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Year : 2020  |  Volume : 31  |  Issue : 1  |  Page : 14-21
Factors affecting empathy among indian dentists

1 Department of Community Dentistry, Goa Dental College and Hospital, Goa, India
2 Department of Public Health Dentistry, Government Dental College and Research Institute, Bangalore, Karnataka, India
3 Public Health Dentistry Unit, Oral Health Sciences Centre, PGIMER, Chandigarh, India

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Date of Submission24-Apr-2018
Date of Acceptance23-Apr-2019
Date of Web Publication02-Apr-2020


Background: Empathy is one of the major essential elements in patient and dentist relationship. Interpersonal Reactivity Index (IRI) has been used extensively to measure empathy among medical and other health professions. However, its validity in dental profession remains to be explored. Aims: To examine the psychometric properties of IRI and also to assess the factors influencing the dental students' empathy. Setting and Design: A cross-sectional questionnaire study was carried out among 100 dental interns and postgraduates using IRI. Materials and Methods: Patients were selected randomly from six dental colleges in Bangalore. Internal consistency of items was evaluated by Cronbach's alpha and construct validity was assessed by confirmatory factor analysis with an orthogonal varimax rotation of factors. Statistical Analysis Used: The data were evaluated using SPSS 22. Descriptive and inferential statistics were performed with significance set at 5%. Results: Internal consistency of IRI (Cronbach's alpha: perspective taking = 0.76, fantasy = 0.80, empathic concern = 0.72, and personal distress = 0.79) was good. A four-factor solution emerged, accounting for 52% of total variance. The mean age of the participants was 24.25 ± 1.95 years. The mean for empathic concern domain was highest (20.75 ± 1.64). Gender, career choice, academic performance, and work satisfaction were associated with increased empathy scores, whereas depression and stress were associated with decreased empathy scores (P < 0.05). Conclusion: This study confirms the construct validity and reliability of the IRI for assessing empathy in dental students. Empathy scores among students varied depending on professional/personal factors.

Keywords: Dentist, empathy, factor analysis, India, Interpersonal Reactivity Index, students

How to cite this article:
Rajput S, Puranik MP, Shanbhag N, Kumar A. Factors affecting empathy among indian dentists. Indian J Dent Res 2020;31:14-21

How to cite this URL:
Rajput S, Puranik MP, Shanbhag N, Kumar A. Factors affecting empathy among indian dentists. Indian J Dent Res [serial online] 2020 [cited 2022 Jan 20];31:14-21. Available from:

   Introduction Top

Empathy is one of the critical aspects of patient care.[1] It is a crucial element of good patient and healthcare provider relationship.[2],[3],[4] In general, it means “standing in others' shoes” or to understand the perspective of the other person. It is considered as an intellectual attribute which differs from sympathy, which is grounded on emotions.[5] In healthcare settings, empathy is considered as conscious intellectual activity and behavioral feature that has the capacity to know patient better in terms of experiences and feelings.[6]

Increased empathic behavior in a healthcare provider has shown to increase diagnostic accuracy skills.[7] It has been found that there is an increase in patient's acceptance, compliance, treatment quality, and increase participation in health education.[8],[9]

Dental care setting has received less importance with respect to empathy. Studies have reported decreased dental fear and increased adherence to treatment and patient satisfaction when there is expression of empathy by the dentist.[4],[6] Previous studies reported a decline in empathy level of dental students during their training period,[10] its association with burn-out,[11] personal well-being,[12],[13] and academic performance.[1]

American Dental Education Association has realized the importance of empathy felt for the patient by the dentist. It states that providing empathy for patients is the second clinical competency for dental training[14] unlike India where empathy is not mentioned in Indian dental curriculum.[15]

It is very difficult to judge empathy and interpersonal skills among any health professionals. Training and observing one's behavior could be practiced, but it is a difficult proposition.[4],[6]

Previous literature has reported using questionnaires/tools to assess empathy like Hogan Empathy Scale (HES), Questionnaire Measure of Empathy Scale (QMEE), Interpersonal Reactivity Index (IRI), and Jefferson Scale of Physician empathy (JSPE).[16]

IRI by Davis[17] is considered to be a comprehensive multidimensional scale of generic (personal) context developed for use in general population. IRI has also been validated in medical, pharmacy, nursing, and engineering disciplines, but its validity and reliability are not explored in a dental setting. When used, it would help in detailed analysis of dental students' empathy rather than focusing on clinical (professional) context.

