Influence of Role Models and Unstructured Relationship on Changes in Medical Student Character, Medical-Specific Empathy, and General Empathy
Main Article Content
Abstract
Purpose: Medical student empathy and character changes are of great interest with clear implications for patient interactions. With much focus on deleterious education culture, this study focuses more on what may bolster empathy and character. Building from interventions highlighting role models, the authors hypothesize the importance of informal relational connections within medical school may promote both modest empathy and character development.
Materials and Method: This study uses unique secondary data that follows a cohort of medical students over time, with two surveys about a year apart. The data is unique not only in the inclusion of time, but also in various relational measures and both a medical-specific empathy as well as a general empathy measure. This allows for modeling change in medical student empathy.
Results and Conclusion: First, general and medical-specific empathy appear to function different. At baseline, receiving positive character feedback from an attending/resident is positively related to medical empathy while negative feedback is inversely related to medical empathy and burnout is related only to general empathy. Over the next year, being around an admirable physician increased both types of empathy, seeing burnt out specialists increased medical empathy, and a sense of calling generally bolsters empathy. Second, exposure to morally admirable role models is broadly, although modestly, related to character development. It is positively associated with expectations for faculty to teach, shape, and train character, and with an increased sense that bad people may not make good physicians. Finally, exposure to these role models tends to increase one’s sense of calling to the profession. While not dramatic, informal relationships can be an important part of professionalization and may affect general and medical-specific empathy differently, and shift changes in student character.
Keywords:
Empathy, character, moral elevation, role models
Article Details
How to Cite
FRANZEN, Aaron B.; CLIFTON, Tristen.
Influence of Role Models and Unstructured Relationship on Changes in Medical Student Character, Medical-Specific Empathy, and General Empathy.
Medical Research Archives, [S.l.], v. 11, n. 7.1, july 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/4140>. Date accessed: 15 may 2024.
doi: https://doi.org/10.18103/mra.v11i7.1.4140.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Neumann M, Edelhaeuser F, Tauschel D, et al. Empathy Decline and Its Reasons: A Systematic Review of Studies With Medical Students and Residents. Acad Med. 2011;86(8):996-1009. doi:10.1097/ACM.0b013e318221e615
2. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69(11):861-871.
3. Michalec B, Hafferty FW. Stunting professionalism: The potency and durability of the hidden curriculum within medical education. Soc Theory Health. 2013;11(4):388-406. doi:10.1057/sth.2013.6
4. Hilton S. Medical professionalism: how can we encourage it in our students? The Clinical Teacher. 2004;1(2):69-73. doi:https://doi.org/10.1111/j.1743-498X.2004.00032.x
5. Martimianakis MA (Tina), Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the Hidden Curriculum, and Educational Reform: A Scoping Review and Thematic Analysis. Academic Medicine. 2015;90(11):S5. doi:10.1097/ACM.0000000000000894
