Investigación original

Colombian medical students' attitudes towards dissection during anatomy classes and their relationship with a score on the Jefferson Scale of Physician Empathy

Andrés Jagua Gualdrón¹, Diana Zulima Urrego Mendoza²

¹ MD. Médico Cirujano, Universidad Nacional de Colombia, Bogotá.
² MD. Especialista en Epidemiología. MSc. en Salud Pública, MSc en Medicina Alternativa Medicina Tradicional China y Acupuntura. Profesora Asociada, Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá.

Correspondencia: ajaguag@unal.edu.co.

Recibido: 17/06/10/ Enviado a pares: 22/08/11/ Aceptado publicación: 18/18/11/

Summary

Background. Anatomical dissection of human corpses is a fundamental tool when teaching anatomy, thereby leading to gaining theoretical and emotional knowledge and raising awareness regarding behaviour which could be important in building up the doctor-patient relationship.

Objective. Characterising undergraduate medical students' attitudes towards dissection and their relationship with a score on the Jefferson Scale of Physician Empathy (JSPE).

Materials and Methods. This was a cross-sectional study which used information collected from 5 medicine faculties in Bogotá (Colombia) during the second semester, 2010. The instrument included socio-demographic variables regarding attitudes towards dissection and the JSPE. Prevalence ratios and the pertinent 95% confidence intervals were calculated.

Results. 904 students were surveyed; their average age in years was 19.4 +/- 2.8 (51.8% were female and 48.2% male). Dissection evoked positive emotions which were related to a greater interest in learning. Average JSPE score was 113.34. Females obtained a significantly higher score (p=0.012). None of the prevalence ratios were significant.

Conclusion. Students' attitudes towards dissection were positive in this study and were not related to a score on the JSPE.

Keywords: dissection, medical education, undergraduate, attitude, empathy. (MeSH).

Introduction

Throughout history the practice of dissecting human cadavers has constituted a tool for acquiring the basic knowledge necessary for understanding the human body. Some researchers have highlighted the importance of such practice during the last few decades as it also contributes towards learning about teamwork, practical abilities and modulating future professionals' attitudes concerning pain and death (1,2). A professional's attitude towards death could condition how the doctorpatient relationship becomes constructed (3).

However, current difficulties regarding obtaining bodies and advances in technology have redefined this practice's role in education (4). The need to increase time spent on other areas of knowledge has meant that time spent on anatomy in medical study plans around the world has become reduced and thus practice in the amphitheatre (5,6). Dissection's historical role and the advantages described by some professor of anatomy have attracted the interest of researchers around the world who have tried to capture students' experience and their attitudes towards such practice (7).

An attitude may be understood as the organisation of a subject's beliefs regarding an object or situation positively or negatively predisposing him/her, having cognitive (knowledge), affective and behavioural components (8,9). An attitude could predispose a student towards studying determined aspects of a set curriculum; attitudes thus form an important component of professional formation (10).

Students' attitudes towards dissection regarding anatomy may determine their learning concepts and affect their path towards professionalisation. Students' positive attitudes towards dissecting human cadavers could be related to a representation of the body, life and death leading to a future professional assuming a more humane relationship with her/his future patients.

Dissection in the amphitheatre evokes agreeable feelings in medical students thereby allowing them to become familiarized with the human body (11). These practices awake interest and motivation towards acquiring new knowledge (7) and positively modulate attitudes and emotions regarding death (12-14).

Medical students may experience feelings of dislike regarding dissection, even though to a lesser extent compared to related degree courses (12,15). Students develop methods of adaptation such as studying more or seeking advice from teachers to make good use of these practices (12,14).

Managing emotions and learning from relationships with others is necessary for establishing empathy (the ability to feel what someone else is feeling) and forming part of the doctor-patient relationship's co-executive and compassionate phases (16-19). Empathy as an attitude present in the doctor-patient relationship leads to gaining an individual"s confidence; on the contrary, a negative attitude (dyspathic reaction) has harmful effects on constructing such relationship (20,21).

Even though there is no solid evidence, some authors have highlighted this practice"s transcendence for the relationship with patients and reduced error regarding medical tension (12,22,23).

