EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

HOJAT ET AL.

THE JEFFERSON SCALE OF PHYSICIAN EMPATHY:

DEVELOPMENT AND PRELIMINARY PSYCHOMETRIC DATA

MOHAMMADREZA HOJAT, SALVATORE MANGIONE,

THOMAS J. NASCA, MITCHELL J. M. COHEN,
JOSEPH S. GONNELLA, JAMES B. ERDMANN,
AND JON VELOSKI
Jefferson Medical College

MIKE MAGEE
Pfizer, Inc.

The present study was designed to develop a brief instrument to measure empathy in
health care providers in patient care situations. Three groups participated in the study:
Group 1 consisted of 55 physicians, Group 2 was 41 internal medicine residents, and
Group 3 was composed of 193 third-year medical students. A 90-item preliminary ver-
sion of the Empathy scale was developed based on a review of the literature and distrib-
uted to Group 1 for feedback. After pilot testing, a revised and shortened 45-item version
of the instrument was distributed to Groups 2 and 3. A final version of the Jefferson Scale
of Physician Empathy containing 20 items based on statistical analyses was constructed.
Psychometric findings provided support for the construct validity, criterion-related
validity (convergent and discriminant), and internal consistency reliability (coefficient
alpha) of the scale scores.

The secret of the care of the patient is in caring for the patient.
—Francis W. Peabody (1927/1984)

The royal road to patient care is paved by understanding the patient

through verbal and nonverbal cues in physician-patient interpersonal
exchanges. A lack of understanding of a patient’s inner experiences can deter
the appropriate diagnosis and consequently hamper the treatment (Neuwirth,

This study was supported in part by a grant from the Pfizer Medical Humanities Initiative,
Pfizer, Inc., New York.
Educational and Psychological Measurement, Vol. 61 No. 2, April 2001 349-365
© 2001 Sage Publications, Inc.
349
350 EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

1997). This notion was elegantly described by Francis W. Peabody in his

landmark article “The Care of the Patient” that was originally published in
1927 and reprinted in 1984. Peabody proposed that “the practice of medicine
in its broadest sense includes the whole relationship of physician with his [or
her] patient” (p. 813).
The importance of factors other than pathophysiological in health and ill-
ness has been described in the biopsychosocial paradigm in medicine (Engel,
1990; Hojat, Samuel, & Thompson, 1995). Curing occurs when the science
of medicine (biomedical aspect of disease) and the art of medicine
(psychosocial aspect of illness) emerge as one discipline. The art of medi-
cine, according to Blumgart (1964, p. 449), consists of the skillful application
of the science of medicine to a particular person for the maintenance of health
and the amelioration of illness. Hence, the science of medicine in treating dis-
eases and the art of medicine in curing human illnesses are supplementary to
one another (Peabody, 1927/1984).
It has been argued that technological advancement in treating disease has
overshadowed the art of healing, which is rooted in establishing a trustful
relationship with the patient. Treatment of a pathophysiologic process may
require no communication, empathy, or compassion, but caring for the
patients in the context of their illnesses certainly needs a humanistic touch
(Novack, 1987; Novack, Epstein, & Paulsen, 1999). “Treatment of disease,”
according to Peabody (1927/1984), “may be entirely impersonal, but the care
of patient must be completely personal” (p. 814). Therefore, for a better clini-
cal outcome, health care professionals should be educated not only in the bio-
medical aspect of disease but also in the psychosocial factors of illness
(Spiro, 1992), considering that dialogue and understanding are indispensable
tools in clinical situations (Engel, 1990).
Health, according to the World Health Organization (WHO) Constitution
(1948), is defined as “a state of complete physical, mental, and social
well-being” (p. 1). This definition of health, coupled with the notion of
biopsychosocial paradigm of health and illness, suggests that the knowledge
and skills required for effective care include but extend the borderlines of
knowledge of the structure and function of the body’s organs. This notion
was confirmed by Sir William Osler, arguably the most influential medical
educator of modern medicine, who said that “it is as important to know what
kind of a man [sic] has the disease, as it is to know what kind of disease has the
man” (cited in White, 1991, p. 74).
An interpersonal relationship has been viewed as a fundamental modality
of existence (Barrett-Lennard, 1993, p. 11), and such a modality is important
in physician-patient encounters for better clinical outcomes. Although devel-
opment of interpersonal skills has long been considered an important aspect
of physician education, the analysis of the components of interpersonal rela-
tionships has not received sufficient empirical scrutiny. A meaningful inter-
 HOJAT ET AL. 351

personal relationship with the patient depends on understanding the patient’s

cognitive and affective states. Such an understanding not only improves the
diagnosis of the illness but also has therapeutic effects in patient care.

