INTRODUCTION

There is agreement among researchers that two components participate in the architecture of empathy: the cognitive and the emotional one.^1-6 Empathy is a complex dynamic relationship ^6,9 between these components, and it is a product of the interaction of neural structures through connective systems¹⁰. The neural complexity of empathy, and the interaction between its components, substantiate the possibility of concretization of intersubjectivity between the dental professional and the patient^1-7. As a result, attitudes between the professionals and patients and vice versa are generated; those attitudes produce positive effects on the patient care process.^1-6

The development of empathy in dental students is problematic in Latin America. One of these problems is the existence of variability in the distribution of empathy across the courses (empathic declination), and also between the sexes.¹¹ The presence of at least five different forms of the distribution of the means of empathy levels across the courses has been observed, and not all of them reflect the classic empathic decline.^1-9Such findings extend to the dimensions of Empathy (Compassionate Care, Perspective Talking or Perspective Adoption, and "Walking in Patient's Shoes").^3,7,11 These results constitute empirical evidence that the classical process of decline is not universal, and that the causes that determine empathic erosion do not operate in the same way in different populations of dental students.^3,7,11 This also happens with the average values of empathy (and its dimensions) between the sexes^8,11,13, and such empirical evidence contradicts the "premise" that women are necessarily more empathetic than men, at least in Latin America.^1-9,11,13 The presence of variability of the empathic response implies that the processes of empathic intervention depend more on the singular and particular processes^1-9 that occur within each university (including each faculty and career), the culture of the country, and, in general, the effects of the ontogeny process to which the students have been exposed.¹² As a consequence, an "empathy diagnosis" is necessary before applying intervention. The concrete and specific findings presented by said diagnosis constitute the compass that allows a serious and responsible intervention to be built.^9,13,14 However, such diagnoses are not considered within the parameters to be evaluated in the accreditation processes at universities in Latin America, and even less within the natural actions derived from the diagnosis. Therefore, the responsibility that universities have regarding the development of empathy is not subject to scrutiny in the accreditation processes. This situation must have an undesirable effect in the development of empathy.

Under the previously described conditions, it will be interesting to determine if there is an increase in the empathy of the dental student from the application of a well-constructed curriculum aimed at the professional improvement of the student. If this were to happen, the certification of accreditations in universities would have, as a side effect, an increase in empathy in students. Consequently, the objective of this study is to compare the levels of empathy assessed in two different years at a university subjected to continuous and successful accreditation processes in 2017 and 2022.

MATERIAL AND METHODS

RESULTS

Descriptive analysis: The first measurement of Empathy (2016)² was made up of a sample of 148 (n) students out of a total of 240 (N) (61.67% of the studied population), between the first and fifth year of the degree. In relation to sex, the sample was made up as follows: male =43 (29.05%), and female =105 (70.94%). In relation to age (in years), it turned out to have a mean=20.54; standard deviation=2.06.² The second measurement (2022) was made up of a sample of 397 (n) students, out of a total of 462 (N) (85.93% of the studied population), between the first and seventh level. Regarding sex, the composition of the sample was as follows: female=293 (73.8%) and male=104 (26.20%). The age (in years) turned out to have a mean=21.49; standard deviation=2.79.

Table 1 shows that all items have asymmetry (As) and kurtosis (Ku) values within the expected limits (As < ±2; Ku < ±7).³⁰

In table 2, the results of the mean and standard deviation of the levels of E, CC, PT or PA, and WIPS in the Y, C, S factors, and the combinations of the levels of these factors are presented.

Reliability: The dimensions of the empathy scale have adequate reliability indices: PT or PA (α=0.89; ω =0.89), CC (α =0.79; ω =0.79), and WIPS (α =0.68; ω =0.68). Similarly, in the sample of women, all three dimensions have acceptable reliability indices: PA (α =0.89; ω =0.89), CC (α =0.77; ω =0.77), and WIPS (α =0.64; ω =0.64). In the sample of males, the three dimensions also present adequate adjustment indices: PA (a=0.89; ω =0.89), CC (α =0.83; ω =0.83), and WIPS (α =0.74; ω =0.75). Validity based on the internal structure: It was evident that the original model of three related factors presents adequate adjustment indices (x² = 329.87; df = 167; p <.01; IFC = .92; TLI = .91; RMSEA = .056 [90 % CI.047 - .064]; SRMR = .057). In addition, in figure 1, that the factor weight of most of the items was adequate.