Few studies have explored medical students' attitudes towards practice in the amphitheatre or medical empathy or explored a relationship between both variables. This study was aimed at characterizing medical students' attitudes towards anatomical dissection using human cadavers, exploring their perception regarding this practice, a score on the Jefferson Scale of Physician Empathy (JSPE) and exploring the relationship between both.

Materials and methods

A cross-sectional observational study was made from August to October 2010, information being collected by using a questionnaire.

Study population. The study population consisted of medical students from five universities in Bogotá, Colombia (Universidad Nacional de Colombia, Universidad del Rosario, Universidad de Ciencias Aplicadas y Ambientales-UDCA, Universidad Militar Nueva Granada, Fundación Universitaria de Ciencias de la Salud-FUCS). Convenience sampling was used and included medical students from the following semesters: second (who had not yet taken anatomy), third (taking anatomy), sixth (beginning clinical rotations) and tenth (finishing clinical rotations). The sample's possible universe consisted of medical students from the five faculties included in the study (around 5,400 students). All students of both sexes who showed their willingness to participate in the study were taken into account.

Study instrument and variables. The instrument used for collecting information was divided into three parts: one was used for collecting basic demographic information, another was used for asking about attitudes to dissection and a third part gave the JSPE which had been previously validated in Spanish (24).

The instrument was used in a pilot test with students who were not included in the study for evaluating consistency and stability regarding information capture. The instrument used is shown in ppendix 1. The information was collected by the main researcher before the start of taught sessions.

Gender, age, university, socioeconomic strata, number of anatomy courses taken, number of practical sessions in the amphitheatre, quality of the cadavers in the amphitheatre, emotional preparation for amphitheatre practice, relationship of emotions with dissection, having been close to a corpse, perception of the concept of a cadaver, feeling of discomfort in the amphitheatre, cause of unpleasant feelings in the amphitheatre, methods of adapting to the perceived discomfort, rating of accompanying teacher, relationship of practice to professional profile and JSPE score were taken as study variables.

Ethical considerations. The research project protocol was revised and approved by the Universidad Nacional de Colombia's Faculty of Medicine's Medical Ethics Committee. The project's implications and objectives were explained to the students before applying the instrument and verbal informed consent was taken; participants" anonymity was guaranteed.

Statistical analysis. Incomplete questionnaires (lacking 50% or more to be completed) were discarded from the analysis (3 questionnaires). Descriptive statistics were used. Prevalence was calculated for each variable and prevalence ratios were used; 95% confidence intervals were calculated for prevalence ratios and a p value less than 0.05 was considered significant. SPSS software (version 17.0 for Windows) was used for statistical analysis.

Results

A total of 907 students from five faculties of medicine in Bogotá were surveyed. Three questionnaires were discarded, leaving 904 to be analysed; these had been filled in by 163 first semester students (95 from university 2, 68 from university 4), 256 second semester (137 from university 1, 85 from university 3 and 34 from university 5), 258 third semester (67 from University 1:university 1, 65 from university 2, 77 from university 3 and 49 from university 4), 30 fourth semester (university 1), 55 sixth semester (university 1), 49 seventh (university 3) and 93 tenth semester students (59 from university 1, 34 from university 3). 51.8% of those surveyed were female and 48.2% male; the male: female ratio was 0.9 and average age was 19.5 years +/- 2.87. Table 1 gives the students' basic characteristics.

Only 18.9% of the students who were taking or had passed their practice in the amphitheatre rated the quality of the cadavers as being good or very good, 24.7% as regular and 43.6% as poor or very poor. Analysis by university showed that university 4 rated the cadavers' quality as being higher compared to the other universities (p=0.000); more students from university 1 rated cadaver quality as poor or very poor (p=0.000).

92.4% of the students stated that they felt or were emotionally prepared for practice in the amphitheatre. No statistically significant differences were found when comparing the universities nor were differences found regarding gender, age or semester.

Characterising attitudes towards dissection in the amphitheatre

Students' amphitheatre practice evoked positive feelings in most students: curiosity (84.7%) and anxiety (23.3%). More females stated experiencing dizziness and fainting (p=0.001). No statistically significant differences were found when comparing universities. Figure 1 shows relative frequency regarding feelings about dissection.

80.1% of those surveyed thought that a cadaver for study during practice in the amphitheatre was a subject which was alive, not an inanimate object (19.9%); a significantly higher number of males considered a cadaver to be an inanimate object (p=0.000). No differences were found regarding age, semester or university.

