Does Postgraduate Clinical Training Reduce Empathy Among Japanese Trainee Dentists? A Multi-perspective Assessment

Background: Even though enhancing empathy in healthcare education is a critical component of delivering better care to patients, the erosion of empathy has been frequently reported, especially when the curriculum transitions to clinical training. However, some studies have questioned the signicance and frequency of this decline in empathy. Thus, this study determined whether postgraduate clinical training reduced dental trainees’ empathy. Methods: This study included 64 trainee dentists at Okayama University Hospital and 13 simulated patients (SPs). The trainee dentists completed the Japanese version of the Jefferson Scale of Empathy for health professionals immediately before conducting initial medical interviews with SPs twice, at the beginning and the end of their clinical training. The SPs evaluated the trainees’ communication using an assessment questionnaire immediately after the interviews. The videotaped dialogue in interview was analyzed using the Roter Interaction Analysis System. Results: Sustained levels of trainees’ self-reported empathy, decreased communication behavior in emotional responsiveness for trainees, and unchanged SPs’ assessment of trainees’ communication were found when comparing results from the beginning and the end of the training. Conclusions: Overall, one-year postgraduate dental training neither reduced nor increased the empathy of the trainees. Providing regular educational support may help trainees to foster their empathy.

Most previous studies have used a single measurement for empathy, especially self-reported measures, which may provide a limited understanding of empathy, because it is a multidimensional attribute.
Colliver et al. [14] noted that patients' perception should be included in assessing health providers' empathy. Therefore, this study used three measures to assess empathy, to evaluate the cognitive aspect, behavioral aspect, and patient perspective. The behavioral dimension was measured by trainee dentists' empathic communication, and patients' perspective was measured by the simulated patients' (SP) assessment of trainee communication during initial medical interviews.
To the best of our knowledge, this is the rst study to examine changes in empathy during postgraduate training in dental education, assessed with multi-perspective measurements.

Participants
The participants for this study consisted of 64 trainee dentists (18  Overview of postgraduate clinical training course for dentists at Okayama University Hospital After graduating high school, dental students in Japan enroll in a six-year undergraduate program, followed by a mandatory one-year clinical training program after acquiring their license. This training is intended to provide comprehensive dental care with one oral cavity unit, understanding patient-centered holistic care.
The postgraduate program consisted of a combination of departments that provide training for pro ciency in basic and common treatments encountered in daily practice. The trainee dentists, under the supervision of the senior dentists, assisted in the treatment and treated the patient themselves. Completing a minimum number of cases for general dentistry basic practices was required. An electronic portfolio was used to encourage the trainees to review their practice critically. After each session, the trainees wrote the details of the treatment they performed, what they noticed in this practice, and what they must change to accomplish what they could not do in this practice. The supervising senior dentists commented on their portfolios, adopting a re ective and supportive approach to facilitate trainee learning. Case presentations and instructive seminars were also required.

Data collection procedure
Each trainee dentist conducted an initial medical interview with an SP twice, at the beginning and end of their training program. The trainee dentists completed the Japanese version of the Jefferson Scale of Empathy (JSE) for health professionals (HP-Version) immediately before the interviews. The SPs presented different dental cases at the beginning and end of the training. The former primarily presented concerns about the potential severity of persistent stomatitis on their tongues, while the latter primarily focused on the potential severity of persistent swelling and dull pain in their cheeks. The interviews were videotaped and had no time limitation. SPs evaluated the trainees' communication using an assessment questionnaire immediately after the interviews.
Measures JSE (HP-Version): Self-assessment of trainees' empathy JSE (HP-Version) is a self-reporting instrument developed to measure empathy speci cally in physicians and health professionals [15]. Ample evidence has supported the reliability and validity of the JSE for health professions students and professionals [16]. The JSE is a broadly used instrument that has been translated into 43 languages and used in over 60 countries [17], and the psychometrics of its Japanese version have also been reported [18]. The internal consistency of the JSE for this study's population was good; Cronbach's alpha at the beginning and end of the training were 0.78 and 0.86, respectively.
The JSE consists of 20 items, each of which is rated on a seven-point Likert-type scale (1 = strongly disagree, 7 = strongly agree), with possible total scores ranging from 20 to 140. Half of the items are reverse scored, so that an overall higher score shows a more empathic orientation toward patient care.