Empathy and Medicine

Two important components of a meaningful interpersonal relationship are

empathy and sympathy. These two distinct concepts are often mistakenly
thrown in one terminological basket. Empathy, according to Aring (1958), is
the act or capacity of appreciation of another person’s feelings without “join-
ing” them. Sympathy is the act or capacity of entering into or joining the feel-
ings of another person. A deep sympathetic feeling in medical care can some-
times interfere with objectivity in diagnosis and treatment (Aring, 1958;
Blumgart, 1964; Spiro, 1992). Empathy, on the other hand, is a cognitive
activity distinguishable from sympathy that is more of an affective response
to a patient’s misfortunes (Brock & Salinsky, 1993; Streit-Forest, 1982;
Wolf, 1980). In fact, the term compassionate detachment has been used to
describe the physician’s concern for the patient while being aware of his or
her own emotional separateness (Blumgart, 1964). Similarly, Jensen (1994)
suggested that “affective distance” may be necessary for personal durability
of physicians. In contrast, empathy is often considered as the backbone of a
meaningful physician-patient communication (Spiro, Curnen, Peschel, & St.
James, 1993) and, according to Bolognini (1997), is a complementary state
of separateness and sharing, which makes empathy, according to Jackson
(1992), a crucial element in healing.
Empathic medicine, according to Nadelson (1993), is ethical medicine. It
has been suggested that empathetic physicians fare better in professional and
familial interpersonal relationships (Guzzetta, 1976) and are more effective
in enhancing the patient’s sense of self (Zinn, 1993). Empathy has been
linked to dutifulness (Wolf, 1980), and it has been reported that training phy-
sicians in empathy improved their communication skills (Feighny, Monaco, &
Arnold, 1995). Cultivating empathy is considered among the important fac-
tors of liberal education of physicians (Fishbein, 1999).
Patients feel comfortable and important when their caregiver is empathic
(Colliver, Willis, Robbs, Cohen, & Swatz, 1998). According to Hogan
(1969), the personal attributes in describing high scorers on empathy were
pleasant, charming, friendly, cheerful, sociable, dreamy, sentimental, imagi-
native, discreet, and tactful. Attributes that described low scorers were cruel,
cold, quarrelsome, hostile, bitter, unemotional, unkind, hard hearted, argu-
mentative, and opinionated. Colliver et al. (1998) asked standardized patients
to indicate whether medical students examining them were empathic. Those
who were identified to be empathetic were more likely than others to put the
patient at ease, reassure them with appropriate touch, and to make sure that
the patient understood directions.
352 EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

The notion of empathy was first discussed in 1872 by Robert Vicher, a

German philosopher, in addressing an observer attributing feelings perceived
from works of art (Jackson, 1992). The term empathy is translated from
Einfuhlung, a German word literally meaning “feeling into” (Zinn, 1994),
which was used by the German psychologist Theodore Lipps in his discus-
sion of aesthetic experiences (Hunsdahl, 1967). Carl Rogers (1959) has
defined empathy as the ability “to perceive the internal frame of reference of
another with accuracy . . . as if one were the other person but without ever los-
ing the ‘as if’ condition” (p. 210).
In a medical context, empathy can be viewed as an uncritical understand-
ing of a patient’s inner feelings and experiences as a separate individual, as
opposed to “feeling with” the patient, which characterizes sympathy. There-
fore, it is important to note that empathy, as opposed to sympathy, is defined
as mostly a cognitive rather than an affective mental process (Nightingale,
Yarnold, & Greenberg, 1991). By observing physicians’ encounters with
their patients, Suchman, Markakis, Beckman, and Frankel (1997) suggested
that the basic empathic skills included recognizing when emotions may be
present but not directly expressed (nonverbal cues) and effectively acknowl-
edging these emotions so that the patient feels understood.
Despite the importance of empathy in a meaningful physician-patient
interpersonal relationship, there has been an absence of empirical investiga-
tion of the concept and its implications for patient care. One reason for this
lack of empirical scrutiny of empathy in medical education and medical care
is the absence of a research instrument (Evans, Stanley, & Burrows, 1993) to
operationally measure the concept in this setting, to empirically study its
development, and to investigate its variation and correlates in different stages
of medical education and among different groups of medical students and
physicians.
There are only a few instruments that measure empathy—among them are
the Interpersonal Reactivity Index (IRI) developed by Davis (1983), the
Empathy scale developed by Hogan (1969), and Emotional Empathy devel-
oped by Mehrabian and Epstein (1972). It is important to note that these
instruments have been developed for the general population, and none is spe-
cific to patient care situations. There is a need for a psychometrically sound
and easily administered instrument to measure empathy among health care
providers in relation to their patients. In particular, considering the growing
concern about the dehumanization of medical care, demonstration of empa-
thy in physicians’ interactions with patients is essential (Suchman et al.,
1997). It is therefore important and timely to develop an instrument to mea-
sure physician empathy supported by psychometric evidence.
The present study was designed to develop a psychometrically sound
instrument to measure empathy in health care professionals in specific
patient care situations.
 HOJAT ET AL. 353

Method

Participants

Three groups participated in the present study. Group 1 consisted of

55 physicians who were either faculty members at Jefferson Medical College
or directors of internal medicine residency programs at other postgraduate
institutions known personally by the investigators. Group 2 consisted of 41
residents in the internal medicine program at Thomas Jefferson University
Hospital and its affiliated institutions. Group 3 consisted of 193 third-year
students at Jefferson Medical College of Thomas Jefferson University.

Instruments

A preliminary version of the Empathy scale was developed based on a

review of literature that included 90 items answered on a 7-point Likert-type
scale ranging from 1 (strongly disagree) to 7 (strongly agree). The final ver-
sion of this instrument after preliminary psychometric analyses consisted of
20 items.
The following research instruments were also used to examine the validity
of scores on the aforementioned Empathy scale.

