Empathy competence and future specialty among medical residents in Japan: a nationwide cross-sectional study

Empathy is essential for physicians to provide patient-centered care. Nevertheless, the degree to which empathy varies among medical residents based on their desired future specialty remains undetermined. This nationwide cross-sectional study compared empathy levels (Jefferson Scale of Empathy, JSE) of 824 year one and two postgraduate residents in Japan by intended medical specialty, individual characteristics, and training and working environment characteristics. Empathy levels were compared with applicants for general medicine, which emphasizes patient-centeredness. The highest mean JSE and the highest percentage of women residents were observed in general medicine (M = 109.74; SD = 14.04), followed by dermatology (M = 106.64; SD = 16.90), obstetrics and gynecology (M = 106.48; SD = 14.31), and pediatrics (106.02; SD 12.18). Residents interested in procedure-centered departments (e.g. ophthalmology, orthopedics) garnered lower JSE scores. Multivariate regression revealed that future general medicine candidates achieved the highest JSE scores (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\beta$$\end{document}β = 6.68, 95% CI 2.39–10.9, p = 0.002). Women achieved significantly higher JSE scores than men (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\beta$$\end{document}β = 2.42, 95% CI 0.11–4.73, p = 0.041). The results have implications for empathy training and postgraduate education strategy in different clinical specialties.

Exclusion criteria.Among all participants (1019) who remained after completing the GM-ITE, 134 were excluded (118 did not undertake the subsequent survey; 16 did not consent).After another 61 respondents were excluded for other reasons (Fig. 1), a total of 824 participants were included in the analysis.

Statistical analysis.
The JSE total score was used as the primary outcome (independent variable).To assess the internal consistency of reliability of the JSE, we calculated Cronbach's alpha; to estimate effect size, we calculated Cohen's d from the t test differences between the two groups.Standard descriptive statistics were used to calculate the number, percentage, mean, median, and interquartile range (IQR) of each variable in the dataset.The chi-square test or Fisher's exact test was used to compare categorical data.Additionally, multivariate linear regression analysis was performed to examine factors associated with total scores on the JSE, which were adjusted based on clinical relevance and previous studies.We also examined variance inflation factors (VIF) to confirm the absence of multicollinearity.Finally, sensitivity analysis was performed by incorporating random effects (i.e.hospital-level variables and resident-level variables) in the multiple regression analysis.All tests were two-tailed, and statistical significance was set at p < 0.05.All analyses were performed using STATA (Stata Corp. 2015, Stata 17 Base Reference Manual).

Ethical considerations.
Ethical approval for this research was obtained from the Ethical Review Committee of Japan Organization of Advancing Medical Education Program, JAMEP, No. 21-7.All participants provided written informed consent before participating in the study in accordance with the Declaration of Helsinki.

Results
A total of 824 residents who consented to participate in the study were included in the analysis (PGY-1 = 364, PGY-2 = 460).Cronbach's alpha was 0.85.Table 1 shows the characteristics of the hospital training sites and residents.Most (81.4%) were trained in community hospitals, 71% were trained in rural areas, and more than 90% of training hospitals had more than 300 beds (mean [M] 552.36,SD 218.8).At the resident level, 28.0% of respondents were women, 55.8% PGY-2, and approximately 70% were on duty in the emergency department 3-5 times monthly, with the most common response of being in charge of 5-9 patients at a time.Sixty-eight percent of residents reported having at least one mentor.The mean GM-ITE score was 46.29 out of a total possible score of 80, and the mean JSE score was 103.61 (SD 15.0%).Women's JSE scores were significantly higher than those of men (women M = 105.66,SD 14.08; men M = 102.81,SD 15.25; p = 0.01).
Table 2 shows the average JSE score and the percentage of women residents in each department of interest (19 primary areas and others not yet decided).Internal medicine, which encompasses many subspecialties, such as cardiovascular, respiratory, gastrointestinal, and collagen disease, had the highest number, with 325 residents (JSE M = 104.60,SD = 14.56), accounting for 39.4% of all residents.Surgery had the next highest number of residents at 90, which accounted for 10.9% of all residents (JSE M = 103.39,SD = 15.32).The department with the highest empathy was general medicine (JSE M = 109.74,SD = 14.04), followed by dermatology (JSE M = 106.64,SD = 16.90),obstetrics and gynecology (JSE M = 106.48,SD = 14.31), and pediatrics (JSE M = 106.02,SD = 12.18).Lower JSE scores were frequently found in procedure-oriented departments, including ophthalmology (JSE M = 96.00,SD = 11.99),orthopedics (JSE M = 99.21,SD = 14.34), radiology (JSE M = 99.35,SD = 13.69),anesthesiology (JSE M = 100.16,SD = 14.25), and urology (JSE M = 101.18,SD = 15.15).Except for general medicine, the top medical specialties with the highest JSE scores (dermatology, obstetrics and gynecology, and pediatrics) also had significantly higher percentages of women physicians.Conversely, orthopedics and surgery had significantly lower percentages of women physicians.Anesthesiology was characterized by a high percentage of women (47.0%) but lower JSE scores (M = 103.61,SD = 15.0)than specialty areas.
Table 3 compares future general medicine candidates with those of other specialties.The results showed no significant differences in hospital-level variables.However, future general medicine candidates were less likely to include PGY-2 residents (40.0%, p = 0.020) and less likely to have a mentor (46.0%, p = 0.028).In addition, they had significantly higher GM-ITE scores and significantly higher JSE scores than residents of other specialties Finally, multiple linear regression analyses were performed using all the above hospital-level and residentlevel variables to determine whether they were relevant factors for the JSE scores (Table 4).The VIF for all items ranged from 1.04 to 1.48, with a mean of 1.14.Among these, only the coefficients found for women ( β = 2.42, 95% CI 0.10-4.7328;p = 0.041) and future general medicine candidates ( β = 6.68, 95% CI 2.39-10.9;p = 0.002) were statistically significant.Finally, a sensitivity analysis was performed, testing various in-and out-of-specialty and item variables.However, only the above variables for women and general medicine were significant, while the other variables, including resident-and hospital-level factors, were not significantly linked with JSE scores.