The Roter Interaction Analysis System (RIAS)
RIAS was used to analyze the videotaped dialogue from the medical interviews. RIAS is a method for coding medical dialogue and is most widely used in Western countries [19]. However, its applicability has also been reported for the Japanese population [20].
The dialogue is divided into 'utterances' that are de ned as the smallest units in the interview. Units vary in length from single words to long sentences composed of one thought or piece of information. Each utterance falls into one of 41 mutually exclusive code categories, excluding unintelligible utterances, according to the Japanese version of the RIAS [19]. In this study, six new categories were added to distinguish dental conversations from other medical conversations. We then consolidated all categories into 14 larger composite clusters based on content similarity (Table 1). Coding was performed directly from videotapes rather than transcripts; therefore, utterances can be categorized based on voice tone and phrasing cues as well as literal meaning.
Two coders (S.W. and T.Y.) independently analyzed 20 videotapes that were not included in this study to assess inter-coder reliability. Both coders completed the RIAS coding training provided by RIAS Japan.
Inter-class correlation coe cients were calculated between results of the two coders for the categories with a mean frequency greater than two per medical interview. SP assessment questionnaire of trainee dentists' communication The SP assessment questionnaire comprises ve items included in Table 2, answered on a four-point scale (0 = disagree, 1 = somewhat disagree, 2 = somewhat agree, 3 = agree). The possible total scores ranged from 0 to 15, where a high score indicates a more positive assessment. This questionnaire was prepared based on the American Board of Internal Medicine's Patient Assessment survey questionnaire, which consists of 10 items [21]. The items which match the rst interview were selected and the language was modi ed to make the Japanese SPs easier to understand. Cronbach's alpha at the beginning and the end of the training were 0.82 and 0.88 respectively, which indicated good internal consistency.

Statistical analyses
The mean total JSE score, frequency of trainees' and SPs' utterances for each category and total SP assessment score for the beginning and end of the training were compared.
Paired t-test was used to evaluate the mean total JSE score because the data were normally distributed.
The mean frequency of trainees' and SPs' utterances and the mean SP assessment score were not expected to be normally distributed, and so the Wilcoxon signed-ranks test was utilized. All statistical analyses were conducted using SPSS version 24 (IBM, Tokyo, Japan). A signi cant difference was de ned as > 0.05.

JSE
The mean JSE total score for all trainee participants, as well as by gender, is provided in   Tables 4 and 5 show the mean frequencies of trainees' and SPs' utterances for the clusters, respectively. The cluster names are shown in quotation marks in this paper. There were no differences in total number of trainees' and SPs' utterances between the two occasions. Giving information about other issues 0.00 0.00 0.02 0.13 -1.000 0.317 *P < 0.05, **P < 0.01. Compared with the trainee dentists at the beginning, those at the end of the training had less 'Emotional expression' by half, which included empathic and legitimizing statements. They were also less involved in 'Gathering medical data' and 'Gathering psychosocial data.' However, they engaged in more 'Gathering dental data.' Consistent with the trainees' results, SPs did not use much 'Emotional expression,' which included expressing their concerns, and were less engaged in giving medical and psychosocial data. However, they gave more dental data in the medical interview at the end of the training.
The individual item scores of the SP assessment at the beginning and the end of the training are shown in Table 2, which shows that the mean total scores of SP assessment at the beginning and end of the training were 10.73 (SD, 2.49; range, 6-15) and 10.38 (SD, 2.79; range, 5-15), respectively. No signi cant difference in the mean total score was found between the two administrations. Only the score for the item 'Did you feel your worries and anxiety were understood?' was signi cantly lower at the end compared to the beginning of the training.