1. Empathetic Concern. Defined as being concerned about the feelings of

less fortunate people (Davis, 1983). This is one of the scales from the IRI
(Davis, 1983) consisting of six items answered on a 5-point scale ranging from
1 (does not apply to me) to 5 (describes me very well). A typical item is “I often
have tender, concerned feelings for people less fortunate than me [sic].”

2. Perspective Taking. Defined as a tendency to spontaneously adopt the

views of the other person. This scale contained seven items from the IRI
(Davis, 1983). A typical item is “When I am upset at someone I usually try to
put myself in his [or her] shoes for a while.”

3. Fantasy scale. Defined as tendencies to transpose oneself imaginatively

into the feelings of fictitious characters in books, movies, or plays. This is
also a scale from the IRI (Davis, 1983) containing six items. A typical item is
“After seeing a play or movie, I have felt as though I were one of the
characters.”

4. Warmth. A personality facet from the NEO PI-R containing eight items.
The NEO PI-R is a widely used personality inventory for measuring major
factors and facets of personality (Costa & McCrae, 1992). The NEO PI-R has
been used with samples of physicians in the United States. Physicians have
354 EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

been found to score higher than the general population of the United States on
the Warmth facet (Hojat et al., 1999). Also, female positive role models in
medicine scored higher than the general population on this personality facet
(Magee & Hojat, 1998).

5. Dutifulness. A personality facet from the NEO PI-R containing eight

items. Both male and female positive role models in medicine scored higher
than the general population on this facet of personality (Magee & Hojat,
1998).

6. Faith-in-People scale. This scale was developed by Rosenberg (1957,

1965) and contains five items measuring one’s degree of confidence in the
trustworthiness of people (Robinson, 1978). A typical item is “Most people
are inclined to help others.”

The following measures of personal attributes were obtained from Group 3

participants. All these concepts were defined on the instrument and were
answered on a 100-point scale. Respondents were asked to identify the extent
to which they currently have those personal attributes by placing a “P’ on the
scale and the extent to which they think it is desirable to have the defined
attribute as a physician by placing a “D” on the scale.

7. Personal attribute of empathy. Defined for the respondents as “standing

in the patients’ shoes in the experience of their illness.”

8. Global sympathy. Defined as “developing feelings for the patient’s

sufferings.”

9. Personal attribute of compassion. Defined for respondents as “sympa-

thy for the patient combined with the intention of doing good and desire to
help.”

10. Trust. Defined as “belief that patients report their illness experience
honestly.”

11. Tolerance. Defined as “the ability to evaluate a patient who shows

offensive and self-destructive behavior without becoming judgmental or los-
ing interest in helping.”

12. Personal growth (through patient interaction). Defined as “learning

and gaining reward through emotionally intense (either positive or negative)
interactions with patients.”
 HOJAT ET AL. 355

13. Communication (of the understanding). Defined as “the capacity to

reflect patient’s emotions by providing some statements which validate the
patient’s feelings.”

14. Self-Protection. Defined as “protecting one’s self from being over-

whelmed by patient’s emotions and/or suffering.”

15. Humor. Defined as the “ability to laugh with the patients about human
foibles and absurdities related to their illness and treatment, as well as to
appropriate jokes and lighter topics unrelated to illness.”

16. Clinical neutrality. Defined as “controlling expressions of emotional

reactions to patients, whether their reactions are positive or negative.”

Development of the Physician Empathy Scale

Preliminary Version

A literature review was conducted by using the MEDLINE database

(1966 to 1999) to identify concepts that would guide developing items for
inclusion in the preliminary version of the instrument. Using “empathy” as a
keyword resulted in 3,541 published sources in the English language.
Crossing the keyword “empathy” and “physician/physicians” resulted in
107 sources. A review of these and other relevant literature resulted in devel-
oping a preliminary version of a questionnaire that contained 90 items for
measuring empathy among health care providers. These items covered broad
areas, such as understanding subjective experiences of the patients and their
families; interpersonal relationships with patients; attention to signals in
interviewing patients; humor; attention to poetry and literature; absorption in
stories, plays, and movies; cognitive and affective sensitivity; emotional dis-
tance between physicians and patients; clinical neutrality; controlling physi-
cians’ emotions; sentiments; imagination; tactfulness; perspective taking;
role playing; and nonverbal communication.
In pilot testing of this preliminary version of the instrument, we employed
a variation of the Delphi method to obtain independent opinions of physi-
cians about the content of the instrument, its face validity, and clarity of the
text. The preliminary version was sent to 100 physicians in 1999. In a cover
letter, a brief description of the study was given, and the study purpose was
described as “to develop a psychometrically sound research instrument for
measuring physicians’ empathy.” Empathy was briefly defined in the cover
letter as “an uncritical understanding of the patient’s experiences, emotions
and feelings” as opposed to sympathy, defined as “feeling with the patient, or
feeling similar emotions that the patient feels.”
356 EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

Respondents were asked to cross out any item that they considered irrele-
vant to measuring empathy as defined. In addition, they were asked to edit the
remaining items for simplicity and clarity and add any new items that they felt
should have been included in a scale of physician’s empathy. Fifty-five physi-
cians responded by making editorial and conceptual comments, as well as
suggestions about revisions, additions, or deletions.

