According to the results of this study, the SRH course positively affected the empathy levels of medical students, especially their emotional identification while the scores in cognitive behavior and social identification dimensions did not differ significantly between pretest and posttest in the intervention group (Table 2b). However, they were also close to significance level. This can be due to the content and design of the course. SRH is not a classical lecture-based course. There are 12 stories selected for different social responsibility topics (SRT) as illustrated in Fig. 3a for each week and discussed with medical students taking the course. Stories are examples of commonly used ones in empathy trainings (28). Topics were chosen from the behavioral, social sciences, and humanities qualifications list of National Core Curriculums (NCCs) for Undergraduate Medical Education (29). In relation with the SRTs, relevant Individual Social Responsibilities (ISR) were emphasized and targeted for internalization as a personal value by the students (Fig. 3b). For example, a case story of disabled person was told to the students in the second week after students had shared their experiences with disabled people and emphasis was put on “Protecting the Weak” as an ISR. It was seen that only a couple of students were able to share some real life events as social interactions (SI) with disabled people. The same was true with most of the other topics. However, some of them were commonly shared and debated by the students, such as pollution, stress, and elders. Despite discrepancies in actual social experience, they were still learning from each other by taking different perspectives during interactive case discussions.
Although most of them had none or very limited social interaction with specific cases, they were able to empathize with the person to the large extent, such as emotionally identifying with the disabled character in the story. On the other hand, cognitive behavior (CB) dimension of empathy requires a rather higher-order empathic skill set (30). This dimension largely reflects the cognitive aspects of empathy as evident from its name. Being able to evaluate the situation and deciding the most appropriate behavioral response to that particular situation certainly necessitate case specific experience, either directly or indirectly by observing others in similar situations as much as possible. Telling and discussing some stories would not be enough for significant positive changes in cognitive empathy. Several different methods can be used for teaching empathy to medical students, such as script writing and reading, role playing, and case simulations (31). These kind of active learning methods should be used more with medical students because some research has shown that empathy is generally decreasing during medical education (32, 33). At least it seems that medical students’ perspectives on empathy is changing from positive to negative, because they might be interpreting empathy wrong (34). Even the worse, they might be taught empathy false by confusing it by compassion or sympathy (35). There can be some other neurocognitive barriers in conceptualizing empathy as well, especially during extraordinary times like pandemics, such as decrease in sleep quality (36). Similar results were found in Turkey (37). Due to lower sleep quality, students’ attention and concentration decrease; and psychological stress is also inhibiting effectiveness of learning (38). Some counseling interventions can be implemented to improve physiological and psychological conditions for increased effectiveness of learning in medical education.
It is well-known that empathy is essential for therapeutic communication,. In comparison to students from higher grades, medical students at preclinical terms stated that physicians should be very empathic (39). Before clinical practicums in hospital, these views appear to change in negative direction. Third year medical students stated that they were mostly afraid of malpractice involvement while they did not have serious concerns about physician-patient communication (40). During clinical trainings, medical students pointed out that interpersonal conflicts between physicians and patients were among the major sources of workplace stress (41) because they had started to face with real patients and unique communication problems as opposed to what they had learned theoretically about managing professional relationships. Therefore, experience-based communication courses should be given to the medical students before they encounter with real patients during their clinical practicums. There are studies of course evaluations as evidence for the difference between theory-based and practice-based course designs in terms of empathy teaching and learning (42). In this study, there were statistically significant differences between intervention and control groups in terms of all empathy dimensions and total empathy at posttest (Table 2d), although there was no difference between groups at pretest (Table 2a). Comparison of the pretest and posttest mean scores of control group within a five months period reflected no significant difference in terms of any empathy dimension (Table 2c). All participants of this study were from preclinical terms, they had not been seeing any real patients. Medical students from clinical terms were excluded from data analysis on purpose. Participants in the control group were also taking some mostly theoretical and lecture-based communication courses but there was no significant difference in their empathy scores from pretest to posttest period. Thus, the change in empathy scores in the intervention group should have come from the SRH course. All these findings are significant evidence for the effectiveness of SRH course on the empathy development in medical students.
Empathy can be taught and learnt via different methods. Real-life experiences are the best teachers for empathy as well as other communication skills. Empathic skills are not only good for interpersonal communication but they also provide people with better emotion regulation (43) and so that contributing to the psychological resilience of healthcare students and professionals. Some people seem to be temperamentally inclined to be more empathic and some environmental conditions can also be effective (44). However, everyone does not have equal chances in both nature and nurture. Hence, medical curriculums should include better approaches for empathic skill development. In the future, new methods can be implemented such as the use of artificial intelligence (AI) in communication trainings (45). The use of virtual reality (VR) appears to facilitate the empathy development in medical students (46). The use of technology is increasing in medical education for most professional competencies. Communication skills should not be exceptions, and thus progressive instruction methods have to be considered in teaching empathy in medical schools. Other instructional technologies can also be applied in social responsibility themed courses like SRH. For instance, stories can be simulated with AI and VR technologies in the future for increased effectiveness of education.
Real life experiences are most valuable, of course. Most of people are at risk because poor living conditions are unfortunately increasing in the world, and these adversities affect health significantly. Illnesses are not only physiological conditions, but there are also psychological and sociocultural influences on well-being. To become better physicians in the future, medical students should gain more awareness towards taking real social responsibilities in health (47). There are many positive effects of volunteerism and advocacy to improve health at local and global levels (48). Findings of this study showed that medical students have become more empathic at the end of the SRH course. Their active participation in real social responsibility projects will contribute even more on their empathy levels: They can reach higher level of empathy and eventually when they graduate, we can meet with more empathic medical staff. Moreover, violence towards medical professionals will hopefully decrease by the help of empathic communication. However, not only healthcare students and professionals but everybody should learn to become more empathic to prevent and intervene with violence and other social conflicts. There are some good project examples (49) that plant seeds of hope in our hearts. In addition to formal medical curriculum, hidden curriculum should also include more volunteerism and advocacy such as variety of social responsibility projects carried out by the medical faculties and professionals in the field (50). Students will take their teachers as role models in becoming more responsible for social living. Empathy can be taught best by real empathic teachers because we should believe and trust that empathy is highly contagious.
There are some limitations and strengths of this study. First of all, relatively small groups of students were compared in a single setting. The effectiveness of SRH should be tested in different settings. Secondly, a self-report scale of empathy was used for data collection. The use of multisource data gathering was recommended in the future. EAS was used to assess the empathy in this study. There are many different empathy self-report scales available but none of them had been found useful for the purposes of this study. For one thing, most empathy scales are unidimensional. Using them, It is not possible to assess the subdimensions of empathy like SI, CB, and EI. Some multidimensional empathy scales are not valid because of reverse item scoring and some of them are too long for practical application. The validity and reliability of EAS was proven in this study but valid and reliable new scales, and even multiple scales can be used to assess empathy in the future. On the other hand, there are some strengths of the current study. The use of similar group for comparison as control is the major evidence for proving the intervention effectiveness. In both groups, students were keen on participating the research. Their voluntary participations were encouraged and appreciated. EAS and SRH course was developed originally by the researcher, stories were created appropriately according to sociocultural environment of the students. That is to say, they were all in accordance with the real life conditions where students live. It was believed that the course effectiveness is highly related to this sense of reality. In the future, design and materials of the SRH course can be developed further to get much more effective results. Students who took the course gave positive feedback about the course. In addition to other sources of course evaluation, students’ detailed feedback will certainly be used to improve the course.