6. Smith C. Moral, Believing Animals: Human Personhood and Culture. Oxford University Press; 2003.
7. Kinghorn WA, McEvoy MD, Michel A, Balboni M. Professionalism in modern medicine: does the emperor have any clothes? Acad Med. 2007;82(1):40-45. doi:10.1097/01.ACM.0000249911.79915.4d
8. Wright S, Wong A, Newill C. The Impact of Role Models on Medical Students. Journal of General Internal Medicine. 1997;12(1):53-56. doi:https://doi.org/10.1046/j.1525-1497.1997.12109.x
9. Passi V, Johnson N. The impact of positive doctor role modeling. Med Teach. 2016;38(11):1139-1145. doi:10.3109/0142159X.2016.1170780
10. Weissmann PF, Branch WT, Gracey CF, Haidet P, Frankel RM. Role Modeling Humanistic Behavior: Learning Bedside Manner from the Experts. Academic Medicine. 2006;81(7):661-667. doi:10.1097/01.ACM.0000232423.81299.fe
11. Haidt J. The Positive Emotion of Elevation. Prevention and Treatment. 2000;3(1). doi:10.1037/1522-3736.3.1.33c
12. Vianello M, Galliani EM, Haidt J. Elevation at work: The effects of leaders’ moral excellence. The Journal of Positive Psychology. 2010;5(5):390-411. doi:10.1080/17439760.2010.516764
13. Baugh RF, Hoogland MA, Baugh AD. The Long-Term Effectiveness of Empathic Interventions in Medical Education: A Systematic Review. Adv Med Educ Pract. 2020;11:879-890. doi:10.2147/AMEP.S259718
14. Chen D, Lew R, Hershman W, Orlander J. A Cross-sectional Measurement of Medical Student Empathy. J GEN INTERN MED. 2007;22(10):1434-1438. doi:10.1007/s11606-007-0298-x
15. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Medical Education. 2004;38(9):934-941. doi:10.1111/j.1365-2929.2004.01911.x
16. 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(9):1182-1191. doi:10.1097/ACM.0b013e3181b17e55
17. Mahoney S, Sladek RM, Neild T. A longitudinal study of empathy in preclinical and clinical medical students and clinical supervisors. BMC Med Educ. 2016;16:270. doi:10.1186/s12909-016-0777-z
18. Underman K, Hirshfield LE. Detached concern?: Emotional socialization in twenty-first century medical education. Social Science & Medicine. 2016;160:94-101. doi:10.1016/j.socscimed.2016.05.027
19. Olsen LD, Gebremariam H. Disciplining empathy: Differences in empathy with U.S. medical students by college major. Health. Published online October 19, 2020. doi:10.1177/1363459320967055
20. Shanafelt TD, West C, Zhao X, et al. Relationship Between Increased Personal Well-Being and Enhanced Empathy Among Internal Medicine Residents. Journal of General Internal Medicine. 2005;20(7):559-564. doi:10.1111/j.1525-1497.2005.0108.x
21. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-1622.
22. Murinson BB, Klick B, Haythornthwaite JA, Shochet R, Levine RB, Wright SM. Formative Experiences of Emerging Physicians: Gauging the Impact of Events That Occur During Medical School. Academic Medicine. 2010;85(8):1331-1337. doi:10.1097/ACM.0b013e3181e5d52a
23. Thomas MR, Dyrbye LN, Huntington JL, et al. How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study. J GEN INTERN MED. 2007;22(2):177-183. doi:10.1007/s11606-006-0039-6
24. Kenny NP, Mann KV, Macleod H. Role Modeling in Physicians’ Professional Formation: Reconsidering an Essential but Untapped Educational Strategy. Academic Medicine. 2003;78(12):1203-1210.
25. Pohontsch NJ, Stark A, Ehrhardt M, Kötter T, Scherer M. Influences on students’ empathy in medical education: an exploratory interview study with medical students in their third and last year. BMC Medical Education. 2018;18(1):231. doi:10.1186/s12909-018-1335-7
26. Ahrweiler F, Neumann M, Goldblatt H, Hahn EG, Scheffer C. Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians. BMC Medical Education. 2014;14(1):122. doi:10.1186/1472-6920-14-122
27. Chrisman-Khawam LM, Manzi JA. Empathy in Medicine Cultivating an Empathetic Professional Identity in Osteopathic Medical Students Through Service Learning: A Qualitative Analysis of Reflective Essays. J Am Osteopath Assoc. 2020;120(4):263-272. doi:10.7556/jaoa.2020.043
28. Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Teaching professionalism in medical education: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Medical Teacher. 2013;35(7):e1252-e1266. doi:10.3109/0142159X.2013.789132
29. Branch WT. Supporting the moral development of medical students. J Gen Intern Med. 2000;15(7):503-508. doi:10.1046/j.1525-1497.2000.06298.x
30. Cruess SR, Cruess RL, Steinert Y. Teaching rounds - Role modelling - making the most of a powerful teaching strategy. Br Med J. 2008;336(7646):718-721. doi:10.1136/bmj.39503.757847.BE
31. Tavakol S, Dennick R, Tavakol M. Medical students’ understanding of empathy: a phenomenological study. Med Educ. 2012;46(3):306-316. doi:10.1111/j.1365-2923.2011.04152.x
32. Benbassat J. Role Modeling in Medical Education: The Importance of a Reflective Imitation. Acad Med. 2014;89(4):550-554. doi:10.1097/ACM.0000000000000189
33. Bombeke K, Symons L, Debaene L, De Winter B, Schol S, Van Royen P. Help, I’m losing patient-centredness! Experiences of medical students and their teachers. Med Educ. 2010;44(7):662-673. doi:10.1111/j.1365-2923.2010.03627.x
34. Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The Prevalence of Medical Student Mistreatment and Its Association with Burnout. Acad Med. 2014;89(5):749-754. doi:10.1097/ACM.0000000000000204
35. Benbassat J. Changes in wellbeing and professional values among medical undergraduate students: a narrative review of the literature. Adv Health Sci Educ. 2014;19(4):597-610. doi:10.1007/s10459-014-9500-1
36. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 2006;81(4):354-373. doi:10.1097/00001888-200604000-00009
37. Self DJ, Schrader DE, Baldwin DC, Wolinsky FD. The moral development of medical students: a pilot study of the possible influence of medical education. Medical Education. 1993;27(1):26-34. doi:10.1111/j.1365-2923.1993.tb00225.x
38. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd edition. Consulting Psychologists Pr; 1996.