Amphitheatre practice was the first moment for contact with the dead for 24% of the students. For those who had been close to a dead body, 34.8% had been in contact with a dead family member, 33.1% with a stranger, 6.8% a known person and 1.3% a friend.

Amphitheatre practice did not induce unpleasant feelings in 68.7% of the students, it produced very few unpleasant feelings in 17.4%, some unpleasant feelings in 13.2% and considerable unpleasant feelings in 0.8% of them. Smell was the most frequent cause of unpleasant feelings (73.2%) followed by seeing the cadaver's face (13.2%), fear of becoming infected (7.0%) and fear of touching some parts of the body (3.5%). No significant differences were found regarding gender, age, strata, semester or university. Students stated that they did nothing (44.6%), studied more (20.2%), sought group support (15.6%), attended tutorials (10.6%) and listened to music (9%) as strategies for controlling unpleasant feelings.

Thoughts and ideas about death. 22.4% of the students had never had thoughts about life and death during their practices in the amphitheatre and 32.1% stated that they occasionally had such thoughts; females were more prone to having such thoughts than males (p=0.001). There were no significant differences by university.

89.2% of the students stated that they had never felt a loss of control in the amphitheatre, 9.5% stated feeling this very rarely and just 0.6% frequently felt this. Only 1% of the students felt that amphitheatre practice disturbed their concentration and this happened frequently in 38.8% of them.

Teacher accompaniment and relationship with medical studies. Teacher accompaniment in the amphitheatre was good or very good for 57.2% of the students; the categories were a reflection of students' perception regarding the accompaniment being offered by the teacher in the amphitheatre. A poor rating could have been related to worse performance during practice; 33.9% considered it to be regular and 8.7% poor or very poor. Males were more prone to rate accompaniment as being poor (p=0.043). Teacher accompaniment also varied by university; more students from university 2 rated teacher accompaniment as very good compared to other universities (p=0.000) whilst more students from university 1 rated accompaniment as regular than in other universities (p=0.000).

The questionnaire was also used for asking about students' perception of amphitheatre practice's relationship to medicine courses' professional profile; 92.9% stated that there was such relationship whilst only 0.2% (2 students) denied such relationship. No differences were reported regarding gender, age or university.

Medical empathy scale. The JSPE has scores ranging from 20 to 140; the greater the score, the greater degree of empathy. The students' scores in this study ranged from 53 to 140 (113.34 average; +/- 14.687). Regarding prevalence, 58.6% of the students obtained a higher average score (115 mean). The greatest JSPE score frequency density occurred between 100 and 125. Extreme values (53 and 140) had lower percentages.

Average score and pertinent confidence intervals were compared, grouping the sample by gender and university. The average score obtained by females was significantly greater (p=0.012) than that for males. There was a significant difference in the average score obtained by some universities; the average for students in university 2 was greater than that for universities 1 and 3 and universities 1 and 4 had higher averages than university 3. Other comparisons between universities and by ages were not significant. Figure 2 shows the comparison between the averages obtained by the universities in question.

Exploratory bivariate analysis. An exploratory analysis was made of the probable relationships between the variables of interest by calculating prevalence ratios for exploring the relationship between attitudes towards amphitheatre practice and JSPE score.

Prevalence was calculated for the variables included in the instrument. Prevalence ratios were constructed from them; no prevalence ratio calculated was statistically significant. Tables 2 and 3 summarise the prevalence ratios calculated and their confidence intervals.

Discussion

The attitudes of students from five medical faculties in Bogotá towards dissection in the amphitheatre were characterised by this study; medical empathy was measured by applying a validated medical empathy test (i.e. the JSPE) and exploring the relationships between them.

Gender distribution and male/female ratio was similar and did not differ significantly from that reported previously. A tendency towards feminisation of medical studies reported in these studies was found in all private universities included in the study was greater than the norm (i.e., an increase in females studying medicine was not observed) (25).