Modified Version

We excluded items from the preliminary version that were deleted by at

least 5 physicians in the pilot study. In addition, we incorporated appropriate
editorial suggestions in revising the instrument. The modified version of the
Empathy scale consisted of 45 items. This modified version, plus the IRI
scales, was completed by 41 resident physicians (Group 2 participants).
Also, the modified 45-item Sympathy scale and other research instruments
(IRI scales, personality facets of the NEO PI-R, Faith-in-People scale, and
Personal Attributes) were distributed to 223 medical students for
psychometric analysis; 193 responded (86%).

Final Version of the Physician Empathy Scale

To screen for the best conceptually relevant items for inclusion in the final
version of the Physician Empathy scale, we employed factor analysis by
using data collected on the 45-item Sympathy scale for medical students
(principal component factoring followed by varimax rotation). Based on the
results of factor analysis, 20 items with the highest factor structure coeffi-
cients (all above .40) on the grand factor were retained. The obtained
eigenvalue for the grand (first) factor was 10.64, with an eigenvalue 3.45 for
the second factor. A relatively large magnitude of eigenvalue for the first
extracted factor is indicative of the strength of this grand factor, and a signifi-
cant drop of the eigenvalues indicates minimal contribution of the other
factors.
The following conceptually relevant item was among those with the high-
est factor structure coefficient on grand factor: “Empathy is an important
therapeutic factor in medical treatment.” Because of insufficient sample size,
factor analysis was not performed on data for the residents, but the examina-
tions of the patterns of inter-item correlations for medical students and resi-
dents showed considerable similarities.

Scoring of the Physician Empathy Scale

Among the 20 retained items, 17 with positive factor structure coefficients

(and positive correlation with aforementioned item) were directly scored on a
 HOJAT ET AL. 357

scale ranging from 1 (strongly disagree) to 7 (strongly agree). The other

3 items that had large negative factor structure coefficients (and negative cor-
relations with aforementioned item) were reverse scored on a scale ranging
from 7 (strongly disagree) to 1 (strongly agree). An example of a directly
scored item is “A physician who is able to view things from another person’s
perspective can render better care,” and an example of a reverse-scored item
is “Emotion has no place in the treatment of medical illness.” A higher score
on the scale indicated greater empathy.

Results of Psychometric Analyses

of the Physician Empathy Scale

Construct Validity

To investigate the underlying structure of the Physician Empathy scale,

data for medical students were subjected to factor analysis using principal
component factoring method with orthogonal varimax rotation. Four factors
emerged, each with an eigenvalue greater than 1 (Kaiser, 1960), accounting
for 56% of the total variance. The magnitudes of eigenvalues were 7.56, 1.30,
1.14, and 1.01, respectively.
As it is shown in Table 1, half of the items (10 items) had factor coeffi-
cients greater than |.40| on Factor I (accounting for 38% of the variance).
Based on the contents of these items, the first factor can be called a construct
of “physician’s view from patient’s perspective.”
Five other items had a factor coefficient greater than |.40| on Factor II
(accounting for 7% of the variance). Also, two items with relatively high
coefficients on Factor I had a moderate correlation with the second factor.
This factor, based on the content of the items with high factor coefficients,
can be a construct involving “understanding patient’s experiences, feelings
and clues.” Only two items had factor coefficients greater than |.40| on Fac-
tor III (accounting for 6% of the variance), described as a factor of “ignoring
emotions in patient care.” Both of these items were reverse scored. Finally,
two items had factor coefficients greater than |.40| on Factor IV (accounting
for 5% of the variance), a bipolar factor that can be called “thinking like the
patient” as opposed to getting emotional in patient-physician relationships.
According to Velicer and Fava (1998), a minimum number of three items per
factor is required for a stable factor. Based on this criterion, Factors III and IV
may not be as stable as the first two factors. Also, a sudden drop in the magni-
tude of the prerotational eigenvalues after extracting the first factor suggests
that Factor I is the most reliable among the extracted factors. All the extracted
factors are consistent with the multifaceted concept of empathy (Spiro et al.,
1993).
358