Figure 1 Confirmatory Factor Analysis of the Scale 

It is, also, clear that the dimensions are related to each other. Factorial Invariance: In table 3 it is observed that the factorial structure of the scale has shown evidence of being strictly invariant for the groups of men and women in the sequence of proposed invariance models: metric invariance (ΔCFI = -.001; ΔRMSEA = -.002), scalar (ΔCFI = -.010; ΔRMSEA = .002) and strict (ΔCFI = -.003; ΔRMSEA = -.001).

Comparative analysis: The results of comparing the dependent variables between the levels of the factors examined are shown in table 4.

The values of the means of e, between both measurements, was not significant (figure 2a), but differences were observed between the two measurements made in relation to the distribution of the means of empathy between c (figure 2a). In cc, differences were found between the years of both measurements (y) and between the courses (c) (figure 2b). In PA no differences were observed between the means (figure 2c) and in WIPS (figure 2d), there were only differences in the S factor.

Figure 2 Results of the distribution of the course averages according to the two years under study 

The comparison between the interactions of the levels of the dependent variables (factors) were not considered because most of them were not significant (p>.05), or they were significant (p<.05) but with very low effect size values (<0.01). In general, the effect size was low in empathy and its dimensions and the power of the test was, in general, high or medium. The coefficient of determination, in empathy, was found to be of 13.6%, which means that the factors explain little of its variation. This same coefficient, estimated in the dimensions of empathy, was lower than that of empathy; therefore, it explains little of the variance of the data in these dimensions.

DISCUSSION

The general characteristics of the two measurements carried out (2016 and 2022) differ in the size of the sample studied and the number of assessed courses; however, they are similar in terms of sex ratio and age. The asymmetry and kurtosis values of the items of both measurements are similar to each other and allow for the comparison of both samples on the basis of these characteristics. The observed results of the internal reliability of the data, allowed to guarantee the degree of stability (consistency of the responses) and it is evidence that the items are measuring the empathy between the student and the patient.³² The results of the validity of the construct in the 2022 sample guaranteed that the model of empathy is constituted by three dimensions, and these are correlated with each other. In addition, the fact that the invariance of the model has been demonstrated makes it possible to guarantee that comparisons between the groups lead to reliable results. The same results are also presented in the 2016 sample.²,¹⁷ In general, the values of the kurtosis and asymmetry of the data, the internal reliability, the validity of the model based on the three-dimensional structure, and the presence of invariance between the sexes constitute a robust and necessary methodological basis that allows for the comparison of the two measurements tested in this work. This procedure could be useful for conducting comparative studies of empathy, whether these are within the same population or among populations of students of the same specialty or different specialties.^3,7,17,^32-35

The fact that the statistical procedure has found that the three dimensions of empathy are related to each other reflects a complex neurobiological phenomenon. In fact, several authors^2,3,8 have argued that the study of the dimensions of empathy separately constitutes an admitted and necessary research approach, from the methodological point of view. However, the fact that empathy is an attribute whose concrete expression arises from the interaction between its dimensions cannot be disregarded. The CC dimension is associated with the limbic system, with the emotions of the subject, and its construction occurs from the early stages of the evolution of human beings (phylogeny).⁸ The PA dimension prevents emotional contagion from occurring, and, therefore, allows the subject to recognize that he differs from another person (from the sufferer, from the patient). The WIPS dimension consists of the property of actively observing a patient and penetrating into his thinking. Therefore, CC is associated with the emotional component, while PT and WIPS with the cognitive one, whose neuroanatomical substrate is located in the front part of the brain and appears subsequently to the limbic system on the evolutionary scale.^8,36 As a consequence, it could be inferred that there is no such thing as an "emotive empathy" and a "cognitive empathy". Empathy is the dialectical interaction (the synthesis) of all its dimensions actively working.^8,37 In extreme cases, when one of its dimensions "fails" (to one degree or another), then empathy, as a system, becomes unbalanced (empathic deficit), and, when the damage is severe, it can lead to psychopathies.^38,39