Moreover, there is dearth in knowledge about the factors affecting dental students' empathy. Hence, this study had two objectives. First, to determine the psychometric properties of IRI.[17] Second, to assess the factors influencing the dental students' empathy.

   Materials and Methods Top

Study design and participants

The study was conducted among dental interns and postgraduates over a period of 2 months (August and September 2017) using a cross-sectional design. Institutional Ethics Committee and Review Board approved the study and it was designed as per World Medical Association Declaration of Helsinki. Permission to conduct the study was taken from the principals of the various dental colleges.

Sampling size of 100 was derived,[18] based on the results of the pilot study (proportion of 83% of participants with empathy, 80% power of study, 10% margin of error) that was conducted in one dental institution on 30 dental interns and postgraduates. The sampling frame consisted of all the dental colleges recognized by the State University.[19] Six dental colleges were selected based on simple random sampling technique. The dental students who were present on the day of the visit and consented were included the study.

Data collection

Responses were elicited from a self-administered questionnaire consisting of two parts. Demography, personal, and professional factors were asked in the first part. The second part included the questionnaire to evaluate empathy of dental students using IRI.[17] IRI has 28 items of the following four subscales and seven items each. The subscales were (1) perspective taking (PT), to understand the psychological point of view of others; (2) fantasy (FS), to revolve imaginatively into the feelings and actions of fictitious characters; (3) empathic concern (EC), having sympathy and concern for unfortunate others; and (4) personal distress (PD), which deals with feelings of personal anxiety.[17] The 5-point Likert scale (ranging from “Does not describe me well” to “Describes me well”) was used.

Collection of data was done through personal visits to each of these colleges. The purpose of the study was explained to the dental interns and postgraduates before distributing the questionnaires and assuring them of confidentiality. The questionnaires were collected back immediately and were checked for completeness. Only completed questionnaires were included in the final analysis with exclusion of pilot study samples.

Statistical analysis

The data were entered into Microsoft Excel spreadsheet; SPSS version 22.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. For analysis of IRI questionnaire, 9 (3, 4, 7, 12, 13, 14, 15, 18, and 19) of the 28 items were worded negatively and were reverse coded. The total score of IRI was determined by addition of scores of all four subscales (0–28). Weightage for each option was given considering positive (4 = describes me well to 0 = does not describe me well) and negative items (0 = describes me well to 4 = does not describe me well).

Descriptive statistics with frequency, mean, and standard deviation were computed. Difference between the groups was assessed by t-test. Questions that had options from very good to poor were dichotomized as “good” (very good and good) and “poor” (fair, poor, and very poor). The final-year BDS percentage was dichotomized (below 65% and 65% or above). The variable that showed a significance of 10% or less (P ≤ 0.10) was considered in binary logistic regression. Each domain score was dichotomized according to the median (PT = 19, FT = 14, EC = 21, PD = 11) and was analyzed for its association with demographic variables and personal factors using binary logistic regression. Alpha level at 5%, with 95% confidence interval was considered significant.

Cronbach's alpha, corrected item-total correlation (CITC), and Cronbach's alpha if item deleted (CAID) values were used to assess the internal consistency of items. Test–retest reliability was also conducted. AMOS 19 was used to perform item homogeneity and construct validity using confirmatory factor analysis with an orthogonal varimax rotation of factors and an eigenvalue cut-off set at 1. The measurement of model fit with the data was checked with model Chi-square goodness of fit index (GFI) and approximate fit index [root mean square error of approximation (RMSEA), root mean squared residual (RMR), GFI, adjusted goodness of fit index (AGFI), normed fit index (NFI), relative fit index (RFI), incremental fit index (IFI), Tucker–Lewis fit index (TFI), and comparative fit index (CFI)]. Item discrimination was done by means of part-whole corrected discrimination indices.