Table 1
Rotated Factor Matrix of the Jefferson Scale of Physician Empathy

Factor
Item I II III IV
A physician who is able to view things from another person’s perspective can render better care. .82 .06 .14 .03
Physicians’ sense of humor contributes to a better clinical outcome. .74 .12 .08 –.10
Physicians’ understanding of their patients’ feelings and the feelings of their patients’ families is a positive treatment factor. .68 .44 .18 .08
For more effective treatment, physicians must be attentive to their patients’ personal experiences. .67 .32 .12 .10
Understanding body language is as important as verbal communication in physician-patient relationships. .64 .40 .06 –.9
Empathy is an important therapeutic factor in medical treatment. .63 .32 .16 .19
Patients feel better when their feelings are understood by their physicians. .58 .45 .11 .01
Physicians’ demonstration of understanding their patients’ emotions is an important factor in interviewing and history taking. .56 .33 .03 .08
Willingness to imagine oneself in another person’s place contributes to providing quality care. .56 .19 .39 –.08
Patients’ illness can be cured only by medical treatment; physicians’ affectional ties with their patients do not have a significant
place in this endeavor.a .47 .22 .32 –.31
What is going on in a patient’s mind can often be expressed by nonverbal cues such as facial expressions or body language that
must be carefully observed by physicians. .24 .71 .13 –.04
A patient who feels understood can experience a sense of validation that is therapeutic in its own right. .23 .67 .24 .01
One important component of the successful physician-patient relationship is the physician’s ability to understand the emotional
status of his or her patients and their families. .20 .63 .32 .06
It is as important to ask patients about what is happening in their lives as it is to ask about their physical complaints. .33 .59 .00 .07
It is acceptable for a physician to be touched by intense emotional relationships between patients and their families. .16 .48 .10 –.51
Reading nonmedical literature and enjoying the arts can enhance physicians’ ability to render better care. .28 .47 –.37 –.10
Because people are different, it is almost impossible for physicians to see things from their patients’ perspectives.a .17 –.13 .79 .04
Emotion has no place in the treatment of medical illness.a .33 .32 .54 –.24
Empathy is a therapeutic skill without which the physician’s success will be limited. .39 .28 .18 .04
The best way to take care of a patient is to think like a patient. .20 .19 .03 .82

Note. Items are listed based on the magnitude of rotated factor structure coefficients within each factor. Values greater than |.40| are in boldface.
a. Responses were reverse scored (1 = strongly agree, 7 = strongly disagree); otherwise, items were directly scored (7 = strongly agree, 1 = strongly disagree).
 HOJAT ET AL. 359

Descriptive Statistics and Reliability

Descriptive statistics were calculated for the 20-item Empathy scale.

Results for residents and medical students are reported in Table 2. As shown
in the table, there are considerable similarities between the 1st-year residents
and the 3rd-year medical students in measures of central tendencies (mean,
median, and mode) and measures of variability (range and standard devia-
tion). The alpha reliability estimate for residents was .87, and for students it
was .89; both coefficients are in an acceptable range for scores from psycho-
logical tests (American Educational Research Association, American Psy-
chological Association, & National Council on Measurement in Education,
1985).

Criterion-Related Validity

To examine the criterion-related validity of scores on the Physician Empa-

thy scale, the scores for residents and medical students were correlated with
the external criterion measures. Results are reported in Table 3.
As reported in the table, scores of the Empathic Concern scale of the IRI
correlated moderately with the Physician Empathy scale scores for both
groups (for residents, r = .40; for medical students, r = .41). Also, as
expected, the self-reported personal attribute of Empathy yielded a moderate
correlation with the score of the Physician Empathy scale (for medical stu-
dents, r = .45; data on this scale were not available for residents). In addition,
scores on the Physician Empathy scale and the following conceptually
related self-reported measure of Compassion (defined as sympathy com-
bined with desire to help on a 7-point scale) were moderately correlated for
the residents (r = .56) and for medical students (r = .48). A measure of physi-
cian’s opinion that sympathy contributes to a positive clinical outcome was
positively correlated with the Empathy scale scores (for residents, r = .27; for
medical students, r = .33). A correlation coefficient of similar magnitude was
obtained between Physician Empathy scale scores and the reported personal
attribute of Sympathy for medical students (on a 100-point scale, r = .26).
Personality facets of Warmth and Dutifulness (from the NEO-PI-R) were
also positively correlated with the Physician Empathy scale scores for medi-
cal students (r = .33 and r = .24, respectively). Data from these personality
facets were not available for the residents. Somewhat smaller positive corre-
lations were found between the Physician Empathy scale scores and
self-reported personal attributes of Trust (r = .27), Tolerance (r = .25), Per-
sonal Growth (r = .15), and Communication (r = .13). Hogan (1969) reported
that correlations of comparable magnitude between his Empathy scale scores
and Tolerance. Scores of the Faith-in-People scale marginally correlated with
the Empathy scale scores (r = .12). Negligible correlations were observed
between Physician Empathy scale scores and self-reported personal attri-
360 EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

Table 2
Descriptive Statistics and Preliminary Norms for the
Jefferson Scale of Physician Empathy (20 items)

Residents (n = 41) Medical Students (n = 193)

M 118 118
SD 12 11
Median (50th percentile) 119 117
Mode 119 112
25th percentile 110 111
75th percentile 126 126
a
Possible range 20 to 140 20 to 140
b
Actual range 88 to 140 87 to 139
Alpha reliability estimate .87 .89

a. The minimum and maximum possible scores.

b. The lowest and highest scores obtained by the samples.

butes of Self-Protection (r = .11), Sense of Humor (r = .05), and Clinical Neu-

trality (r = –.05).
Correlations between scores of the Empathy scale and desirable attributes
of physicians are also reported in Table 3. Desirability of the following attrib-
utes were associated with higher empathy scores: Empathy attribute (r = .37),
Tolerance (r = .26), Personal Growth (r = . 25), Sense of Humor (r = .20),
Communication (r = .18), Compassion (r = .17), and Trust (r = .16).
The findings that the Empathy scale scores yielded a higher correlation
with the external criterion measures that were more conceptually related to
physician empathy (e.g., Empathic Concern, Sympathy, Compassion,
Warmth) than other less relevant criterion measures (e.g., Self-Protection,
Clinical Neutrality) provided evidence in support of the criterion-related
validity of the Physician Empathy scale (convergent and discriminant valid-
ity, respectively; Campbell & Fiske, 1959).