39. Campbell DA, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery. 2001;130(4):696-705. doi:10.1067/msy.2001.116676
40. Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. A model of burnout and life satisfaction amongst nurses. Journal of Advanced Nursing. 2000;32(2):454-464. doi:https://doi.org/10.1046/j.1365-2648.2000.01496.x
41. Shanafelt TD. Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care. JAMA. 2009;302(12):1338. doi:10.1001/jama.2009.1385
42. Duffy RD, Dik BJ, Douglass RP, England JW, Velez BL. Work as a calling: A theoretical model. Journal of Counseling Psychology. 2018;65(4):423-439. doi:http://dx.doi.org.ezproxy.hope.edu/10.1037/cou0000276
43. Pohling R, Diessner R. Moral Elevation and Moral Beauty: A Review of the Empirical Literature. Review of General Psychology. 2016;20(4):412-425. doi:10.1037/gpr0000089
44. Thomson AL, Siegel JT. Elevation: A review of scholarship on a moral and other-praising emotion. The Journal of Positive Psychology. 2017;12(6):628-638. doi:10.1080/17439760.2016.1269184
45. Shepherd AM, Schnitker SS, Leffel GM, et al. Developing the Good Physician: Spirituality affects the development of virtues and moral intuitions in medical students. The Journal of Positive Psychology. 2018;13(2):143-154. doi:10.1080/17439760.2016.1269185
46. Rasinski KA, Curlin FA, Yoon JD. Methods for Project on the Good Physician. Published 2014. Accessed December 28, 2018. https://pmr.uchicago.edu/projects/project-on-the-good-physician/
47. Thomas CL, Cuceu M, Tak HJ, et al. Predictors of Empathic Compassion: Do Spirituality, Religion, and Calling Matter. South Med J. 2019;112(6):320-324. doi:10.14423/smj.0000000000000983
48. Davis MH. A multidimensional approach to individual differences in empathy. JSAS Catalog of Selected Documentsin Psychology. 1980;10:85.