   Results Top

In all, 100 dental students participated in this study in which 61 were females and 39 were males. Ages ranged between 22 and 24 years with a mean of 24.45 ± 1.95 years.

Item analysis

All 28 items were loaded above 0.30 in homogeneity analysis in all four factors [Table 1]. All part-whole corrected discrimination indices varied between 0.22 (item 9: “When I see someone being taken advantage of, I feel kind of protective towards them”) and 0.49 (item 4: “Sometimes I don't feel very sorry for other people when they are having problems”) and were positive (>0.20).
Table 1: Rotated factor loading for the IRI among dental students (n=100)

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Test analysis

Reliability: Reliability analyses showed that all four domains (Cronbach's alpha: PT = 0.76, FS = 0.80, EC = 0.72, and PD = 0.79) of IRI had good internal consistency. Reliability over time of the four empathy subscales, an independent sample of 30 dental students (15 undergraduates and 15 postgraduates) of one dental college completed the questionnaire twice with a gap of 15–22 days. For undergraduates, the correlations ranged from 0.71 to 0.77, and for postgraduates from 0.76 to 0.80. The CITC values ranged between 0.462 and 0.751 and CAID value decreased for all 28 items.

Construct validity: Principal components analysis used for assessing factorial validity [Table 1] (Kaiser–Meyer–Olkin = 0.821, Bartlett's test of sphericity: P <0.001, χ2 = 2081.92) revealed four factors. About 52% of total variance was contributed by it suggesting a satisfactory unambiguous structure. The second factor (Fantasy scale) was the most consistent. Approximate fit indexes (RMSEA = 0.056, RMR = 0.027, GFI = 0.936, AGFI = 0.912, NFI = 0.923, RFI = 0.911, IFI = 0.943, TFI = 0.952, and CFI = 0.957) showed acceptable model fit.

Demographics and IRI subscales' characteristics

The overall mean for domain 1 (perspective taking) was 19.35 ± 1.98 (range: 15-22), domain 2 (Fantasy scale) was 13.79 ± 1.59 (range: 15-22), domain 3 (empathetic concern) was 20.75 ± 1.64 (range: 17–23), and domain 4 (personal distress) was 10.54 ± 1.52 (range: 8–14).

Bivariate analysis was performed using independent t-test, which revealed statistically significant difference in relation to gender, presence of depression, relationship with family members and colleagues, career choice, academic performance, presence of stress, and satisfaction with their work in all four domains. Whereas relationship with teachers was statistically significant for PT and EC, communication competence was significant for three domains (except for FS) [Table 2].
Table 2: Demographic and IRI characteristics of dental students in study (N=100), with their mean IRI scores

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Multivariate analysis of demographic and IRI characteristics

Females (Odd's ratio (OR) =2.44), participants who chose dentistry by choice (OR = 1.85), academic achievers (OR = 1.05), and participants satisfied with work (OR = 1.39) were more likely, and participants suffering from depression (OR = 0.54) and stress (OR = 0.76) were less likely to have perspective taking empathy.

Females (OR = 1.32) and satisfaction with work (OR = 1.58) were more likely and participants suffering from stress (OR = 0.26) were less likely to have fantasy empathy.

Females (OR = 4.86), participants who chose dentistry by choice (OR = 1.78), academic achievers (OR = 1.45), and satisfaction with work (OR = 2.78) were more likely, and participants suffering from depression (OR = 0.62) and stress (OR = 0.38) were less likely to have empathic concern.

