó el coeficiente alfa de Cronbach para medir la consistencia interna de la escala.

Resultados

El análisis exploratorio de factores permitió identificar tres factores con valores eigen mayores o iguales a uno. Todos los reactivos que registraron coeficientes mayores a 0.30 que integraron el factor 1, fueron las preguntas redactadas en forma positiva y correspondieron al dominio toma de perspectiva. Por otra parte, siete de las diez preguntas planteadas en forma negativa cargaron en un segundo factor, con coeficientes mayores a 0.40; todas ellas estuvieron relacionadas con el dominio de cuidado con compasión. Por último, otras dos preguntas negativas conformaron el factor 3; este factor incluyó el dominio habilidad para "ponerse en los zapatos del paciente". La consistencia interna fue de 0.74.

Conclusiones

Los resultados de este estudio indicaron validez de la EEMJ. En lo que respecta a la confiabilidad, la consistencia interna se encontró dentro del rango aceptable para pruebas de personalidad. En la medida en que el médico entienda lo que el paciente piensa y siente, mejor será la atención que ofrezca; de este modo, la empatía se convierte en el vehículo de la relación interpersonal médico-paciente. La medición de la empatía es el primer paso para examinar su nivel de permanencia desde el ingreso a la carrera de medicina hasta el tiempo de una especialidad médica. También permite analizar el impacto de estrategias educativas dirigidas a aumentar la empatía, con beneficios potenciales para el desarrollo profesional del médico y de la salud de sus pacientes.

Introduction

A meaningful doctor-patient relationship is a key factor in medical practice and in the art of curing. In the past, several institutions have recommended the addition of humanistic education among medical doctors not only for enhancing the doctor-patient relationship, but also for improving the quality of medical care. In fact, an empathic physician-patient relationship has been associated with better clinic outcomes.

In spite of recommendations, medical empathy is still an unexplored research area in medical education for two reasons. One of these is that theoretical research on empathy is not easy because of a lack of clarity in its conceptualization. Another reason for the dearth of empirical research is the absence of a valid and reliable operational tool by which to measure empathy in patient care situations. A team from the Center for Research in Medical Education and Health Care at the Medical College of Thomas Jefferson University, developed the Jefferson Scale of Physician Empathy (JSPE). The English version factor structure is consistent with conceptual aspects of a multidimensional scale that measures the perspective taking, compassionate care and "standing in the patient’s shoes" factors. The JSPE has shown satisfactory psychometric properties; construct, discriminant, and criterion validity has been confirmed among medical students with an internal consistency of 0.89.

Empathy may vary among individuals depending on social, educational, and personal experiences, and it corresponds to an interpersonal ability and a clinical competence component. Hence, the availability of a valid and reliable instrument for measuring empathy among medical doctors is a critical issue. However, the instrument should be culturally adapted for the population of interest. Therefore, the present study was designed for evaluating the validity and reliability of the Spanish version of the JPES among Mexican medical students.

Material and methods

Subjects: 1022 medical students (mean age 21±2.7 years) from the School of Medicine at the Autonomous University of Nuevo Leon, in Monterrey, Mexico (494 women and 528 men).

Instrument: The students’ version of the JSPE was used to measure the orientation of medical students towards empathy in patient care situations. The JSPE consists of 20 items on a seven-point Likert scale (1=strongly disagree, 7= strongly agree).

Procedures: The JSPE was translated into Spanish and back translated following the guidelines to adaptate psychological evaluation instruments. The questionnaire was answered by first (n=687), third (n=183) and fifth grade (n=152) medical students. They were assured of the strict confidentiality of the test and of the individual responses.

Plan of analysis: Dimensionality of 20 items was assessed with factors analysis using the principal components extraction method and orthogonal rotation. Cronbach’s alpha was calculated for evaluating the internal consistency.

Results

The exploratory factor analysis allowed the identification of three factors with eigen values greater or equal to one. All the items with coefficients greater than 0.30 of the first factor were positive and corresponded to the perspective taking domain. On the other hand, seven out of ten negative questions loaded to the second factor with coefficients greater than 0.40; all of them were related to compassionate care. Finally, there were other two questions with high loading on the third factor, which matched to "standing in the patient’s shoes" domain. The internal consistency was 0.74.

The mean of empathy scores was 110 and the standard deviation, 14. The observed range was 44-140 compared to the possible range of 20-140. The mean empathy score was higher for women than men (111.9 ±13.9 vs. 109.08± 14.1, p=.002). Age was not significantly correlated with empathy scores, even after controlling for sex (women: r=-0.01; men: r=0.02).

Conclusions

The results of study supported the validity of the JSPE among medical students in Mexico. The first factor (perspective taking) corresponded to the main component of empathy. The other two factors, compassionate care and "standing in the patient’s shoes", were related to specific components of the doctor-patient relationship. The observed internal consistency was satisfactory for personality tests. The findings showed significantly higher empathy scores for women than men, suggesting that female doctors might render a different type of medical care. These findings are consistent with those reported for U.S.A. medical students. It has been informed that women are more receptive to emotional signs than men and that they devote more time and offer more preventive care to their patients. More scientific evidence is needed to explain these sex differences which represents different implications for the selection of medical training. Interpersonal relationships are especially critical between physicians and patients. Failures in understanding a patient’s perspective may result in communication problems, which in turn contribute to the patient’s dissatisfaction with care. As soon as the doctor understands what his/her patient thinks and feels, he/she can offer a better care. This is how empathy translates into the vehicle of a meaningful doctor-patient relationship.

Finally, empathy measurement is meaningful because it constitutes the first step for examining permanence from the first years of the medical career up to specialty training years. It also allows for the analysis of the impact of educational strategies designed to improve empathy and achieve potential benefits not only for the doctors’ professional development but also for their patients’ health.