Discussion
This study used a nationwide cross-sectional survey across Japan to assess variations in empathy levels among residents (PGY-1 and PGY-2) based on their intended future specialty.The findings, measured using the JSE, revealed disparities in empathy levels correlated with future specialty choices before residents' specialty training, with the highest levels observed in those leaning toward the choice of general medicine.In addition, after adjusting for the training environment and resident level, general medicine was associated with significantly higher empathy scores among the 19 primary medical specialties as well as with a higher number of women majoring in the field.The Cronbach's alpha of the JSE was high for medical students (0.80) and physicians (0.80) in the US (0.84), which is comparable to the level reported for medical students (0.80) and physicians (0.81) in Japan; this study demonstrated similar results (0.84) 20,21 .Our discussion focuses on three areas to help frame our results: (1)

Differences in empathy among each specialty. Previous research indicates that physicians employed
in patient-centered specialties, such as general medicine, internal medicine, psychiatry, and pediatrics, exhibit notably higher levels of empathy compared to those in procedure-and technology-centered specialties, such as surgery, anesthesiology, plastic surgery, orthopedics, and neurosurgery 3,21,32 .The findings of a Polish study are particularly noteworthy as it highlights that family physicians display the highest levels of empathy, which aligns with the current study's observation of high empathy among Japanese generalists 32 .Although not directly comparable numerically to our study, as shown in Table 2, the empathy of residents who sought to train in procedureand technology-oriented departments tended to be lower.This trend was similar to previous studies 16,22,24 .Other studies have suggested that a patient-centered communication style predicts medical error outcomes in primary care physicians but not in surgeons, proceduralists, and technique-centered practice, and the reasons are still unknown 33 .It remains unclear whether these disparate levels of empathy are due to self-selection into a specialty or the result of their unique training effects and experiences 17,24,34,35 .In this study, the evidence highlights the differences in empathy levels depending on the specialty of interest that exist even before residents begin specialty training.Several other studies have suggested that empathy may decrease after surgical training 23,24 .This may be due to the unique empathic characteristics of surgeons, which differ from those in general medicine and internal medicine 24 .Therefore, some training for personnel in specialties where empathy tends to be low may be helpful, and numerous educational studies have been reported 19,20,36,37 .
Potential explanations for high empathy levels among general medicine physicians.Several previous studies have consistently demonstrated that physicians practicing in environments that prioritize patient-centered principles exhibit elevated empathy levels 3,21 .Notably, the prospective general medicine physicians in our study displayed significantly higher empathy levels than the average residents.Since they were residents before embarking on their specialized training in general medicine, it is improbable that the influence of their major program accounts for this difference.Instead, it is plausible that residents who initially chose to pursue a career in general medicine may have prioritized empathy as a crucial factor in their decision-making process.Thus, we must carefully consider the potential impact of the general internal medicine specialty certification program, which commenced in 2018, and its stated competencies 38 , as it may further illuminate the observed higher empathy levels among general internists.The General Medicine Board-Certified Programs include human-centered medicine and care (patient-centered medicine, family-oriented medicine and care, and communication to facilitate collaboration with patients and families) as the first of six competencies 25,38,39 .That is, residents who agree with the importance of these competencies are likely to further increase their empathy scores by applying them to general medicine.In Japan, there is only a slight disparity in salaries among medical specialties, and the lack of competition allows residents to choose their specialty according to their medical www.nature.com/scientificreports/interests and aptitude 21 .While this situation may be unique and different from that in North America 40 , the apparent high level of empathy among residents who wish to pursue general medicine adds new evidence to previous studies.