Gender Comparison

The scores of the Physician Empathy scale for 115 male and 78 female
medical students were compared. Women scored higher (M = 119.8, SD =
10.5) than men (M = 115.9, SD = 11.0), t = 2.41, p < .05. The gender differ-
ence in empathy score is consistent with the notion that women are more
empathic than men. This may be related to the women’s greater capacity for
empathic communication (Davis, 1983; Hatcher et al., 1994). In Hogan’s
study (1969), not only did female subjects (high school and college students)
score higher on empathy than their male counterparts, but substantial differ-
ences were also observed on empathy scores between delinquents and prison
inmates and psychology, medical, and education students in the favor of the
students. Men, according to Zinn (1993), are more often inclined to offer
 HOJAT ET AL. 361

Table 3
Correlations of Scores on the Jefferson Scale of Physician Empathy (20 items) With External
Criterion Measures for Residents and Medical Students

Residents Medical Students

Criterion Measure (n = 41) (n = 193)

Interpersonal Reactivity Index (IRI) scalesa

Empathic Concern .40* .41*
Perspective Taking .27*** .29*
Fantasy .32* .24*
b
Self-Reported (7-point scale)
Compassion .56* .48*
Sympathy .27*** .33*
c
NEO PI-R personality facets
Warmth .33*
Dutifulness .24*
d
Faith-in-People (misanthropy) .12***

Personal Desirable
e
Attributes (100-point scale)
Empathy .45* .37*
Compassion .31* .17**
Trust .27* .16**
Sympathy .26* .13***
Tolerance .25* .26*
Personal Growth .15** .25*
Communication .13*** .10
Self-Protection .11 .19*
Humor .05 .20*
Clinical Neutrality –.05 .01

a. Scales from Interpersonal Reactivity Index (Davis, 1983).

b. Single items.
c. Personality facets from the NEO PI-R (Costa & McCrae, 1992).
d. Faith-in-People scale (Rosenberg, 1957, 1965).
e. Self-reported personal attributes on a 100-point scale. Data were not available for the residents.
*p < .01. **p < .05. ***p < .10.

rational solutions, whereas women are more likely to offer measures of emo-
tional support and understanding.

Conclusions
Training humane physicians has long been a concern of the medical pro-
fession but has become even more timely in the past few decades. The rapid
rise of technology and the resulting shift away from the bedside and into the
labs have probably contributed to the public perception that physicians have
become too “detached” to care (Kaufman, 1991; Verres, 1996). Many studies
have actually supported this view, showing that students and residents alike
362 EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

grow more cynical and less compassionate during medical training

(Feudtner, Christakis, & Christakis, 1994; Lu, 1995; Self, Schrader,
Baldwin, & Wolinsky, 1993).
To address these issues, the American Board of Internal Medicine
(ABIM) published a position paper that asked program directors to evaluate
their trainees’ humanistic qualities by repeated observation of actual behav-
ior over time (ABIM, 1983). This process was well received by directors and
residents alike and subsequently reviewed and improved at the beginning of
the 1990s. Since then, however, concern has been raised about its validity.
Who, for instance, is best suited to judge residents’ humanistic qualities?
Program directors, attending physicians, nurses, or patients themselves? Per-
ceptions can, in fact, vary significantly. There is, for example, only a modest
correlation between nurses’ and attendings’ assessments (Butterfiel &
Mazzaferri, 1991; Butterfiel, Mazzaferri, & Sachs, 1987; Kaplan & Centor,
1990), and nurses’ perceptions actually correlate more closely to those of the
patients. Some authors have therefore suggested that patients should be the
final judges (Wooliscroft, Howell, Patel, & Swanson, 1994), but this may be
cumbersome and not always feasible. As a result, many have called for a vali-
dated and equitable instrument that could ascertain the empathy, compassion,
and humanism of health professionals.
The concept of empathy has indeed been well discussed in the health care
literature, but empirical investigation among health professionals has been
wanting. One of the reasons for this paucity of information is the lack of a
psychometrically sound research instrument that could operationalize the
concept of empathy. To address this need, a 20-item scale of physician empa-
thy was developed based on the literature on empathy in health care via pilot
testing and collection of empirical data from samples of residents and medi-
cal students.
Factor analysis of the Physician Empathy scale showed that the major
underlying construct of the instrument described the physician’s view of the
world from the patient’s perspective (Factor I). Other constructs contained in
the instrument were defined as understanding the patient’s experiences, feel-
ings, and clues (Factor II); ignoring emotion in patient care (Factor III); and
thinking like the patient (Factor IV). These factors are consistent with the
components of physician empathy discussed in the literature (e.g., Spiro
et al., 1993) and therefore provide evidence in support of the construct valid-
ity of the scale scores.
Correlational analysis showed that the scores of the Physician Empathy
scale were correlated with conceptually relevant measures, such as Compas-
sion, Empathic Concern, Perspective Taking, Sympathy, Fantasy, Tolerance,
Personal Growth, and Faith-in-People. These correlations were not high
enough in magnitude to indicate a substantial overlap between empathy and
the aforementioned concepts. Correlations of these magnitudes suggest
 HOJAT ET AL. 363