49. Spreng RN, McKinnon MC, Mar RA, Levine B. The Toronto Empathy Questionnaire: Scale Development and Initial Validation of a Factor-Analytic Solution to Multiple Empathy Measures. Journal of Personality Assessment. 2009;91(1):62-71. doi:10.1080/00223890802484381
50. Dik BJ, Eldridge BM, Steger MF, Duffy RD. Development and Validation of the Calling and Vocation Questionnaire (CVQ) and Brief Calling Scale (BCS). Journal of Career Assessment. 2012;20(3):242-263. doi:10.1177/1069072711434410
51. Steger MF, Frazier P, Oishi S, Kaler M. The meaning in life questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology. 2006;53(1):80-93. doi:http://dx.doi.org/10.1037/0022-0167.53.1.80
52. Damiano RF, de Andrade Ribeiro LM, dos Santos AG, da Silva BA, Lucchetti G. Empathy is Associated with Meaning of Life and Mental Health Treatment but not Religiosity Among Brazilian Medical Students. J Relig Health. 2017;56(3):1003-1017. doi:10.1007/s10943-016-0321-9
53. Yoon JD, Shin JH, Nian AL, Curlin FA. Religion, Sense of Calling, and the Practice of Medicine: Findings from a National Survey of Primary Care Physicians and Psychiatrists. South Med J. 2015;108(3):189-195. doi:10.14423/SMJ.0000000000000250
54. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321. doi:10.1007/s11606-009-1129-z
55. Campbell WK, Bonacci AM, Shelton J, Exline JJ, Bushman BJ. Psychological Entitlement: Interpersonal Consequences and Validation of a Self-Report Measure. Journal of Personality Assessment. 2004;83(1):29-45. doi:10.1207/s15327752jpa8301_04
56. Leffel GM, Mueller RAO, Curlin FA, Yoon JD. Relevance of the rationalist–intuitionist debate for ethics and professionalism in medical education. Adv in Health Sci Educ. 2014;20(5):1371-1383. doi:10.1007/s10459-014-9563-z
57. Thomson AL, Nakamura J, Siegel JT, Csikszentmihalyi M. Elevation and mentoring: An experimental assessment of causal relations. The Journal of Positive Psychology. 2014;9(5):402-413. doi:10.1080/17439760.2014.910824
58. Erschens R, Keifenheim KE, Herrmann-Werner A, et al. Professional burnout among medical students: Systematic literature review and meta-analysis. Medical Teacher. 2019;41(2):172-183. doi:10.1080/0142159X.2018.1457213
59. Silva V, Costa P, Pereira I, et al. Depression in medical students: insights from a longitudinal study. BMC Medical Education. 2017;17:184. doi:10.1186/s12909-017-1006-0
60. Siegel JT, Thomson AL. Positive emotion infusions of elevation and gratitude: Increasing help-seeking intentions among people with heightened levels of depressive symptomatology. The Journal of Positive Psychology. 2017;12(6):509-524. doi:10.1080/17439760.2016.1221125
61. Shapiro J, Rucker L. The Don Quixote Effect: Why Going to the Movies Can Help Develop Empathy and Altruism in Medical Students and Residents. Families, Systems, & Health. 2004;22(4):445-452. doi:10.1037/1091-7527.22.4.445
62. Schnall S, Roper J. Elevation Puts Moral Values Into Action. Social Psychological and Personality Science. 2012;3(3):373-378. doi:10.1177/1948550611423595
63. Ahmadian Yazdi N, Bigdeli S, Soltani Arabshahi SK, Ghaffarifar S. The influence of role-modeling on clinical empathy of medical interns: A qualitative study. J Adv Med Educ Prof. 2019;7(1):35-41. doi:10.30476/JAMP.2019.41043
64. Afghan B, Besimanto S, Amin A, Shapiro J. Medical Students′ Perspectives on Clinical Empathy Training. Educ Health. 2011;24(1):544.
doi:10.4103/1357-6283.101451
2. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69(11):861-871.
3. Michalec B, Hafferty FW. Stunting professionalism: The potency and durability of the hidden curriculum within medical education. Soc Theory Health. 2013;11(4):388-406. doi:10.1057/sth.2013.6
4. Hilton S. Medical professionalism: how can we encourage it in our students? The Clinical Teacher. 2004;1(2):69-73. doi:https://doi.org/10.1111/j.1743-498X.2004.00032.x
5. Martimianakis MA (Tina), Michalec B, Lam J, Cartmill C, Taylor JS, Hafferty FW. Humanism, the Hidden Curriculum, and Educational Reform: A Scoping Review and Thematic Analysis. Academic Medicine. 2015;90(11):S5. doi:10.1097/ACM.0000000000000894
