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Empathy among Medical Students Studying Different Curricula: A Comparative Study

3 relationship. In medical education, empathy is considered to be an essential professional attribute for clinicians therefore enhancement of empathy among medical students is an aim of medical education. Doctor patient relationship is a vital component of physician work and this relationship depends on number of factors like communication skills, ability to understand patient's perspective and empathic attitude. If a doctor fails to understand patient's point of view or if he does not show empathy then the patients will be dissatisfied and his trust on 4-6 doctor affected. Literature shows that with increasing years of medical education, empathy is diminishing among 4 students which may affect the quality of health care. while some studies are not in favor of the hypothesis Empathy among Medical Students Studying Different Curricula: A Comparative Study


Introduction
Empathy is to feel what another person is experiencing. It has been evident that empathy among the practitioners can reduce patient's risk, improve patient's health, allay anxiety among patients and increase compliance of patients and 1,2 thus improve outcome. Empathy is very much linked with good social and interpersonal that increasing in years of education causes decrease 7 empathy among medical students. A study, to assess students' perception about the factors that promote the development of empathy among students revealed that early contact of st u d e n t s w i t h p a t i e n t s a n d t ra i n i n g i n professionalism and communication skills help in 8 increasing empathy among them. Recently there is shift of medical education, traditional curriculum is now replaced with integrated curriculum in which students are exposed to the patients from the first year of medical education. Moreover, teaching of medical ethics and professionalism is started from the first year of their training. Empathy is an important topic to be taught in medical schools as it not only increases their interpersonal relationships but it also makes patients comfortable and satisfied. The present study was conducted with an aim, to compare empathy among students studying two different curricula and to ascertain the gender difference regarding empathy. It was hypothesized that students who have studied integrated curriculum are more empathic than those of conventional or traditional curriculum.

Materials and Methods
The study design was cross-sectional, carried out at the Department of Community Medicine, Wah Medical College from January 2018 to June 2018. The sample size was 90, calculated by Open epi version 3; the confidence Interval was taken as 95%, Power 90% and ratio of sample was 1. Mean and standard deviations used for calculating sample size were 9 44.2+6.59 and 39.7+ 6.54. As the ratio was one, sample size was distributed in two equal groups The sample was selected by using stratified sampling technique, 45 students from Second year MBBS studying integrated curriculum and 45 students from Fourth year MBBS who were taught traditional curriculum. A pre-designed validated structured questionnaire was used for collection of data and confidentiality and anonymity were maintained at all the times during the study. The first part of the questionnaire included demographic information and second part was based on Toronto Empathy Questionnaire. The questionnaire had 16 questions and scored between 0-64. The Cronbach alpha 10 reliability of the questionnaire was 0.85. The questionnaires were filled by the students themselves and empathy questions were responded on a Likert scale of never, rarely, sometimes, often and always, scoring 0-4 on items 1,3,5,6,8,9,13 and 16 while items 2,4,7,10,11,12, 14 and 15 scored reversely. The total score was calculated of each respondent. Data was analyzed by using software program of SPSS version 20, descriptive statistics including frequency of gender, use of social network, working status of mother, family income and mean scores of empathies were reported. Mann Whitney U test was applied on mean scores of empathies of the two groups studying different curricula and also on mean empathy scores of male and female students at p value of less than 0.05.

Results
The study was carried out on 90 medical students, 45 each from second year studying integrated curriculum and from fourth year enrolled in traditional curriculum. The descriptive statistics of qualitative variables are presented in Table 1.
Mean scores of empathy among students was 42.89 and standard deviation was 8.535 and its distribution is shown in Figure 1. Mann Whitney U test was applied on mean empathy scores of two different years of medical education studying different curricula and also on male and female students which showed significant difference at p value of 0.05. The results are presented in Table 2 and 3.
showed that students who studied integrated 9,12 curriculum showed higher level of empathy. Another important finding of our research was decreasing empathy scores with increasing time spent in medical education as fourth year students showed less empathy. This finding was supported by 4 13 14 Mahoney et al , Chen et al and Dongju et al. The results of these studies showed that the students who were in later years of education showed less empathy as compared to those who were in initial years of medical education. Few studies showed contradictory results, Magalhaes et alconcluded that 15 final year students showed more empathy while Tariq et al found no effect of duration of medical 16 education on empathy of students. The mean empathy scores of students studying integrated curriculum was significantly more as compared to the students exposed to traditional curriculum. Literature also support the role of teaching professionalism, empathy, ethics and communication skills by different means of teaching. Those students who had been taught these disciplines showed higher empathy which is very essential for gaining trust and confidence of 6,17,18 patients.
Our study also showed that female students had higher empathy scores than male students Higher empathy levels in females is also supported by a 19 20 study conducted by Hojat et al , Helena et al and 21 Thema et al while few studies found no difference in 22,23 empathy scores related to gender. The reason of this difference might be due to nature of females as they have stronger sense of caring for other people, they can provide emotional support to others and they tend to show more social sensitivity and care oriented attitudes.
There are some limitations of the study, the sample size is small and other factors affecting empathy should also be identified. This study will help in modifying the curriculum and bring change in students' behavior and attitude.

Conclusion
It is concluded that mean empathy among students is low. The students enrolled in integrated modular curriculum has shown comparatively higher empathy scores than students studying conventional or traditional system. Moreover, female students showed significantly higher scores.

Discussion
In medical education, empathy is considered to be an essential professional characteristic for clinicians. The link between doctors and patients depend upon compassionate behavior, communication skills, knowledge and intention of the doctor to help the patient in every possible way. This relationship is very important for the management of patients therefore, it is one of the needs of medical education that students should be trained enough on communication skills, empathy and professionalism. The college was in transition phase and at a time both types of teaching, integrated and traditional, were carried out so it was planned to assess empathy levels among students studying two different curricula. The students of second year were taught separate course of professionalism, ethics and empathy while it was not imparted to the fourthyear students. The mean empathy scores of all students was found out to be 42.89, which is low. The result was comparable with a study carried out by Nazish et al in two different institutions of Lahore, Pakistan which also concluded that mean empathy scores of students from two different institutions 11 were low as compared to the previous literature. In our study the second-year students studying integrated curriculum showed higher level of empathy as compared to the fourth-year students. Similar results were reported by other studies

Recommendations
Based on the study it is concluded that teaching empathy, medical ethics and professionalism play vital role in the development of empathy among students. So, in addition to routine lectures counseling sessions about human attitude, behavior and emotions should be arranged focusing more on male students and it must be ensured that the students should spend more time with patients as this can inculcate more empathy among them.