that empathy should be considered as a distinct personal trait that has a limited
overlap with other concepts, such as compassion, concern, sympathy, per-
spective taking, imagination, warmth, dutifulness, tolerance, personal
growth, trusting others, and communication. These findings support the
notion that empathy is a unique personal trait that is multidimensional
(Davis, 1983).
The observed gender differences in the scores of the Physician Empathy
scale in the expected direction provided further support for the construct
validity of the scale scores. In addition, the magnitude of the alpha reliability
estimates indicated that the scores are internally consistent. Although these
preliminary psychometric findings are encouraging, further psychometric
research is needed to investigate underlying factors, correlates, stability of
empathy scores over time, and group differences using a larger, more repre-
sentative sample of physicians and other health professionals.
The present scale of physician empathy was primarily developed to mea-
sure empathetic qualities and tendencies among health care students and pro-
fessionals. We are conducting a study to slightly modify this scale by placing
more emphasis on behavioral manifestations of empathy among practicing
physicians with regard to their interpersonal relationships with their patients.

References
American Board of Internal Medicine. (1983). Evaluation of humanistic qualities in the internist
by subcommittee of evaluation of humanistic qualities in the internist of the American Board
of Internal Medicine. Annals of Internal Medicine, 99, 720-724.
American Educational Research Association, American Psychological Association, & National
Council on Measurement in Education. (1985). Standards for educational and psychologi-
cal testing. Washington, DC: American Psychological Association.
Aring, C. D. (1958). Sympathy and empathy. Journal of American Medical Association, 167,
448-452.
Barrett-Lennard, G. T. (1993). The phases and focus of empathy. British Journal of Medical Psy-
chology, 66, 3-14.
Blumgart, H. L. (1964). Caring for the patient. New England Journal of Medicine, 270, 449-456.
Bolognini, S. (1997). Empathy and “empathism.” International Journal of Psycho-Analysis, 78,
279-293.
Brock, C. D., & Salinsky, J. V. (1993). Empathy: An essential skill for understanding the
physician-patient relationship in clinical practice. Family Medicine, 25, 245-248.
Butterfiel, P. S., & Mazzaferri, E. L. (1991). New rating form for use by nurses in assessing resi-
dents’ humanistic behavior. Journal of General Internal Medicine, 6, 155-161.
Butterfiel, P. S., Mazzaferri, E. L., & Sachs, L. A. (1987). Nurses as evaluators of the humanistic
behavior of internal medicine residents. Journal of Medical Education, 62, 842-849.
Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation by the
multitrait-multimethod matrix. Psychological Bulletin, 56, 81-105.
Colliver, J. A., Willis, M. S., Robbs, R. S., Cohen, D. S., & Swatz, M. H. (1998). Assessment of
empathy in a standardized-patient examination. Teaching and Learning in Medicine, 10,
8-11.
364 EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT

Costa, P. T., Jr., & McCrae, R. B. (1992). Revised NEO Personality Inventory (NEO PI-R) and
NEO Five Factor Inventory (NEO-FFI): Professional manual. Odessa, FL: Psychological
Assessment Resources.
Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimen-
sional approach. Journal of Personality and Social Psychology, 44, 113-126.
Engel, G. L. (1990). The essence of the biopsychosocial model: From 17th to 20th century sci-
ence. In H. Balner (Ed.), A new medical model: A challenge for biomedicine? (pp. 13-18).
Amsterdam, the Netherlands: Swets & Zeitlinger.
Evans, B. J., Stanley, R. O., & Burrows, G. D. (1993). Measuring medical students’ empathy
skills. British Journal of Medical Psychology, 66, 121-133.
Feighny, K. M., Monaco, M., & Arnold, L. (1995). Empathy training to improve physician-patient
communication skills. Academic Medicine, 70, 435-436.
Feudtner, C., Christakis, D. A., & Christakis, N. A. (1994). Do clinical clerks suffer ethical ero-
sion? Students’ perception of their ethical environment and personal development. Aca-
demic Medicine, 69, 670-679.
Fishbein, R. H. (1999). Scholarship, humanism, and the young physician. Academic Medicine,
74, 646-651.
Guzzetta, R. (1976). Acquisition and transfer of empathy by the parents of early adolescents
through structural learning training. Journal of Counseling Psychology, 23, 449-453.
Hatcher, S. L., Nadeau, M. S., Walsh, L. K., Reynold, M., Gales, J., & Marz, K. (1994). The
teaching of empathy for high school and college students: Testing Rogerian methods with
the Interpersonal Reactivity Index. Adolescence, 29, 961-974.
Hogan, R. (1969). Development of an empathy scale. Journal of Consulting and Clinical Psy-
chology, 33, 307-316.
Hojat, M., Nasca, T. J., Magee, M., Feeney, K., Pascual, R., Urbano, F., & Gonnella, J. S. (1999).
A comparison of the personality profiles of internal medicine residents, physician role mod-
els, and the general population. Academic Medicine, 74, 1327-1333.
Hojat, M., Samuel, S., & Thompson, T. L., II. (1995). Searching for the lost key under the light of
biomedicine: A triangular biopsychosocial paradigm may cast additional light on medical
education, research and patient care. In S. K. Majumdar, L. M. Rosenfeld, D. B. Nash, & A. M.
Audet (Eds.), Medicine and health care into the twenty-first century (pp. 310-325). Easton:
The Pennsylvania Academy of Science.
Hunsdahl, J. (1967). Concerning einfuhlung (empathy): A concept of its origin and early devel-
opment. Journal of the History of the Behavioral Sciences, 3, 180-191.
Jackson, S. W. (1992). The listening healer in the history of psychological healing. American
Journal of Psychiatry, 149, 1623-1632.
Jensen, N. (1994). The empathetic physician. Archives of Internal Medicine, 154, 108.
Kaiser, H. (1960). The application of electronic computer factor analysis. Educational and Psy-
chological Measurement, 20, 141-151.
Kaplan, C. B., & Centor, R. M. (1990). The use of nurses to evaluate house officers’ humanistic
behavior. Journal of General Internal Medicine, 5, 410-414.
Kaufman, M. (1991, October 27). Try a little tenderness. The Philadelphia Enquirer Sunday
Magazine, p. C3.
Lu, M. C. (1995). Why it was hard for me to learn compassion as a third-year medical student.
Cambridge Quarterly of Healthcare Ethics, 4, 454-458.
Magee, M., & Hojat, M. (1998). Personality profiles of male and female positive role models in
medicine. Psychological Reports, 82, 547-559.
Mehrabian, A., & Epstein, N. A. (1972). A measure of emotional empathy. Journal of Personal-
ity, 40, 525-543.
Nadelson, C. C. (1993). Ethics, empathy, gender, in health care. American Journal of Psychiatry,
150, 1309-1314.
Neuwirth, Z. E. (1997). Physician empathy: Should we care. Lancet, 350, 606.
 HOJAT ET AL. 365