6. Smith C. Moral, Believing Animals: Human Personhood and Culture. Oxford University Press; 2003.
7. Kinghorn WA, McEvoy MD, Michel A, Balboni M. Professionalism in modern medicine: does the emperor have any clothes? Acad Med. 2007;82(1):40-45. doi:10.1097/01.ACM.0000249911.79915.4d
8. Wright S, Wong A, Newill C. The Impact of Role Models on Medical Students. Journal of General Internal Medicine. 1997;12(1):53-56. doi:https://doi.org/10.1046/j.1525-1497.1997.12109.x
9. Passi V, Johnson N. The impact of positive doctor role modeling. Med Teach. 2016;38(11):1139-1145. doi:10.3109/0142159X.2016.1170780
10. Weissmann PF, Branch WT, Gracey CF, Haidet P, Frankel RM. Role Modeling Humanistic Behavior: Learning Bedside Manner from the Experts. Academic Medicine. 2006;81(7):661-667. doi:10.1097/01.ACM.0000232423.81299.fe
11. Haidt J. The Positive Emotion of Elevation. Prevention and Treatment. 2000;3(1). doi:10.1037/1522-3736.3.1.33c
12. Vianello M, Galliani EM, Haidt J. Elevation at work: The effects of leaders’ moral excellence. The Journal of Positive Psychology. 2010;5(5):390-411. doi:10.1080/17439760.2010.516764
13. Baugh RF, Hoogland MA, Baugh AD. The Long-Term Effectiveness of Empathic Interventions in Medical Education: A Systematic Review. Adv Med Educ Pract. 2020;11:879-890. doi:10.2147/AMEP.S259718
14. Chen D, Lew R, Hershman W, Orlander J. A Cross-sectional Measurement of Medical Student Empathy. J GEN INTERN MED. 2007;22(10):1434-1438. doi:10.1007/s11606-007-0298-x
15. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Medical Education. 2004;38(9):934-941. doi:10.1111/j.1365-2929.2004.01911.x
16. 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(9):1182-1191. doi:10.1097/ACM.0b013e3181b17e55
17. Mahoney S, Sladek RM, Neild T. A longitudinal study of empathy in preclinical and clinical medical students and clinical supervisors. BMC Med Educ. 2016;16:270. doi:10.1186/s12909-016-0777-z
18. Underman K, Hirshfield LE. Detached concern?: Emotional socialization in twenty-first century medical education. Social Science & Medicine. 2016;160:94-101. doi:10.1016/j.socscimed.2016.05.027
19. Olsen LD, Gebremariam H. Disciplining empathy: Differences in empathy with U.S. medical students by college major. Health. Published online October 19, 2020. doi:10.1177/1363459320967055
20. Shanafelt TD, West C, Zhao X, et al. Relationship Between Increased Personal Well-Being and Enhanced Empathy Among Internal Medicine Residents. Journal of General Internal Medicine. 2005;20(7):559-564. doi:10.1111/j.1525-1497.2005.0108.x
21. Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-1622.
22. Murinson BB, Klick B, Haythornthwaite JA, Shochet R, Levine RB, Wright SM. Formative Experiences of Emerging Physicians: Gauging the Impact of Events That Occur During Medical School. Academic Medicine. 2010;85(8):1331-1337. doi:10.1097/ACM.0b013e3181e5d52a
23. Thomas MR, Dyrbye LN, Huntington JL, et al. How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study. J GEN INTERN MED. 2007;22(2):177-183. doi:10.1007/s11606-006-0039-6
24. Kenny NP, Mann KV, Macleod H. Role Modeling in Physicians’ Professional Formation: Reconsidering an Essential but Untapped Educational Strategy. Academic Medicine. 2003;78(12):1203-1210.
