Health, Spirituality and Medical Ethics

Soheila Darmiani1* , Mahbubeh Haghi Rudi2 , Reza Dastjerdi3
1. Department of Endodontics, School of Dentistry, Birjand University of Medical Sciences, Birjand, Iran.
2. Dentist, Khaf, Razavi Khorasan, Iran.
3. Department of Psychology, School of Allied Medical Sciences, Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran.
* Corresponding Author:
Soheila Darmiani, PhD.
Address: Department of Endodontics, School of Dentistry, Birjand University of Medical Sciences, Birjand, Iran.
Phone: +98 (56) 32381704
E-mail: soheiladarmiani@yahoo.com
Research Paper:
Evaluation of Empathy With Patients and Related
Factors in Dental Students
Background and Objectives: A human is a social being and needs social cohesion, support, and
understanding. The relationship between the dentist and patient is a specific example of social
support and empathy. The patient is also an example of social support. An empathetic dentistpatient
relationship can effectively improve the physical, psychological, and social wellbeing
of the patient. In this relationship, a physician can make a better diagnosis and deliver a more
satisfactory treatment outcome. Therefore, this study aimed to evaluate empathy and its related
factors in dental students of Birjand University of Medical Sciences, Birjand City, Iran, in 2020.
Methods: The study population consisted of all students of clinical dentistry. After obtaining
informed consent from the students, Jefferson’s questionnaire was distributed among them.
Students’ demographic information was asked in the questionnaire. The obtained data were
analyzed by ANOVA and the independent t test at the significant level of 0.05.
Results: A total of 78 (42.3% male and 57.7% female) dental students participated in this study.
Their Mean±SD score of empathy was 57±5.57. The mean empathy score was significantly
higher in females than males (P=0.04). The mean score of empathy was significantly higher in
students who were more interested in their field (P=0.03). The mean score of empathy for students
was not significantly different in terms of study semester (P=0.06), marital status (P=0.95),
communication skills (P=0.16), and mother’s (P=0.11), and father’s (P=0.92) education.
Conclusion: The mean score of empathy was significantly higher in females and students who
were more interested in their field.
A B S T R A C T
Keywords:
Dentistry, Dental education,
Students, Empathy, Patients
Please cite this article as Darmiani S, Haghi Rudi M, Dastjerdi R. Evaluation of Empathy With Patients and Related
Factors in Dental Students. Health, Spirituality and Medical Ethics Journal. 2021; 8(3):155-162. http://dx.doi.org/10.32598/
hsmej.8.3.3
: http://dx.doi.org/10.32598/hsmej.8.3.3
Use your device to scan
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Article info:
Received: 06 Oct 2020
Accepted: 10 Aug 2021
Publish: 01 Sep 2021
156
September 2021. Volume 8. Number 3
Introduction
human is a social being and needs social
cohesion, support, understanding, and being
understood. The dentist-patient empathic
relationship can effectively improve
the physical, mental, and social wellbeing
of the patient and, reciprocally, that of the dentist [1]. It
should be acknowledged that medicine and clinical communication
between patient and dentist are essentially
ethical. The philosophy of this relationship is the need
to care for the patients and relieve their pain. Therefore,
the relationship between dentist and patient is the cornerstone
of the medical profession and, consequently, medical
ethics. Having an empathetic view of patients is one
of the main components of this relationship. Empathy
is a communication ability whereby one can understand
the experiences and concerns of others and express oneself.
It manifests as an ability to understand the experiences
and inner feelings of other people, to see the world
through their eyes, and to enter the emotional realm of
other people by entering their emotions [2, 3].
One situation for empathy to manifest itself is the relationship
between the dentist and the patient. Research indicates
that the emphatic patient-dentist relationship and
effective interaction with the patient are associated with
patient satisfaction and improved treatment outcomes [1,
4-6]. Empathy facilitates the process of diagnosing the
disease, such that the patient feels more relaxed and explains
the details of the disease more precisely [7].
One of the concepts associated with empathy is social
intelligence. Areas of empathy and social intelligence
overlap to a certain extent [8]. Social intelligence implicitly
borders upon social skills, social competence, and
emotional and interpersonal intelligence [9].
No positive attitude of dentists to empathize with patients
is one of the problems and concerns of society [10].
Nowadays, communication and mutual understanding
of the providers and recipients of oral and dental health
services are seriously considered in the dentistry educational
system, and the critical point in this effective relationship
is the ability to understand along with a degree
of empathy between the patient and the dentist [11].
The negative attitude of patients towards the dentist
reduces patient satisfaction and increases the number of
functional errors of the dentist and complaints of patients
[12]. With greater empathy, therefore, dentists and physicians
acquire greater competence in obtaining patient
history, performing a clinical examination, assessing demands,
preparing the treatment plan, giving post-treatment
instructions, and attracting the cooperation of patients [13].
When a dentist is aware of and understands the patient’s
emotional state, as well as his or her dental condition,
chances of an accurate diagnosis would rise [14].