Discussion
We examined whether empathy, as assessed by three indicators, decreased over the course of the oneyear postgraduate clinical training among Japanese trainee dentists. This study found that trainees' selfreported empathy levels remained static, and communication behavior decreased in emotional responsiveness during trainees' medical interviews. Additionally, total score of SP assessment of trainees' communication remained unchanged; however, there was a decline in trainees' attitudes about accepting SPs' concerns and anxiety from SPs' perspective. Although many studies reported declining self-assessed empathy at the clinical phase in undergraduate education [12,[22][23][24] as well as postgraduate residency [25,26], unchanged stable empathy was found in our study, which is consistent with very few previous studies [27]. Some studies reported that empathy of the resident, measured using the same JSE, was comparable to our results [28,29], and others reported increased results [27,30]. As mentioned in an earlier study [31], the timing of clinical training varies by country, as does the number of years it takes to graduate. Therefore, differences in maturity may have led to differences in cognitive empathy by country.
On the other hand, we found the decreased communication behavior in emotional expression for trainees, which may suggest that cognitive measures of empathy may not be completely in accordance with behavioral measures. Our nding is inconsistent with the results of an earlier study using the same measurements as ours, as this earlier study examining the relationship between communication behavior of medical students and their self-reported empathy found that emotional responsiveness was the among the predictors of the self-assessed empathy score [32].
One explanation for this decline in emotional expression in medical interviews could be that trainees are becoming more focused on their diagnosis and skills, as crucial factors in the success of treatment. Our nding that trainees engaged in more data gathering, including a history of the current dental problem, would support this explanation. Holmes et al. [33] reported in their qualitative study exploring medical students' clinical clerkship experience that students realized that meeting a patient was a matter of gathering the information needed to make a diagnosis and presentation to the mentor.
Another possible explanation is that there is no change in their empathy on the cognitive level. They are convinced that they should empathize, but may nd it di cult to enact. Since the trainees are beginners, they may be unable to both collect relevant information for an accurate diagnosis and respond to patients' emotions to draw out their concerns. It may take longer to combine 'science' and 'art' together in the medical interview. This speculation needs to be investigated in future research.
Another reason for the decline in the assessment item regarding trainees' understanding of SPs' worries could be attributed to the decrease in the trainees' empathic communication, which may suggest that SPs' assessment re ects the trainees' empathic communication. The decrease in SPs' empathic expression may also be related to this decline of the SPs' assessment because communication is a reciprocal interaction. The decrease in the trainees' legitimizing and empathic communication may prevent patients from raising concerns. This is consistent with our previous study [34]. However, considering the fact that total patient assessment has not declined, the effects of trainees' empathic attitudes may have a limited effect on SP satisfaction.
Moreover, some studies that showed an increase in dental students' empathy and noted that this could be due to recently completed communication lectures and practices [35]. Training in communication skills, including role playing with simulated patients who provide feedback, is effective in increasing empathy, but the effect is not sustained [36]. Although we provided medical interviewing training immediately after their enrollment, speci c communication instruction focused on empathy was not implemented during their residency in the present study. Thus, it may be helpful to regularly provide some practice focused on empathetic communication skills during their training period. Although we have employed a portfolio for trainees to re ect on their practice as well as for their instructors to review, the current system has not resulted in more empathetic students. Therefore, instructors may need to emphasize feedback not only on the trainees' manual skills but also on their patient communication.
This study had several limitations. First, it was conducted at a single institution with a small sample size. Second, we cannot eliminate the potential in uence of gender on communication during the interview.
Third, we only analyzed communication during the medical interview and excluded other interactions, which may have affected the measurement of the behavioral aspect. Therefore, we should be cautious to generalize these ndings. Further studies are required to verify these ndings.

Conclusion
One-year postgraduate dental training may be insu cient to foster empathy cognitively and behaviorally and ful ll SPs' satisfaction with trainees' communication during the medical interview. Providing communication-focused training and instructors' feedback on trainees' empathic communication with patients regularly during clinical training may be necessary to enhance empathy, but further research is required to demonstrate the effectiveness of these educational methods to conclude this. We are grateful to all of the trainee dentists and SPs who participated in the study. We also wish to thank the residents who helped with our data collection. Additionally, we would like to thank Editage for English language editing.

Funding
This work was supported by the Grant-in-Aid for Scienti c Research (KAKENHI) (C) of the Ministry of Education, Culture, Sports, Science and Technology, Japan under grant number: 17K12047.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Authors' contributions
All authors (TY, SW, TK, HT, NS, HS, YN, and YT) were involved in the research design. TY, SW, TK and HT were involved data collection and analysis of this study. TY, NS, HS, YN and YT evaluated the credibility of the data analysis. TY worked substantially on writing the manuscript, and all authors revised and approved the nal version of the paper.

Ethics approval and consent to participate
This study was approved by the Ethics Committee of Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences (No. 1706-050). Participants were given oral descriptions and written documents regarding this study. All trainees provided their signed consent after con rming their understanding. All SPs provided their consent via e-mail.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.

Authors' information
Toshiko Yoshida, MA, PhD, is an assistant professor at Center for Education in Medicine and Health Sciences (Dental Education), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.