A significant difference in the number of sessions in the amphitheatre was found (between university 2 and others); this could have been due to variations in the curriculum in each university included in the study. The poor quality of the amphitheatre cadavers reported by close to half the students could have had important implications for students" learning and shaping their attitudes towards anatomy. Even though not included in the questionnaire, several students wrote about the lack of motivation created by seeing cadavers in a poor state in the margin of the sheet. Emotional management and the representation of death (two abilities which students begin to acquire during amphitheatre practice) could also have been negatively affected cadaver quality. Future studies could explore such impact on learning and academic performance.

Most students stated that they felt emotionally prepared for the practices. These results agreed with previous studies where similar results were obtained (26,27). Suitable emotional preparation for amphitheatre practice prepares the way for good learning.

Most medical students (more than 80%) had positive thoughts about practice in the amphitheatre; more than this being an imposition or motive for inducing stress, these represent a valuable study tool for students, motivating them to learn about anatomy. This study's results coincide with a previous one involving Spanish students characterising students' attitudes towards dissection (12). The students' good attitude could be exploited for optimising learning about anatomy.

Being with a cadaver is the first scenario for confronting the reality of life for medical students and instils a sense of responsibility in them regarding caring for human beings. More than two-thirds of the students assumed that a cadaver's human nature meant that it was an individual who had had a history of a life to tell (more than just being an object); such representation of a cadaver constituted a first step in adopting a human approach to patients. The amphitheatre could become a scenario for discussing the nature of life and how to confront death in everyday life.

Many students stated that amphitheatre practice did not create unpleasant feelings; only 14% of practice in the amphitheatre produced unpleasant feelings. These results were better than those reported in other studies (28,29) and similar to those in a study involving Jordanian students (26). The few unpleasant feelings produced by practice could lead to improving a student's performance during practice.

Smell as a cause of unpleasant feelings in the amphitheatre (73.2%) was higher than that reported previously (58.5% (26), 8% (29) and 3.65%) (30). Other causes of unpleasant feelings such as seeing a cadaver"s face, fear of becoming infected or touching some parts of a dead body were presented with similar frequency to that reported previously (26). The unpleasant feelings produced by amphitheatre practice could have negative effects on performance during amphitheatre sessions and professional training. A disagreeable experience in the amphitheatre could cause alterations in ethical development (7); if a student is insensitive or has not adequately explored the emotions which arise when confronting the idea of death then this could alter how students learn how to approach patients (30).

The results of the present study showed that if students had thoughts about life and death then only a third of them had them frequently and an impact making it impossible to concentrate only occurred in 1% of them. These results suggest that the amphitheatre offers a space for reflection about death which does not alter how practice develops (at least regarding concentration).

Amphitheatre practice is the first space in medical studies for confronting the reality of death. This moment may be exploited for beginning to educate and raise student awareness about the topic; future studies could go deeper into this aspect. Another study characterised medical students' attitudes and knowledge about curriculum subjects; it was found that students considered that anatomy is an essential subject in their professional training and that anatomical dissection of human cadavers in the amphitheatre is a pedagogical strategy arousing interest in students (31).

Rating teacher accompaniment revealed that a low percentage of students (8.7%) perceived this negatively. Good teacher accompaniment during practice could mean optimum learning and a more human approach to everything implied by dissection in the amphitheatre (acquiring knowledge, attitudes and skills). Teachers share experience and knowledge with students from their own store of professional experience so that they can see the importance of anatomy for professional practice and the values learned through practice, such as managing feelings and ethics.

Even though this was not evaluated in the present study, similar studies have shown the importance of good teacher-student interaction in the amphitheatre. Some experience at sites where students interact with teachers and residents from medical-surgical specialties during amphitheatre practice have shown that student perception has improved. A study could be designed for evaluating such measures' impact on learning (7). Amphitheatre practice was perceived by almost all students (92.9%) as having a positive relationship with professional profile; this result agreed with already-mentioned observations forming students' positive attitudes.

This study also explored JSPE. Previous reports have shown that the score obtained on a medical empathy test may become reduced with the passing of years spent in medical school (32) due to factors such as stress, excessive workload and increased time spent on the medical studies (33,34). Medical empathy is a complex construction including aspects of an individual's personal life with professional training and other individuals' experience.