Females (OR = 2.68), suffering from depression (OR = 1.65), and stress (OR = 1.61) were more likely, and who chose dentistry by choice (OR = 0.43), academic achievers (OR = 0.53), and satisfaction with work (OR = 0.40) were less likely to have personal distress [Table 3].
Table 3: Multivariate analysis of demographic and IRI characteristics of dental students

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   Discussion Top

Empathy is an affective mode of understanding and is considered as essence in interpersonal relationship.[1] There exists gradient in possession of empathy between individuals. This gradient can be inherent or secondary acquired.[1] Significant relationships between patients and healthcare provider can be built by having empathy. It enhances patient–dentist communication and trust and makes treatment effective.[7],[8]

Good and effective communication skills including an empathetic behavior makes one a good dental clinician alongside adequate scientific knowledge and skills. This study was conducted among dental students to explore the factors affecting dental student's empathy.

Empathy is an important aspect of human behavior. It allows for an inclusive concept of empathy by appraising cognitive abilities on a fantasy and a perspective taking scale. The second of these domains contains the affective components of empathy assessed through the Empathic Concern and Personal Distress scales.[20] IRI has been traditionally validated in general population. Because of its comprehensive nature, it has been used in this dentist population. Therefore, this study also evaluated validity and reliability of IRI in dental setting.

Earlier studies used only IRI[12],[20],[21],[22] or in combination with other empathy scales like JSE-HPS,[16],[23] JSE-S,[24] and Medical Outcomes Study Short Form (SF-8).[13] This index was used among medical students,[10],[13],[24],[25],[26] psychology students,[17] pharmacy students,[16] students from various fields,[20] and normal functioning adults.[21],[27] In this study, IRI has been validated for the first time in India among dental students. Hence, comparison was done with studies done in other disciplines. Interpretation must be done with caution.

Factor analysis revealed extraction of four factors in favor of original structure. Literature pertaining to structure of the IRI is not clear [Table 4]. Couple of studies have reported the presence of a stable four-factor structure consistent with the four IRI subscales,[20],[21] while other studies have found inconsistent factor solutions.[22],[26],[28] This may be due to different target population considered, use of different translations of the instrument, or cultural differences. But the issues regarding the boundaries of emotional and cognitive processes in empathy[22] are still debatable which would have resulted in three-factor structure of IRI.
Table 4: Comparison of psychometric properties with previous studies and this study

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In this study, level of internal consistency of IRI for all four domains measure was “good” as reported by Davis,[17] Fernandez et al.,[20] De Corte et al.,[21] and Pulos et al.[26] However, one study done in Hong Kong reported “acceptable” level of internal consistency.[22]

There is no benchmark to determine whether empathy among dental students was low or high. Considering the mean and median of each domain with reference to midpoint (maximum score 28 for each domain, 14 = 28/2), participants scored high for perspective taking (mean = 19.35; median = 19) and empathic concern (mean = 20.75; median = 21) domain; whereas for fantasy (mean = 13.79; median = 14) and personal distress (mean = 10.54; median = 11) it was low which was in line with other studies,[10],[13],[20],[21],[24] whereas in one study empathic concern scored low.[27]

Eighteen years is the age of admission into medical or dental course in India. The mean age of the study participants was 24.45 years (22–28 years) and is comparable with few studies[13],[16],[20],[25],[26] and in contrary to other studies where range was 14–29 years.[22],[27] There was no significant difference in empathy age-wise which was similar to a study,[27] and this may be attributed due to narrow range of age groups in this study though one study[22] found older individuals scoring better for empathy compared with young individuals. This can be due to their altered metacognition and being unaware of changes in their behavior to feel more empathic in older age.[27]

There is a wave of women dentists surging through dentistry in India, which is reflected in this study. This finding was similar to a few other studies.[16],[20],[21],[24] However, other studies reported male dominance.[10],[13],[27] Females scored high for empathy and personal distress which corroborate with other studies.[13],[17],[20],[21],[22],[24],[25] This can be because of intrinsic factors such as inherent empathic nature[3] and extrinsic factors such as caring nature and extrovert.[5],[22] However, in one study there was no gender difference reported.[16]

Internship and postgraduation pose a lot of challenges with respect to responsibilities and patient load which may impact their daily activities. Equal number of dental interns and postgraduates were included in this study. Both demonstrated similar responses to IRI. However, the results reported in literature are equivocal. Studies have reported a decline (IRI),[10] increase (JSPE-HP), or no change (JSPE-HP)[23] in the levels of empathy in different countries. This increase may be attributed to importance given to dentist–patient relationship, practice management, and handling of different types of patients during final year of BDS. Academic demands that are inherent in postgraduate curriculum make it difficult for PDs to concentrate on patients and especially spend time to empathize with them.

