Empathic Divergence: Partially Blunting an Affective Empathic Response While Maintaining Cognitive Empathy is an Important Skill for Medical Students to Acquire

Main Article Content

Bruce W. Newton, PhD Zachary T. Vaskalis, PhD


Background: Establishing an empathic bond of trust with patients is a trait that is important to learn during medical school. There are two types of empathy: affective and cognitive. Being able to partially blunt a detrimental affective response while maintaining cognitive empathy is beneficial for both the patient and the physician.

AIM: To find those students who have partially blunted their affective empathy while maintaining or enhancing their cognitive empathic skills.

Methods: Affective and cognitive empathy was measured using the Balanced Emotional Empathy Scale and the Jefferson Scale of Empathy, respectively. The survey instruments were given during entrance into medical school, at the start of years 3-4, and a final administration just before graduation. Students who fit the aim of the study, had blunted their BEES score by -0.5 to -1.5 s.d. below the male or female population norms, as well as being at or above the 75th percentile for JSE scores as established by the Project in Osteopathic Medical Education and Empathy study. Desired specialty choice and sex was also collected at each timepoint. Five specialties are “people-oriented” and have a large amount of patient contact and continuity of care, and include Family and Internal Medicine, Ob/Gyn, Pediatrics and Psychiatry. Most other specialties are more “procedure- or technical-oriented” and are those with little or no patient contact and/or continuity of care (e.g., Surgery, Emergency Medicine, Anesthesiology).

Results: Only a small subset of students (n = 15/345) fell within the above parameters upon entering medical school. It was a different, small cadre (n = 13) that had these traits upon graduation. Ergo, there was no student who fell within the parameters for all four years of their undergraduate medical education.

Conclusions: Few students had the ability to partially blunt their affective empathic response while maintaining the ability to give a reassuring cognitive empathic response to patients. This indicates an increased emphasis needs to be placed on teaching empathic skills during the basic science years of the curriculum. However, the onus needs to fall upon the physicians who are empathic role-models during the clinical rotation year.


Article Details

How to Cite
NEWTON, Bruce W.; VASKALIS, Zachary T.. Empathic Divergence: Partially Blunting an Affective Empathic Response While Maintaining Cognitive Empathy is an Important Skill for Medical Students to Acquire. Medical Research Archives, [S.l.], v. 12, n. 1, jan. 2024. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/4772>. Date accessed: 03 mar. 2024. doi: https://doi.org/10.18103/mra.v12i1.4772.
Research Articles


1. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86(3):359-364.
doi: 10.1097/ACM.0b013e3182086fe1
2. Hojat M, Louis DZ, Maxwell K, Markham F, Wender R, Gonnella JS. Patient perceptions of physician empathy, satisfaction with physician, interpersonal trust, and compliance. Int J Med Educ. 2010;1:83–87. doi: 10.5116/ijme.4d00.b701
3. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553–559. doi: 10.1001/jama.1997.03540310051034
4. Hojat M. Ten approaches for enhancing empathy in health and human services cultures. J Health Hum Serv Adm Spring. 2009;31(4):412–50. doi: 10.2307/25790741
5. Hafferty FW. Beyond curriculum reform - confronting medicine's hidden curriculum. Acad Med. 1998;73(4):403-407. doi: 10.1097/00001888-199804000-00013
6. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Acad Med. 2008;83(3):244-249. doi:10.1097/ACM.0b013e3181637837
7. 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
8. Newton BW, Vaskalis ZT. Cognitive empathy of osteopathic students. A longitudinal study with data comparisons to the Project in Osteopathic Medical Education and Empathy (POMEE). JOM. 2023. doi.org/10.1515/jom-2023-0014
9. 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;24:1318–1321.
Doi: 10.1007/s11606-009-1129-z
10. Kay J. Traumatic deidealization and the future of medicine. JAMA.1990;263:572–573.
doi: 10.1001/jama.1990.03440040111039
11. Newson M, Zhao Y, El Zein M, et al. Digital contact does not promote wellbeing, but face-to-face contact does: a cross-national survey during the COVID-19 pandemic. New Media & Society. 2021:1-24.
doi: 10.177/1461448211062164
12. Kujath CL. Facebook and MySpace: complement or substitute for face-to-face interaction? Cyberpsychol Behav Social Networking. 2011;14:No.1-2.
Doi: 10.1089/cyber.2009.0311
13. Silver HK, Glicken AD. Medical student abuse. Incidence, severity, and significance. JAMA. 1990;263(4):572-532. PMID: 2294324
14. Newton BW. Walking a fine line: is it possible to remain an empathic physician and have a hardened heart? In: Enticott P, ed. The Neural Underpinnings of Vicarious Empathy. Front Hum Neurosci. 2013;11(7):233. doi: 10.3389/fnhum.2013.00233
15. Singer T, Seymour B, O’Doherty J, Kaube H, Dolan RJ, Frith CD. Empathy for pain involves the affective but not sensory components of pain. Science. 2004;303:1157–1162. doi: 10.1126/science.1093535
16. Walter H. Social cognitive neuroscience of empathy: concepts, circuits and genes. Emotion Rev. 2012;4:9–17. doi: 10.1177/1754073911421379
17. Mehrabian A, Young AL, Sato S. Emotional empathy and associated individual differences. Curr Psychol Res Rev. 1988;8:221-240. doi: 10.1007/BF0268667
18. Mehrabian A. Manual for the Balanced Emotional Empathy Scale (BEES). 1996 (Newton received permission for use for educational purposes in 1996. It is no longer available from Dr. Albert Mehrabian).
19. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psych. 2002;159(9):1563–1569. doi: 10.1176/appi.ajp.159.9.1563
20. Hojat M. Empathy in Health Professions Education and Patient Care. Springer International; 2016. doi: 10.1007/978-3-319-27625-0
21. Newton BW. “Having Heart: The Different Facets of Empathy”. In: Empathy – Advanced Research and Application. Ventura, S. ed. IntechOpen; London, United Kingdom. 2022.
doi: 10.5772/intechopen.106517
22. Stefanello E. Your pain is not mine: a critique of clinical empathy. Bioethics. 2022;36:486-493. doi:10.1111/bioe.12980
23. McDonald PS, O’Dowd TC. The heartsink patient: a preliminary study. Fam Pract. 1991;8:112–116.
24. Cameron CD, Hutcherson CA, Ferguson AM, Scheffer JA, Hadjiandreou E, Inzlicht M. Empathy is hard work: people choose to avoid empathy because of its cognitive costs. J Experiment Psychol.: General. 2019;148(6): 962–976.
Doi: 10.1037/xge0000595
25. Larson E, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA. 2005;293:1100-1106.
Doi: 10.1001/jama.293.9.1100
26. Zegarra-Parodi R, Esteves JE, Lunghi C, Baroni F, Draper-Rodi J, Cerritelli F. The legacy and implications of the body-mind-spirit osteopathic tenet: a discussion paper evaluating its clinical relevance in contemporary osteopathic care. Int J Osteopath Med. 2021;41:57-65.
Doi: 10.1016/j.ijosm.2021.05.003
27. Newton BW. Having heart: affective and cognitive empathy scores vs. residency specialty match at an osteopathic medical school. Med Sci Educ. 2022;32:423-436.
doi: 10.1007/s40670-022-01526-9
28. Newton BW, Clardy J, Barber L, Cleveland E. Who has heart? Vicarious empathy vs. residency match. Med Sci Educ. 2014;24(1):45-50. Doi: 10.1007/s40670-014-0021-6
29. Hojat M, Mangione SA, Nasca TJ, et al. The Jefferson Scale of Physician Empathy: development and preliminary data. Educ Psychol Meas. 2001;61:349-365.
doi: 10.1177/00131640121971158
30. Hojat M, Shannon SC, DeSantis J, Speicher MR, Bragan L, Calabrese LH. National norms for the Jefferson Scale of Empathy: a nationwide Project in Osteopathic Medical Education and Empathy (POMEE). JAOA. 2019;119(8):520-532. Doi: 10.7556/jaoa.2019.091
31. Mehrabian A. Relations among personality scales of aggression, violence and empathy: validational evidence bearing on the Risk of Eruptive Violence Scale. Aggressive Behav. 1997;23:433-445. Doi: 10.1002/(SICI)1098-2337(1997)23:6<433::AID-AB3>3.0.CO;2-H
32. IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.
33. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-373. doi: 10.1097/00001888-200604000-00009
34. Backović DV, Zivojinović JI, Maksimović J, Maksimović M. Gender differences in academic stress and burnout among medical students in final years of education. Psychiatr Danub. 2012;24(2):175-181. PMID: 22706416
35. Hojat M, DeSantis J, Shannon SC, Speicher MR, Bragan L, Calabrese LH. Empathy as related to gender, age, race, ethnicity, academic background and career interest: a nationwide study of osteopathic medical students in the United States. Med Educ. 2020;54:571-581. Doi: 10.1111/ medu.14138
36. Paro HBMS, Silveira PSP, Perotta B, et al. Empathy among medical students: is there a relation with quality of life and burnout? PLoS ONE. 2014;9(4): e94133.
Doi: 10.1371/journal.pone.0094133
37. Morse, DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med. 2008;168(17):1853-1858.
Doi: 10.1016/s0738-3991(02)00173-8
38. Fletcher KE, Furney SL, Stern DT. (2007) Patients speak: what's really important about bedside interactions with physician teams. Teach Learn Med. 2007;19(2):120-127. Doi: 10.1080/10401330701332193
39. Lamm C, Decety J, Singer T. Meta-analytic evidence for common and distinct neural networks associated with directly experienced pain and empathy for pain. Neuroimage. 2011;54:2492–2502.
Doi: 10.1016/j.neuroimage.2010.10.014
40. Cheng Y, Lin C-P, Liu H-L, et al. (2007). Expertise modulates the perception of pain in others. Curr Biol. 2007;17:1708–1713. Doi: 10.1016/j.cub.2007.09.020
41. Decety J, Yang C-Y, Cheng Y. (2010). Physicians down-regulate their pain empathy response: an event-related brain potential study. Neuroimage. 2010:50:1676–1682.
Doi: 10.1016/j.neuroimage.2010.01.025
42. Peterson CD, Rdesinski RE, Biagioli FE, Chappelle KG, Elliot DL. Medical student perceptions of a behavioural and social science curriculum. Ment Health Fam Med. 2011;8(4):215-226. PMCID: PMC3487603
43. Petrou L, Mittelman E, Osibona O, et al. The role of humanities in the medical curriculum: medical students’ perspectives. BMC Med Educ. 2021;21:179.
Doi: 10.1186/s12909-021-02555-5
44. Tseretopoulou X, Stratou A, Stavrinou P, Souretis G, Dimoliatis, IDK. Students do not consider all subjects to be equally relevant. Α method for quantifying relevance; implications for curriculum timetabling, teaching and learning, and student assessment of teachers. Archives Hellenic Med. 2011;28(2):227-233.
45. Bayne HB. Training medical students in empathic communication. J Spec Group Work. 2011;36:316-329.
Doi: 10.1080/01933922.2011.613899
46. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Affairs. 2010;29(7): 1310-1318.
Doi: 10.1377/hithaff.2009.0450
47. Lases SSL, Arah OA, Pierik EGJMR, Heineman E, Lombarts MJMHK. Residents’ engagement and empathy associated with their perception of faculty’s teaching performance. World J Surg. 2014;38:2753-2760. doi: 10.1007/s00268-014-2687-8
48. Riess H, Kraft-Todd G. EMPATHY: a tool to enhance nonverbal communication between clinicians and their patients. Acad Med. 2014;89:1108–12.
Doi: 10.1097/ACM.0000000000000287.
49. Batt-Rawden SA, Chisolm MS, Anton B, Flickinger TE. teaching empathy to medical students: an updated, systematic review. Acad Med. 2013:88(8):1171-1177.
doi: 10.1097/ACM.0b013e318299f3e3
50. Stepien KA, Baernstein A. Educating for empathy: a review. J Gen Intern Med. 2006;21:524-530. doi: 10.111/j.1525-1497.2006.00443.x
51. Kataoka H, Iwase T, Ogawa H, et al. Can communication skills training improve empathy? A six-year longitudinal study of medical students in Japan. Med Teach. 2019;41(2):195-200.
Doi: 10.1080/0142159X.2018.1460657
52. Harden RM. Twelve tips on teaching and learning how to break bad news. Med Teach. 1996;18(4):275–8. Doi: 10.3109/ 0142159 9609034177
53. Bylund CL, Makoul G. Empathic communication and gender in the physician-patient encounter. Patient Educ Couns. 2002;48:207-216. doi: 10.1016/s0738-3991(02)00173-8
54. Varkey P, Chutka DS, Lesnick TG. The Aging Game: improving medical students' attitudes toward caring for the elderly. J American Med Direct Assoc. 2006;7: 224-229.
doi: 10.1016/j.jamda.2005.07.009.
55. Henry BW, Douglass C, Kostiwa IM. Effects of participation in an aging game simulation activity on the attitudes of allied health students toward older adults. The Internet Journal of Allied Health Sciences and Practice (IJAHSP). 2007;5(4):Article 5.
doi: 10.46743/1540-580X/2007.1166
56. Berkhof M, van Rijssen HJ, Schellart AJM, Anema JR, van der Beek AJ. Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews. Patient Educ Couns. 2011;84:152-162. Doi: 10.1016/j.pec.2010.06.010
57. Konstaninos F, Crampton PES. The effectiveness of teaching clinical empathy to medical students: a systematic review and meta-analysis of randomized controlled trials. Acad. Med. 20220;95(6):947-957. Doi: 10.1097/ACM.0000000000003058
58. Hojat M, DeSantis J, Cain RA, et al. Attitudes toward osteopathic medicine scale: development and psychometrics. Int J Med Educ. 2021;12:222-232.
doi: 10.5116/ijme615c.2cfa