A two-way process of exchanging or shaping ideas, feelings, and information between dentist and patient has created keen interest in dental society. The best way to achieve effectively exchanging and shaping ideas depend on the credibility of the dentist that is how he defines empathy practically. ¹ Empathy is to see with the eyes of other, to hear with the ears of another, and to feel with the heart of another (Alfred Adler). Empathy was derived from two Greek terms, "em" and "pathos," meaning "feeling into" and has its origin from the German word "Einfulung." It facilitates dental professionals to recognize patient′s concerns, feelings, and experiences. ² , ³ The basic difference between empathy and sympathy is that empathy means intellectual understanding, ⁴ , ⁵ while sympathy means sharing sentiments. ⁶ The American Dental Education Association always emphasized on including empathy as a part of the dental curriculum as it plays an important role in healthy dentist and patient relationship. ⁷ Undergraduate medical students have shown a decline in empathy level during their graduation course. ⁸ Sherman and Cramer ¹ reported a similar decline in empathy levels among the dental students during the 2 ^ndyear of dental training, but in contrary some studies ¹ , ⁹ , ¹⁰ , ¹¹ reported vice-versa. In view of such varying empathy findings from different countries, it is the need of the hour to understand empathy levels among dental students in the Indian context. The present study is the first of its kind in India and few among the world to explore the empathy level among dental students.

Objectives

To measure the self-reported empathy levels among dental undergraduate and postgraduate students of the dental program (BDS, MDS)

A cross-sectional institutional and self-reporting questionnaire based study was conducted among students pursuing their graduation and postgraduation in two private dental institutions located in the North West part of the country, Rajasthan, India. The curriculum in India pertaining dental education offers 5 years course during graduation and 3 years of course during postgraduation. The present study was cleared by the Ethical Committee of the SDCRI and Maharaja Ganga Singh Dental College. This research has been conducted in full accordance with the World Medical Association Declaration of Helsinki. Data were obtained from the 1 ^stto final (4 ^th) year students, interns, and postgraduate students enrolled in Bachelor of Dental Surgery and Master of Dental Surgery Program, respectively, in these two institutions from January to April 2015. The students were briefly explained about the nature of the study, and their written consent was taken. They were assured of keeping the contents confidential. All performas were coded to avoid identification of the students by the authors. The inclusion criterion for the present study was that students must have completed 6 months following admission. Those students who were either unable to provide the required information or incomplete questionnaire form were excluded. The initial sample consisted of 1041 students but after applying the inclusion and exclusion criteria, the final sample comprised 978 students.

Jefferson Scale of Physician Empathy ⁶ , ¹² - Health Profession Students (JSPE-HPS) version questionnaire (already validated) was administered to assess the empathy level. The questionnaire consists of twenty components using 7-point Likert scale (for every single component) and score ranges from 20 to 140 with upper values representing greater empathy. Along with JSPE-HPS questionnaire, sociodemographic data were obtained. Internal consistency was analyzed using coefficient alpha. There are four subcategories measuring different dimensions of empathy such as "perspective taking," "compassionate care," "standing in patient′s shoes," and "personal distress." Confirmatory factor analysis was used to recognize the dimensionality of the JSPE-HPS version using (a) Kaiser′s criteria, ¹³ , ¹⁴ (b) an eigenvalue ¹⁵ , ¹⁶ , ¹⁷ (>1.25 was used), and (c) only retaining items if coefficients were ≥0.30. ¹⁸ After evaluation of results, 3-factor pathway was selected, i.e., "perspective taking," "compassionate care," as well as "standing in patient′s shoes." The above outcome resulted in approximately 37% of the overall described variance. Among the components, half had a positive response and half had a negative response.

Data so collected were tabulated in an Excel sheet under the guidance of statistician. Data were analyzed using the IBM SPSS. Statistics Windows, Version 20.0. (Armonk, NY: IBM Corp) for generation of descriptive, as well as inferential statistics. The statistical significant difference among groups was determined by the t-tests and ANOVA including post hoc tests.