25. Pohontsch NJ, Stark A, Ehrhardt M, Kötter T, Scherer M. Influences on students’ empathy in medical education: an exploratory interview study with medical students in their third and last year. BMC Medical Education. 2018;18(1):231. doi:10.1186/s12909-018-1335-7
26. Ahrweiler F, Neumann M, Goldblatt H, Hahn EG, Scheffer C. Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians. BMC Medical Education. 2014;14(1):122. doi:10.1186/1472-6920-14-122
27. Chrisman-Khawam LM, Manzi JA. Empathy in Medicine Cultivating an Empathetic Professional Identity in Osteopathic Medical Students Through Service Learning: A Qualitative Analysis of Reflective Essays. J Am Osteopath Assoc. 2020;120(4):263-272. doi:10.7556/jaoa.2020.043
28. Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Teaching professionalism in medical education: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Medical Teacher. 2013;35(7):e1252-e1266. doi:10.3109/0142159X.2013.789132
29. Branch WT. Supporting the moral development of medical students. J Gen Intern Med. 2000;15(7):503-508. doi:10.1046/j.1525-1497.2000.06298.x
30. Cruess SR, Cruess RL, Steinert Y. Teaching rounds - Role modelling - making the most of a powerful teaching strategy. Br Med J. 2008;336(7646):718-721. doi:10.1136/bmj.39503.757847.BE
31. Tavakol S, Dennick R, Tavakol M. Medical students’ understanding of empathy: a phenomenological study. Med Educ. 2012;46(3):306-316. doi:10.1111/j.1365-2923.2011.04152.x
32. Benbassat J. Role Modeling in Medical Education: The Importance of a Reflective Imitation. Acad Med. 2014;89(4):550-554. doi:10.1097/ACM.0000000000000189
33. Bombeke K, Symons L, Debaene L, De Winter B, Schol S, Van Royen P. Help, I’m losing patient-centredness! Experiences of medical students and their teachers. Med Educ. 2010;44(7):662-673. doi:10.1111/j.1365-2923.2010.03627.x
34. Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The Prevalence of Medical Student Mistreatment and Its Association with Burnout. Acad Med. 2014;89(5):749-754. doi:10.1097/ACM.0000000000000204
35. Benbassat J. Changes in wellbeing and professional values among medical undergraduate students: a narrative review of the literature. Adv Health Sci Educ. 2014;19(4):597-610. doi:10.1007/s10459-014-9500-1
36. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 2006;81(4):354-373. doi:10.1097/00001888-200604000-00009
37. Self DJ, Schrader DE, Baldwin DC, Wolinsky FD. The moral development of medical students: a pilot study of the possible influence of medical education. Medical Education. 1993;27(1):26-34. doi:10.1111/j.1365-2923.1993.tb00225.x
38. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd edition. Consulting Psychologists Pr; 1996.
39. Campbell DA, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among American surgeons. Surgery. 2001;130(4):696-705. doi:10.1067/msy.2001.116676
40. Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. A model of burnout and life satisfaction amongst nurses. Journal of Advanced Nursing. 2000;32(2):454-464. doi:https://doi.org/10.1046/j.1365-2648.2000.01496.x
41. Shanafelt TD. Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care. JAMA. 2009;302(12):1338. doi:10.1001/jama.2009.1385
42. Duffy RD, Dik BJ, Douglass RP, England JW, Velez BL. Work as a calling: A theoretical model. Journal of Counseling Psychology. 2018;65(4):423-439. doi:http://dx.doi.org.ezproxy.hope.edu/10.1037/cou0000276
43. Pohling R, Diessner R. Moral Elevation and Moral Beauty: A Review of the Empirical Literature. Review of General Psychology. 2016;20(4):412-425. doi:10.1037/gpr0000089
44. Thomson AL, Siegel JT. Elevation: A review of scholarship on a moral and other-praising emotion. The Journal of Positive Psychology. 2017;12(6):628-638. doi:10.1080/17439760.2016.1269184
45. Shepherd AM, Schnitker SS, Leffel GM, et al. Developing the Good Physician: Spirituality affects the development of virtues and moral intuitions in medical students. The Journal of Positive Psychology. 2018;13(2):143-154. doi:10.1080/17439760.2016.1269185
46. Rasinski KA, Curlin FA, Yoon JD. Methods for Project on the Good Physician. Published 2014. Accessed December 28, 2018. https://pmr.uchicago.edu/projects/project-on-the-good-physician/
47. Thomas CL, Cuceu M, Tak HJ, et al. Predictors of Empathic Compassion: Do Spirituality, Religion, and Calling Matter. South Med J. 2019;112(6):320-324. doi:10.14423/smj.0000000000000983
48. Davis MH. A multidimensional approach to individual differences in empathy. JSAS Catalog of Selected Documentsin Psychology. 1980;10:85.