This knowledge may, in turn, improve the dental treatment
process and increase the chances of patients’ adherence
to the dentist’s advice [15]. The ability to communicate
and empathize with patients reduces the patients’
fear and anxiety about dentistry [16, 17]. It improves
therapeutic outcomes for oral and facial pains [18] and
stimulates the desire to cooperate in receiving dental,
orthodontic, dental removal, treatment, root canal, and
prosthetic and implant services [19-21].
Also, the results of some studies have shown that when
patients are more satisfied with the emotional care of
their dentists, they are less likely to file a dental complaint
against the dentist, even though they may not be
satisfied with the dental results. Symptoms of empathy
between the dentist and the patient appear in verbal and
nonverbal communication [22].
While there are different ways to assess empathy, such
as self-assessment, patient assessment, collateral assessment,
psychometric tests, and behavioral observations,
the most common method used in health is self-assessment
[23]. Due to the lack of a positive attitude among
some dentists towards empathy with patients and the
importance of this issue in the treatment and patient satisfaction,
we decided to examine empathy and related
factors in dental students of Birjand University of Medical
Sciences, Birjand City, Iran, in 2020.
Methods
In this descriptive-analytical, cross-sectional study, the
study population comprised all dental students in the
field of clinical dentistry (semesters 6 to 12) at Birjand
University of Medical Sciences in 2020. The inclusion
criterion was signing the written consent forms. The exclusion
criteria consisted of being a guest or transfer student
and not completing the study questionnaire. After
the study design was approved by the Research Council
and the Ethics Committee of Birjand University of Medical
Sciences (IR.BUMS.REC.1398.333), the study was
initiated in the university’s Dental School.
Students were first explained about the procedure and
objectives of the study and were informed that their participation
was voluntary. Also, they would complete the
Jefferson scale of empathy (health care provider’s ver-
A
Darmiani et al. Evaluation of Empathy and Related Factors. Health Spiritual Med Ethics J. 2021; 8(3):155-162
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September 2021. Volume 8. Number 3
sion) if they were willing to participate in the study. At
the beginning of the questionnaire, students were asked
about their demographic characteristics, such as gender
and the level of education of their parents.
The Jefferson scale of empathy contains 20 items
scored on a 4-point Likert scale. The maximum score
is 60, and the is 0. These scores are classified into completely
positive, negative, and completely negative attitudes.
This scale was assessed in 2015 by Karimi et al. in
Mashhad University of Medical Sciences, Mashhad City,
Iran, under the title “Surveying the factor structure and
reliability of the Persian version of the Jefferson scale
of physician empathy-health care provider student version”.
The Persian version was also standardized [24].
The collected data were analyzed in SPSS v. 18, and
the results were reported as mean, standard deviation,
and relative frequency distribution. The Kolmogorov-
Smirnov test was used to confirm the normal data distribution.
The independent t test and 1-way analysis of
variance were used to analyze the obtained data. The
significance level was set at α=0.05.
Results
This study included 78 dental students at Birjand University
of Medical Sciences, most of whom were female. Other
demographic characteristics are presented in Table 1.
Based on the students’ responses, the majority (n=44;
56.4%) had not passed the communication skills course.
Computation of the empathy score revealed an Mean±SD
score of 40.83±5.57 on the Jefferson scale of empathy.
The mean score of empathy in terms of gender was assessed
using the independent t test. It was found that female
students (41.93±5.39) had a significantly higher empathy
than their male counterparts (39.33±5.54) (P=0.04).
The results showed no significant relationship between
the mean empathy score and students’ academic semester
(P=0.06). But, there was also a significant association
between the mean empathy score and students’ interest
in their field (P=0.03); those who were more interested
in the field, obtained higher mean scores. The post hoc
test results showed a statistically significance in low and
moderate interest in the field of study (P=0.49). The mean
scores of empathy were not significantly different between
single and married students (P=0.95). Also, there
Table 1. Demographic characteristics of participating students
Variables Status No. (%)
Gender
Male 33(42.3)
Female 45(57.7)
Semester
6 19(24.4)
8 24(30.8)
10 22(28.2)
12 13(16.7)
Marital status
Single 65(83.3)
Married 13(16.7)
Father’s education level
High school diploma or lower 15(19.2)
Associate or bachelor’s 42(53.8)
Master’s or higher 21(26.9)
Mother’s education level
High school diploma or lower 27(34.6)
Associate or bachelor’s 35(44.9)
Master’s or higher 16(20.5)
Darmiani et al. Evaluation of Empathy and Related Factors. Health Spiritual Med Ethics J. 2021; 8(3):155-162
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was no significant difference in the mean score of empathy
in students who passed or did not pass the communication
skills course (P=0.16). There was no significant
difference between the mean score of students’ empathy
and the education level of students’ parents (Table 2).
Discussion
One of the most critical components of communication
between a dentist and a patient is the ability to create
an understanding to demonstrate clinical empathy. Empathy
is a characteristic of a dentist and depends upon
his/her innate ability to understand the patient’s feelings.
