This document contains 3 letters responding to an article on empathy decline among medical students. The first letter proposes a multi-institutional longitudinal study to identify causal factors for empathy decline internationally. Empathy is important but current studies are cross-sectional. The second letter questions the significance of small empathy declines found in medical school given that burnout is very high after graduation, negatively impacting patient care. The third letter supports a longitudinal study and notes a large study found empathy declines in Indian medical students as well, suggesting it's a universal issue important for good patient outcomes worldwide.

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Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
Academic Medicine, Vol. 96, No. 3 / March 2021 317
3 Kane L. Medscape National Physician
Burnout, Depression & Suicide Report 2019.
https://www.medscape.com/slideshow/2019-
lifestyle-burnout-depression-6011056.
Accessed September 4, 2020.
4 Del Carmen MG, Herman J, Rao S, et al.
Trends and factors associated with physician
burnout at a multispecialty academic
faculty practice organization. JAMA
Netw Open. 2019;2:e190554. doi:10.1001/
jamanetworkopen.2019.055.
5 Schattner A. An antidote to burnout?
Developing broad-spectrum curiosity as
a prevailing attitude [published online
ahead of print December 23, 2019]. QJM.
doi:10.1093/qjmed/hcz322.
Through a multi-institutional cross-
sectional study across India, analyses
ongoing, we have also investigated
this in over 2,000 medical students.
To our knowledge, it is the largest
study of empathy in medical students
in the developing world. We, like
Hojat and colleagues,1,2
found a
significant longitudinal decline in
students’ empathy. We found that
certain sociodemographic, cultural,
and academic characteristics were
significant covariates of this decline.
However, these works, due to their
cross-sectional nature, are insufficient
for determining the causal factors of this
decline. Thus, we need multi-institutional
prospective cohort studies to determine
these factors.
Disclosures: None reported.
Ahmad Ozair
Fourth-year medical student, King George’s
Medical University, Lucknow, Uttar Pradesh, India;
ahmadozair@kgmcindia.edu; ORCID: https://orcid.
org/0000-0001-6570-4541.
Kaushal Kishor Singh
Second-year medical student, King George’s Medical
University, Lucknow, Uttar Pradesh, India.
Pradeep Kumar, MBBS, MD
Professor, Department of Physiology, King George’s
Medical University, Lucknow, Uttar Pradesh, India.
References
1 Hojat M, Shannon SC, DeSantis J, Speicher MR,
Bragan L, Calabrese LH. Does empathy decline
in the clinical phase of medical education? A
nationwide, multi-institutional, cross-sectional
study of students at DO-granting medical
schools.Acad Med. 2020;95:911–918.
2 Hojat M, Vergare MJ, Maxwell K, et al. The
devil is in the third year: A longitudinal study
of erosion of empathy in medical school.
Acad Med. 2009;84:1182–1191.
3 Ahmed AA, Hwang WT, Thomas CR Jr,
Deville C Jr. International medical graduates
in the US physician workforce and graduate
medical education: Current and historical
trends. J Grad Med Educ. 2018;10:214–218.
4 Biswas B, Haldar A, Dasgupta A, Mallick N,
Karmakar A. An epidemiological study on
empathy and its correlates: A cross-sectional
assessment among medical students of a
government medical college of India. Indian
J Psychol Med. 2018;40:364–369.
5 Paro HB, Silveira PS, Perotta B, et al.
Empathy among medical students: Is there
a relation with quality of life and burnout?
PLoS One. 2014;9:e94133. doi:10.1371/
journal.pone.0094133.
To the Editor: Physician empathy is
crucial for strengthening the physician–
patient relationship and improving
patients’ satisfaction and comfort.
However, Hojat and colleagues’ excellent
cross-sectional study1
reports a significant
decline in empathy among DO-degree
medical students in the United States
from the preclinical to clinical phases
of education. Their current findings
are similar to those of their previous
landmark cohort study of U.S. MD-
degree medical students.2
Outside
the United States, while several cross-
sectional studies have been conducted,
multi-institutional cohort studies to
determine the causal factors of this
decline have not yet been undertaken.
We propose an international multi-
institutional prospective cohort study to
pinpoint these factors. Its findings could
help mitigate this decline among students
worldwide, many of whom will go on to
become international medical graduates
(IMGs) that practice in the United States.
Nearly a quarter of resident physicians
in the United States are IMGs, with
approximately 20% of these having
attended medical schools in India.3
A
similar decline of empathy is reported
from India as well, where levels of
empathy among students were, notably,
lower than their Western peers.4
Another
cross-sectional study in Brazil5
found
that trainees’ empathy correlated with
burnout levels. Thus, students’ empathy
needs preservation universally, so that
they deliver the best possible patient care
worldwide.
Decline of Empathy During
Medical Education
To the Editor: While one cannot help
but admire the exhaustive study by Hojat
and colleagues of empathy changes in
10,751 doctor of osteopathic medicine
(DO) students across 4 years of medical
school,1
I, and probably other readers
as well, was left with a feeling of “much
ado about nothing.” Medical students,
DO students included, spend a mere 4
years in medical school, whereas they
emerge with their full career span ahead,
encompassing at least 40 years of practice.
Assuming their initial first-year empathy
scores are rather high—115.0; 12.5 (mean;
standard deviation on the Jefferson
Scale of Empathy) for DO students and
116.5; 10.6 for MD students—and do
not change much over the course of their
medical school education (113.0; 13.2
for DO students in their fourth year1
),
why should this result be important
when immediately after graduation from
medical school, 69% of DO residents
report emotional exhaustion and 74.4%
report depersonalization at moderate to
high levels?2
These data, entirely supported
by the 2019 Medscape National Physician
Burnout, Depression & Suicide Report,3
are common to all specialties and to all
settings and demonstrate a disturbing
recent increase in prevalence.3,4
This clearly
indicates that while the Jefferson Scale of
Empathy scores in medical schools may be
fascinating to study, their value in the real
world is quite limited, since empathy to
patients and their families is dependent on
physicians’ wellness and is among the first
casualties when they burn out.5
Disclosures: None reported.
Ami Schattner, MD
Professor of medicine, Faculty of Medicine, Hebrew
University–Hadassah Medical School, Jerusalem,
Israel; amischatt@gmail.com.
References
1 Hojat M, Shannon SC, DeSantis J, Speicher
MR, Bragan L, Calabrese LH. Does
empathy decline in the clinical phase of
medical education? A nationwide, multi-
institutional, cross-sectional study of
students at DO-granting medical schools.
Acad Med. 2020;95:911–918.
2 Chan AM, Cuevas ST, Jenkins J 2nd. Burnout
among osteopathic residents: A cross-
sectional analysis. J Am Osteopath Assoc.
2016;116:100–105.
Letters to the Editor