Forms of distress like depression and stress are evident in dentistry due to various challenges, expectations, and vigorous working hours. Depression and stress decrease the ability to confront the barriers. It has been postulated that there is reduction in signal rate of mirror neurons.[29] Functions performed by mirror neurons stop functioning such as to have empathy and appreciate the feelings of other people when there is existence of depression and stress.[29],[30] Participants suffering from depression and stress were having less empathy and more personal distress which corroborate with couple of studies.[11],[12]

Health improves student's competency, compassion, and nurtures their coping ability.[12],[13] Students who perceived their overall health as good scored high for empathy and low for personal distress than who perceived as poor although there was no statistically significant difference.

Empathy and human relationships are interrelated.[29] It helps to understand others and in the process develop a sense of belonging.[5] Participants who responded that their relationship is good with family members, colleagues, and teachers were reported to have significantly higher empathy and low distress. Constructive ambience has a positive influence on students view, professionalism, and learning environment[11] which might have resulted in their increased empathy. Therefore, developing of empathy may help people socializing.

The choice of college in India depends on merit, financial constrain, and accessibility. Participants who chose dentistry as a career by choice performed well in examinations and obtained high empathy and low personal distress scores. This is an indication of their interest in dentistry that would engage themselves more extensively and influence their empathy toward patients. On the contrary, in a study done by Hojat et al., study participant's performance in objective examinations did not correlate with empathy scores significantly.[1]

Communication skill is important to influence patient attitudes. It is one of the verbal ways to show the empathy toward patients. Participants who reported that their communication skills were good also had high empathy scores although it was not statistically significant. Dental students due to work load give less importance to communication, whereas communication brings more emotional reactions among patients; it makes patient feel valued, understood, and accepted.[5]

Work satisfaction reduces distress and enhances positive aspects of students with respect to happiness, well-being, and competency,[12] which might have resulted in increased empathy in students who were satisfied with their work. Binary logistic regression was performed to predict the factors affecting empathy. Gender, depression, stress, career choice, academic performance, and career choice were found to be associated with IRI domains suggesting that empathy remains unaffected by relationship and communication competence in this study.

This study has some limitations. First, responses are self-reported measurement of empathy which is subjected to potential bias. Second, the study was cross-sectional in nature, hence causality is open to question. Third, depression, stress and satisfaction with work were self-reported, and no standardized questionnaire was used to assess those factors. Some of the factors such as self-esteem, intelligence quotient, personality traits, emotional intelligence, and social skills might have influenced the responses which were not assessed. Moreover, IRI convergent and discriminant validity was beyond the scope of the study. However, it is the first study done in dental setting using IRI scale after being validated. Hence, further studies are recommended to incorporate the aforementioned personality traits and behavior for better understanding of empathy and improved quality of care.

As the goal of dental education in India is to acquire adequate knowledge, skills, and attitude to render high-level care to patients, one of the ways to achieving it is by demonstrating empathy for them. Empathy in dental profession can be addressed at various levels. At the policy level, empathy should be given consideration in dental curriculum to make students realize the importance of it. At institution and individual levels, reinforcement should be given during their clinical posting and orientation classes. Moreover, there should be provision for approachable faculty, so that if students are suffering from depression and stress due to personal or professional factors, they can be counselled and helped to nurture their well-being. Creating healthy environment at institution will also aid in enhancing empathy in reduction of personal distress.

   Conclusion Top

This study validated IRI scale in dental settings. Gender, depression, stress, career choice, academic performance, and satisfaction with work were the factors affecting empathy among dental students. Being female, career choice, and work satisfaction corresponded with high empathy, while depression and stress lowered levels of empathy.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Soni Rajput
Department of Community Dentistry, Goa Dental College and Hospital, Bambolim - 403 802, Goa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_365_18

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