It plays many essential functions in the dentist-patient
relationship. Focusing on the patient, listening to the patient’s
medical and dental history, and understanding the
patient’s emotions are some of these functions that significantly
affect the patient’s treatment process [13, 25,
26]. Therefore, given the importance of this issue, this
study aimed to investigate the degree of empathy and
related factors in dental students of Birjand University of
Medical Sciences in 2020.
In this study, the average score of Jefferson’s empathy
for female students was significantly higher than that of
the male students. Generally, women have stronger emotional
feelings than men, and their emotions are aroused
earlier, helping them communicate with people faster
and with better quality. The results of this study were
consistent with studies conducted by Shahab et al. [27],
Hojjat et al. [28], Archer et al. [29], Mirani et al. [30], and
Sadeghiyeh et al. [31]. However, Kazemipoor et al. [32],
Ameh et al. [33], and ALaee et al. [34] reported that the
mean score of empathy was not significantly associated
with gender. Among the reasons for this discrepancy are
differences in study populations and the type of instruments
employed in the study. In our study, only general
dental students participated, while other studies recruited
general medicine and specialized dental students or dentists,
where the participants were different in age.
Table 2. Comparing the mean empathy scores of students as per variables
Parameters Status Mean±SD P
Semester
6 42.73±5.68
0.06
8 40.87±5.25
10 38.36±5.42
12 42.15±5.28
Degree of interest in the field of study
Low 38.62±3.37
Moderate 39.58±5.36 0.03
High 42.67±5.76
Marital status
Single 40.81±5.51
0.95
Married 40.92±6.11
Clinical communication skills course
passed or not
Yes 39.82±5.81
0.16
No 41.61±5.32
Father’s education level
High school diploma or lower 40.80±6.29
Associate or bachelor’s 40.64±5.71 0.92
Master’s or higher 41.23±4.98
Mother’s education level
High school diploma or lower 39.81±4.82
Associate or bachelor’s 40.45±5.68 0.11
Master’s or higher 43.37±6.07
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In this study, there was no significant association between
the mean score of empathy of the students and
their academic semester. Similarly, the results of Kazemipoor
et al. [32] and Ameh et al.’s studies [33] indicate
that the mean score of students’ empathy was not significantly
associated with their academic semester.
Shariat et al. [35], Shahab et al. [27], Hashemipour et
al. [36], La Monica et al. [37], Chen et al. [11], Mirani
et al. [30], and Archer et al. [29] found a significant relationship
between the mean score of empathy of dental
students and their academic semester, which does not
correspond with our findings. One of the reasons for this
discrepancy is that moral characteristics, such as empathy,
require a long time to form. It is likely that this trait
was influenced by the student’s family and community
environment before the study period and that the study
period was less effective.
There was no significant correlation between the marital
status of students and the average score of empathy
of students participating in the study. Likewise, in the
studies of Kazemipoor et al. [32] and Shariat et al. [35],
there was no significant relationship between the average
score of students’ empathy and marital status. In Shahab
et al.’s study [27], there was a significant relationship
between the average score of empathy and marital status
of students, such that the average score of empathy
in married students was significantly higher than that of
single students. This finding fails to correspond with our
results. One reason for this discrepancy is the difference
in the human samples recruited in the two studies.
In Kazemipoor et al.’s study [32], the mean score of
empathy of students who passed the communication
skills course was significantly higher than students who
did not pass, which does not correspond with our results.
One of the reasons for this discrepancy is that in Kazemipour
et al.’s study, junior and senior students of dentistry
constituted 80% of the participants, while in our study,
only 45% of students were in the last two years of the
dentistry program. It can also be noted that although
some effects and training play an essential role in increasing
empathy, these effects are short-lived [26, 38].
In this study, the students who were more interested in
the field had obtained higher mean scores. According to
Esagian et al.’s study [39], clinical interest resulted in
a better understanding of the patient’s mental state and
greater empathy. Finally, despite the limitations of this
study, it is suggested that the students choose their field
based on their interests.
Conclusion
According to the study results, the average scores of
empathy of female students and students who were very
interested in their field showed a significant difference
from those of male students and students who were less
interested in their field of study. However, no significant
relationship was found between the average score of empathy
and the variables of marital status, academic semester,
and the education level of students’ parents.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Council and the
Ethics Committee of Birjand University of Medical Sciences
(IR.BUMS.REC.1398.333).
Funding
The paper was extracted from the thesis PhD dissertation
of the second author, Department of Endodontics of
Dental Faculty of Birjand University of Medical Sciences.
Authors' contributions
Conceptualization and supervision: Soheila Darmiani
and Reza Dastjerdi; Methodology: Mahbubeh Haghi
Rudi; Investigation, Writing – original draft, and Writing
– review & editing: All authors; Data collection: Mahbubeh
Haghi Rudi ; Data analysis: Hamid Salehinia.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors would like to thank the Dental School of
Birjand University of Medical Sciences, who participated
in this study.
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