Potential explanations for high empathy among women.
Numerous studies have consistently suggested a higher level of empathy among women physicians and medical students 3,17,21,41,42 .This finding has historically been attributed to intrinsic factors (e.g.biological and evolutionary sex differences) and extrinsic factors (e.g.socialization, sex [gender] role norms, and societal expectations) 21,42 .In our study of medical residents, the average JSE scores were higher among women, which is consistent with previous studies.At least one study from Japan also noted that among women residents, the medical specialty choice is influenced by work-life integration (e.g.perceived balance between work and childcare) 21 .However, we were unable to correlate the choice of specialty among women physicians with levels of empathy found among physicians in various specialties, primarily because of the relatively low representation of women among the residents in our study.This study has additional limitations.First, as this was a cross-sectional study, we cannot know whether PGY-1 residents will, in fact, enter their identified future specialty as they reported in our questionnaire.The percentage of PGY-2 residents that aspired to become general medicine physicians was slightly lower compared to PGY-1 residents.However, the data from PGY-2 residents are more reliable because the career paths of almost all residents are already determined at the time of the end-of-year examinations.Second, we excluded www.nature.com/scientificreports/by each resident.The Japanese postgraduate clinical training requirements entail a minimum of 24 weeks in internal medicine, 12 weeks in emergency medicine, and 4 weeks each in surgery, pediatrics, obstetrics and gynecology, psychiatry, and community medicine.However, it is essential to consider that if the residents receive additional training in certain technology-oriented departments during the selection period, such as surgery or anesthesiology, it could potentially impact empathy levels and, consequently, lead to different study results 24 .
Our survey is the first to be used nationally to reveal differences in empathy among Japanese medical residents according to their future specialties.Our study confirms a high degree of empathy among physicians who aspire to be general medicine physicians, a specialty that values patient-centeredness. Empathy tended to be higher in more human-centered departments and lower in more procedure-and technology-oriented departments.However, in multivariate analysis, only aspirations for general medicine and being a woman were linked with significantly higher levels of empathy.No differences were found after adjustment for other medical specialties, training, working environment, or other factors.The findings of this study strengthen the evidence from previous studies conducted outside of Japan.Our results may have implications of postgraduate education; for example, empathy training strategies may be created for use in specialties wherein physicians tend to have lower empathy scores.However, further research is needed to determine why there are differences in the levels of empathy among applicants and to what extent these differences affect clinical practice.

Table 1 .
Background factors and resident characteristics.PGY postgraduate years, GM-ITE general medicine in-training examination, ED emergency department.

Table 2 .
Jefferson scale of empathy mean scores and proportion of women according to future specialty among Japanese resident physicians.

Table 3 .
Comparison of future general medicine candidates with the rest of the specialties.PGY postgraduate years, GM-ITE general medicine in-training examination, ED emergency department.Bold font indicates statistically significant differences.

general medicine candidate, n = 50 Others, n = 774 p-value
respondents that chose more than one specialty.The results would likely have been slightly different if they had been included.Third, general medicine in Japan is a relatively new specialty, and the fields of general internal medicine, hospital medicine, and family medicine overlap; hence, some residents of internal medicine might pursue hospital medicine or general internal medicine.Fourth, the current distribution of training facilities in Japan consists of approximately 45% university hospitals and 55% city hospitals.Notably, this study's data are significantly well represented by the participation of the city hospitals.This can be attributed to the pronounced popularity of the GM-ITE among city hospitals, contributing approximately 80% of the participants, despite the involvement of over 630 training facilities annually.However, while there exists a disparity in the participant ratio between university hospitals and city hospitals, the ratio of affiliations between examinees and training participants remains nearly identical.Fifth, this study lacks specific details on the training departments chosen

Table 4 .
Multivariate linear regression analysis for the Jefferson scale of empathy.PGY postgraduate years, GM-ITE general medicine in-training examination, ED emergency department.To adjust for potential confounders of medically significant factors associated with the Jefferson Scale of Empathy, the following variables were incorporated in the multivariate analysis: hospital-level variables (hospital type, hospital location, number of beds) and resident-level variables (sex, postgraduate year, ED duties per month, average number of inpatients in charge, resident duty hours per week, study time per week, presence of a mentor(s), future general medicine candidates, and GM-ITE scores).Bold font indicates statistically significant differences.