Overall 978 students took part in this study having 309 males and 669 females. The female: male ratio in the present study was 2.7:1 Table 1. There was a statistically significant difference reported when empathy was tested in relation to gender (between males and females), as well as for age (P < 0.05). The lowest and highest mean empathy score was found in postgraduate (mean = 108.77, standard deviation [SD] =9.12) and 1 ^styear (mean = 117.23, SD = 14.19) dental students, respectively. Empathy score when tested according to experience using ANOVA and post hoc test was found to be statistically substantial (P < 0.05).{Table 1}

Ten components were computed on subscale-1 and components value arraying between 0.697 and 0.518 describing 22.85% of the variability. The most important component was "health-care providers" understanding of the emotional status of the patients, as well as that of their families′. Five components were computed on subscale-2 and components value arraying between 0.207 and 0.023 describing 10.18% of the variability. Most important component was "I believe that emotion has no place in the treatment of medical illness." Five components were computed on subscale-3 and components value arraying between − 0.572 and − 0.327 describing 9.34% of the variability. Two components were common among subscale 2 and subscale 3, i.e., component 14 ("I believe that emotion has no place in the treatment of medical illness") and component 11 ("patients′ illnesses can be cured only by targeted treatment; therefore, health-care providers′ emotional ties with their patients do not have a significant influence in treatment outcomes"). The required Cronbach′s alpha value for satisfactory internal consistency should be above 0.70 and in the present study Cronbach′s value for subscale 1, 2, and 3 were 0.79, 0.76, and 0.48, respectively Table 2.{Table 2}

Few components brought out eminent mean values: "Patients feel better when their health-care providers understand their feelings" (mean = 5.93, SD = 1.17), whereas component, "I believe that empathy is an important factor in patients′ treatment" brought out a mean value of 5.27 (SD = 1.31). Results of all the components are fully elaborated in Table 2.

The aim of the contemporary study was to define the properties of JSE-HPS, as well as to measure the empathy among students of dental colleges in Sri Ganganagar, Rajasthan, India. The present study reported that postgraduate students had statistically lower empathy score as compared to all other years of students. This difference may be due to the fact that during the initiation of the dental course, students believe in idealism, i.e., sharing the feeling of the patients but with the progression of the dental course these feelings vanish, i.e., idealism gives way to the realization (means to get through the various level of dental degree meritoriously, requisite is to acquire enormous dimensions of facts). Hence, significant perspectives such as sharing the thoughts and feelings of the patients are put aside and emphasis swings on facts-based examinations. The mean empathy score of the present study ranges from 103 to 117 which is similar with the other studies among dental ¹ and medical students, ¹¹ , ¹⁹ , ²⁰ , ²¹ , ²² while in contrary, other studies ²³ , ²⁴ reported 78-90 mean empathy score.

While analyzing the empathy among male and female in the present study, females showed higher empathy level than males which is similar with the other studies, ¹ , ⁶ , ⁹ , ¹⁰ but this was against the studies done by Rose et al. ²⁵ and Babar et al. ³ This might be due to the fact that women′s brains probably show more empathy than men′s brains. When females were probed to recognize other human′s feeling, female′s brain action showed that they themselves feel the same sentiments as well while in contrary male′s brain action showed noetic assessment - a more objective position. ²⁶ In the present study, it was found that empathy score differs by age while the same was not reported by Babar et al. ³

Subscale-1, 2, and 3 are parallel with the studies described previously. ²⁷ , ²⁸ , ²⁹ As empathy is an essential component of maintaining healthy rapport between the dentist and patient, ³⁰ thus amending empathy is the vital chore of health training. ³⁰

Recently, Bonvicini et al. ³¹ conducted a study regarding communication skills exercise to find whether it will result in rise of the empathy level or not. The conclusion of the study was that communication skill exercise led to increase in empathy among the students. The present study showed that empathy levels were dropping with the progression of dental course. Therefore, the need is to introduce exercise regarding empathy among dental students at the initiation of and during their dental course. However, there is an argument regarding the introduction of training in empathy as Newton et al. ³² doubts whether student′s empathy will rise during their graduation course. The author proposes to introduce administrative modifications which motivate students scholastically and sensitively during their dental course. This will result in interprofessional education, growth of team effort principle, as well as alterations in judgment method.

The author has taken a maximum sample for the present study. Hence, results of the present study can be implemented among other dental institutions also. The limitation of the present study is that valuation of empathy was constructed on subjective evaluation of a validated questionnaire; therefore, observational approaches such as the history-taking rating scale could be used with JSE-HPS to measure empathy level in dental students. Cross-sectional studies make it impossible to understand the process of changes in empathy level through the years of dental course.

The present study showed year-wise fall in empathy among dental students. Dental health educators should consider this fall in empathy seriously as early as possible during the dental course. Empathy-related teaching exercises must be implemented among the dental students to endorse the growth of empathy so that fall in empathy should be prevented. More longitudinal research is required to investigate the outcome of communication exercise in cultivating empathy among dental students.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.