Nightingale, D. S., Yarnold, P. R., & Greenberg, M. S. (1991). Sympathy, empathy, and physi-
cian resource utilization. Journal of General Internal Medicine, 6, 420-423.
Novack, D. H. (1987). Therapeutic aspects of the clinical encounter. Journal of General Internal
Medicine, 2, 346-355.
Novack, D. H., Epstein, R. M., & Paulsen, R. H. (1999). Toward creating physician-healers: Fos-
tering medical students’ self-awareness, personal growth, and well being. Academic Medi-
cine, 74, 516-520.
Peabody, F. W. (1984). The care of the patient. Journal of American Medical Association, 252,
813-818. (Original work published 1927)
Robinson, J. P. (1978). General attitudes toward people. In J. P. Robinson & P. R. Shaver (Eds.),
Measures of social psychological attitudes (pp. 587-589). Ann Arbor, MI: Institute for So-
cial Research.
Rogers, C. R. (1959). A theory of therapy: Personality and interpersonal relationships as devel-
oped in the client-centered framework. In S. Koch (Ed.), Psychology, a study of science:
Foundations of the person and the social context (Vol. 3, pp. 184-256). New York:
McGraw-Hill.
Rosenberg, M. (1957). Occupations and value. Glencoe, IL: The Free Press.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton Univer-
sity Press.
Self, D. J., Schrader, D. E., Baldwin, D. C., & Wolinsky, F. D. (1993). The moral development of
medical students: A pilot study of the possible influence of medical education. Medical Edu-
cation, 27, 26-34.
Spiro, H. (1992). What is empathy and can it be taught? Journal of the American Medical Associ-
ation, 116, 843-846.
Spiro, H. M., Curnen, M. G., Peschel, E., & St. James, D. (1993). Empathy and the practice of
medicine: Beyond pills and the scalpel. New Haven, CT: Yale University Press.
Streit-Forest, U. (1982). Differences in empathy: A preliminary analysis. Journal of Medical
Education, 57, 65-67.
Suchman, A. L., Markakis, K., Beckman, H. B., & Frankel, R. (1997). A model of empathetic
communication in the medical interview. Journal of the American Medical Association, 277,
678-682.
Velicer, W. F., & Fava, J. L. (1998). Effects of variable and subject sampling on factor pattern re-
covery. Psychological Methods, 3, 231-251.
Verres, M. (1996). Touch me. Journal of the American Medical Association, 276, 1285-1286.
White, K. L. (1991). Healing the schism: Epidemiology, medicine, and the public’s health. New
York: Springer-Verlag.
Wolf, E. S. (1980). The dutiful physician: The central role of empathy in psychoanalysis, psy-
chotherapy, and medical practice. Clinical Psychiatry, 2, 41-56.
Wooliscroft, J. O., Howell, J. D., Patel, B. P., & Swanson, D. B. (1994). Resident-patient interac-
tion: The humanistic qualities of internal medicine residents as assessed by patient, attending
physicians, program supervisors and nurses. Academic Medicine, 69, 216-224.
World Health Organization. (1948). World Health Organization constitution: Basic documents.
Geneva, Switzerland: Author.
Zinn, W. (1993). The empathetic physicians. Archives of Internal Medicine, 153, 306-312.
Zinn, W. (1994). The empathetic physicians. Archives of Internal Medicine, 154, 108.