Considering the aforementioned, it is possible to infer that empathy is modulated by interactions of a different order: a) an internal one, determined by the interaction between its dimensions, and b) said interaction is also modulated by external factors (ontogeny) that condition the form of interaction of the emotional and cognitive components.^2,3,8,40-44 Essentially, empathy is the product of a strong association between exogenous and endogenous factors that are interacting, and whose dialectic consists of the active unity that occurs in the convergence between "close" (ontogeny) and "distant" (phylogeny) processes.^12,45 However, it is possible that the processes of ontogeny, at this time, have a greater influence on the modulation of empathy.^8,12 As a consequence, empathy is a complex attribute and this characteristic should be considered when considering the application of an empathic intervention.¹³

The observed categorization of the size of the effect and the power of the estimated test, in the significant comparisons, allow us to affirm that these differences exist, but they are small and that the probability of committing the Type II error is relatively low. On the other hand, the values found in the coefficients of determination of empathy (and their dimensions) allow us to infer that the factors studied are not the only ones that are influencing empathy (multifactorial modulation on empathy).

It was found that there were no differences in E, PA, and WIPS between the years (table 2); but there was a decrease in CC levels in 2022 compared to the 2016 measurement (table 2 and table 4). If the levels of Empathy are compared with the cut-off points established in dentistry students in Latin American countries¹⁷, it is observed that the Empathy of the examined students can be qualitatively classified in the middle level range [61-107], and, specifically, in 2016 they are placed in the 75th Percentile (P₇₅), and, in 2022, in the 50th Percentile (P50). The CC values, on the other hand, can be classified in the range of high levels [28-56] in both moments, and, specifically, 2016= P90 and 2002=P25. In PA, as happened with CC, it can be classified in the range of high levels [42-70]; specifically, 2016 and 2022= P50. Finally, in WIPS, the values can be classified at low levels [2-7]; specifically, 2016 and 2022= P95. The absence of differences found in sex in relation to Empathy and in the CC and PT dimensions allow for the inference that there were no substantial changes between the studied moments, despite the small difference found in the WIPS dimension in favor of women (table 2 and table 4). These classifications of the empathy scores, and their dimensions, from a quantitative perspective, allowed to appreciate that the CC values decreased in the measurement of the year 2022, but maintained their classification of high levels; the WIPS values maintained their classification of low levels and PA retained their respective values in the range of high values. These results allow to infer that the classification of the average levels of empathy, observed in the examined dental students, depend on the decrease of the values of CC (emotional dimension) and the low values of WIPS (cognitive dimension).

It should be expected that the parameters evaluated in successful accreditations will show a positive evolution (quantitative, and, especially, qualitative increases). However, despite the fact that the UEES accreditation process was successful in 2017 and 2022, dental students did not exceed the average levels of empathy that characterized them in both analyzed stages, and there was no qualitative change in empathy. The current institutional accreditation of universities in El Salvador does not include the requirement of empathic training of students, and the same happens in most universities in Latin America. The "parameter" empathy is not included in this process, despite the importance given to this attribute as an indispensable element in the training of dentists.^1-9,46-48 Nonetheless, universities have a social responsibility to provide correct professional and humanized training,⁴⁹ therefore, the introduction of the teaching-learning of empathy should be demanded and systematized in any accreditation process.

CONCLUSIONS

It was found that the levels of empathy were classified at the average level in both moments under study. The study allows us to say that possibly the systematic absence of teaching empathy could be a factor why this attribute has not increased. The introduction of the teaching-learning of empathy should be systematized and evaluated in the institutional accreditation processes at universities. The replication of this study in other Dental Schools in Latin America is recommended. The limitations of this study are related to the fact that the conclusions drawn cannot be mechanically extrapolated to other populations of dental students.