49. Spreng RN, McKinnon MC, Mar RA, Levine B. The Toronto Empathy Questionnaire: Scale Development and Initial Validation of a Factor-Analytic Solution to Multiple Empathy Measures. Journal of Personality Assessment. 2009;91(1):62-71. doi:10.1080/00223890802484381
50. Dik BJ, Eldridge BM, Steger MF, Duffy RD. Development and Validation of the Calling and Vocation Questionnaire (CVQ) and Brief Calling Scale (BCS). Journal of Career Assessment. 2012;20(3):242-263. doi:10.1177/1069072711434410
51. Steger MF, Frazier P, Oishi S, Kaler M. The meaning in life questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology. 2006;53(1):80-93. doi:http://dx.doi.org/10.1037/0022-0167.53.1.80
52. Damiano RF, de Andrade Ribeiro LM, dos Santos AG, da Silva BA, Lucchetti G. Empathy is Associated with Meaning of Life and Mental Health Treatment but not Religiosity Among Brazilian Medical Students. J Relig Health. 2017;56(3):1003-1017. doi:10.1007/s10943-016-0321-9
53. Yoon JD, Shin JH, Nian AL, Curlin FA. Religion, Sense of Calling, and the Practice of Medicine: Findings from a National Survey of Primary Care Physicians and Psychiatrists. South Med J. 2015;108(3):189-195. doi:10.14423/SMJ.0000000000000250
54. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009;24(12):1318-1321. doi:10.1007/s11606-009-1129-z
55. Campbell WK, Bonacci AM, Shelton J, Exline JJ, Bushman BJ. Psychological Entitlement: Interpersonal Consequences and Validation of a Self-Report Measure. Journal of Personality Assessment. 2004;83(1):29-45. doi:10.1207/s15327752jpa8301_04
56. Leffel GM, Mueller RAO, Curlin FA, Yoon JD. Relevance of the rationalist–intuitionist debate for ethics and professionalism in medical education. Adv in Health Sci Educ. 2014;20(5):1371-1383. doi:10.1007/s10459-014-9563-z
57. Thomson AL, Nakamura J, Siegel JT, Csikszentmihalyi M. Elevation and mentoring: An experimental assessment of causal relations. The Journal of Positive Psychology. 2014;9(5):402-413. doi:10.1080/17439760.2014.910824
58. Erschens R, Keifenheim KE, Herrmann-Werner A, et al. Professional burnout among medical students: Systematic literature review and meta-analysis. Medical Teacher. 2019;41(2):172-183. doi:10.1080/0142159X.2018.1457213
59. Silva V, Costa P, Pereira I, et al. Depression in medical students: insights from a longitudinal study. BMC Medical Education. 2017;17:184. doi:10.1186/s12909-017-1006-0
60. Siegel JT, Thomson AL. Positive emotion infusions of elevation and gratitude: Increasing help-seeking intentions among people with heightened levels of depressive symptomatology. The Journal of Positive Psychology. 2017;12(6):509-524. doi:10.1080/17439760.2016.1221125
61. Shapiro J, Rucker L. The Don Quixote Effect: Why Going to the Movies Can Help Develop Empathy and Altruism in Medical Students and Residents. Families, Systems, & Health. 2004;22(4):445-452. doi:10.1037/1091-7527.22.4.445
62. Schnall S, Roper J. Elevation Puts Moral Values Into Action. Social Psychological and Personality Science. 2012;3(3):373-378. doi:10.1177/1948550611423595
63. Ahmadian Yazdi N, Bigdeli S, Soltani Arabshahi SK, Ghaffarifar S. The influence of role-modeling on clinical empathy of medical interns: A qualitative study. J Adv Med Educ Prof. 2019;7(1):35-41. doi:10.30476/JAMP.2019.41043
64. Afghan B, Besimanto S, Amin A, Shapiro J. Medical Students′ Perspectives on Clinical Empathy Training. Educ Health. 2011;24(1):544.
doi:10.4103/1357-6283.101451