The average scores obtained by students showed significant differences by university. This could be explained by the different styles of teaching adopted by each faculty; the difference could also have been due to differences in the profile of students entering a school of medicine motivated by the professional profile offered by each university. Analysing the replies by semester showed that the average score obtained by first semester students was greater when compared to third, sixth being greater than third and sixth being greater than tenth. Bearing in mind the context in which these semesters happen, then these results agreed with lower average JSPE scores being recorded in semesters where topic content required more time to be spent on studying. Excessive workload could thus reduce the quality of attention paid to patients. Studies should be carried out to measure this in students, doctors, residents and specialists.

Average score obtained by females was significantly greater than that for males; this observation was similar to that reported in a sample of Mexican students (24). The average total obtained in the present study was significantly higher than that reported in Mexican (24) and Japanese students (35) and similar to that obtained in the USA (34). Cultural differences could have affected empathy scores; qualitative studies could go deeper into this topic and help in constructing medical empathy tests and ways of measuring empathy. Cultural background could also provide an explanation for the differences obtained between males and females, as social norms often impose repressing feelings on males and placing less importance on them.

None of the prevalence ratios calculated for exploring the relationship between JSPE scores were significant. There were no previous theoretical referents for comparing the results. One explanation could have been that attitudes modulated medical empathy in a much more complex way, for example, by indirectly exposing students to the topic of death or modulating control over their emotions.

No relationship between attitudes about dissection and JSPE score was found in this study.

This cross-sectional study had some limitations. The way the information was collected made it susceptible to bias regarding remembrance, especially when students from the last semesters were surveyed; nevertheless, more than half of the instrument used did not involve questions about topics requiring memory to answer them. Another limitation concerned the medical empathy test used. The JSPE is a recognised scale; however, there is still no consensus concerning its use and the available evidence does not allow discerning which of the available scales is superior to the others (36).

Future studies should explore the factors related to JSPE score and characterise its evolution. Attitudes about dissection should also be dealt with in more depth, as should how they can affect learning about anatomy and acquiring the values and attitudes necessary for professional performance.

Financing

This study was financed by the Universidad Nacional de Colombia's Bogotá Research Division and the Universidad Nacional de Colombia's Faculty of Medicine.

References

1. Gustavson N. The effect of human dissection on firstyear students and implications for the doctor-patient relationship. J Med Educ. 1988; 63:62-4.

2. Heyns M. A strategy towards proffesionalism in the dissecting room. European Journal of Anatomy. 2007; 11 (Suppl 1):85-9.

3. Vera-Delgado A. Humanismo y medicina, y algunas reflexiones pertinentes. Rev Col Cardiol. 2004; 11: 270- 76.

4. McLachlan JC, Bligh J, Bradley P, Searle J. Teaching anatomy without cadavers. Medical Education. 2004; 8:418-24.

5. Sugand K, Abrahams P, Khurana A. The anatomy of anatomy: a review for its modernization. Anat Sci Educ. 2010; 3:83-93.

6. Granger NA. Dissection laboratory is vital to medical gross anatomy education. Anat Record. 2004; 281B: 6-8.

7. Mukhtar Y, Mukhtar S, Chadwick SJ. Lot at sea: anatomy teaching at undergraduate and postgraduate levels. Medical Education. 2009; 43:1078-9.

8. Lancheros LML, Manrique M, Mendivelso M. Conceptos básicos acerca de las pruebas de actitud. Avances en Medición. 2007; 5:163-77.

9. Escalante-Angulo C. Medición de actitudes. Bogota: Fondo nacional universitario. 1989. Página 13.

10. González-Maura V, González-Tirados RM. Competencias genéricas y formación profesional: un análisis desde la docencia universitaria. Revista Iberoamericana de Educación. 2008; 47:185-209.

11. Lempp HK. Perceptions of dissection by students in one medical school: beyond learning about anatomy. A qualitative study. Medical Education. 2005; 39:318-25.

12. Arráez-Aybar LA, Castaño-Collado G, Casado-Morales MI. Dissection as a modulator of emotional attitudes and reactions of future health professionals. Medical Education. 2008; 42:562-71.

13. Montemayor-Flores B. El significado de la práctica de la disección para los estudiantes de medicina. International journal of morphology. 2006; 24:575-80.

14. Pérez MM, Porta-Riba N, Ortíz-Sagrista JC, Martinez A, Götzens-García V. Anatomía humana: estudio de las reacciones de los estudiantes de primero de medicina ante la sala de disección. Educación médica. 2007; 10:105-13.

15. Meskell M, O'connor JE. Nursing student's perceptions on the use of anatomical prosections as an educational tool. European Journal of Anatomy. 2007; 11(Suppl 1):73-77.

16. Lain Entralgo P. La relación médico enfermo. Madrid: Revista de Occidente. 1964.

17. Rodriguez-Silva H. La relación médico-paciente. Rev Cubana Salud Pública 2006; 32. Consultada el 6 de mayo de 2010. Disponible desde URL http://bvs.sld.cu/revistas/spu/vol32_4_06/spu07406.htm.

18. González-Menéndez R. La relación médico-paciente y su significación profesional. Educ Med Sup 2003; 17 (4). Consultada el 28 de abril del 2010. Disponible desde URL: http://bvs.sld.cu/revistas/ems/vol/17_4_03/ems02403.htm.

19. Barbado-Alonso JA, Aizpiri-Diaz JJ, Cañones-Garzon PJ, Fernández-Camacho A, Goncalvez-Estella F, Rodriguez JJ, et al. Aspectos históricos antropológicos de la relación médico-paciente. Habilidades en salud mental. 2005; 70:31-6.

20. Salgueiro-Meneses ME. Entrevista médica. Rev Paceña Med Fam. 2003; 5:137-41.

21. 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 Pshychiatry. 2002; 159: 1563-9.

22. Cragno A, García Dieguez M. La seguridad del paciente, error médico y educación médica. Consultado el 22 de enero del 2010. Disponible desde URL http://www.errorenmedicina.anm.edu.ar. Academia Nacional de Medicina, Buenos Aires. 2009.

23. Lester H, Tritter J. Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error. Medical Education. 2001; 35:855-61.

24. Alcorta-Garza A, González-Guerrero JF, Tavitas-Herrera SE, Rodriguez-Lara FJ, Hojat M. Validación de la escala de empatía médica de Jefferson en estudiantes de medicina mexicanos. Salud Mental. 2005; 28:57-63.

25. Escobar-Gaviria RH. Estadísticas básicas pregrado y especialidades médico quirúrgicas 2006. Asociación Colombiana de Facultades de Medicina. Disponible desde URL http://www.ascofame.org.co/images/ascofame/documentos/educacin%20medica%20en%20colombia.pdf (consultada el 1 de noviembre del 2010).

26. Bataineh ZM, Hijazi TA, Hijleh MF. Attitudes and reactions of jordanian medical students to the dissecting room. Surg Radiol Anat. 2006; 26:416-21.

27. Abu-Hijleh MF, Hamdi NA, Moqattash ST, Harris PF, Heseltine GFD. Attitudes and reactions of arab medical students to the dissection room. Clin Anat. 1997; 10:272-8.

28. Finklestein P, Mathers L. Post-traumatic stress among medical students in the anatomy dissection laboratory. Clin Anat. 1990; 3:219-26.

29. Snelling J, Sahai A, Ellis H. Attitudes of medical and dental students to dissection. Clin Anat. 2003; 16:165-72.

30. Evans EJ, Fitzgibbon GH. The dissection room: reaction of first year medical students. Clin Anat. 1992; 5: 311-20.

31. Rodriguez-Ruiz HM, Urrego-Mendoza DZ, Jagua-Gualdrón A. Conocimientos, sentidos y actitudes en relación con la anatomía en estudiantes de segundo año de medicina. Universidad Nacional de Colombia. 2009. Rev Fac Med. 2010; 58:306-15.

32. Newton BW, Savidge MA, Barber L, Cleveland E, Clardy J, Beeman G, et ál. Diferences in medical students empathy. Academic Med. 2000; 75:1215.

33. Bellini LM, Baime M, Shea JA. Variation in mood and empathy during intership. JAMA. 2002; 287:3143-6.

34. Brazeau CML, Schroeder R, Rovi S, Boyd L. Relationships between medical student burnout, empathy, and professionalism climate. Acad Med. 2010; 85: S33-S36.

35. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. Measurement of empathy among japanese medical students: psychometrics and score differences by gender and level of medical education. Acad Med. 2009; 84:1192-7.

36. Hemmerdinger JM, Stoddart SDR, Lilford RJ. A systematic review of test of empathy in medicine. BMC Medical Education. 2007; 7:24.