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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 46-52

A level of empathy and spirituality among undergraduate medical students of a tertiary hospital in Telangana: A cross-sectional study

Department of Psychiatry, Mamata Medical College, Khammam, Telangana, India

Date of Submission18-Dec-2021
Date of Decision17-Jan-2022
Date of Acceptance14-Feb-2022
Date of Web Publication30-May-2022

Correspondence Address:
Dr. Ramana Gattavali
Department of Psychiatry, Mamata General Hospital, Giriprasad Nagar, Khammam - 507 002, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjp.tjp_46_21

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Introduction: Patients' care with empathy has shown a higher clinical competence with great rapport. It leads to an accurate diagnosis with fewer medical errors. Patients tend to be more satisfied with improved outcomes both psychologically and pharmacologically. Empathy supports medical students to achieve capabilities essential for patient-centered care and in development of affective skill, manners, and personal as well as professional growth.
Aims and Objectives: To assess the level of empathy among medical students and to assess the level of spiritual well-being and its relation with empathy.
Materials and Methods: The cross-sectional study was carried out from January 2021 to March 2021 period. A total of 200 medical students were selected for the study, fifty from each year. Jefferson Scale of Physician Empathy Student version (JSPE-S), Toronto Empathy Questionnaire (TEQ), Spiritual Well-Being Scale (SWBS), and Demographic Questionnaire were used for the collection of data.
Results: The mean JSPE-S score was 108.41 (14.19), mean TEQ score was 44.89 (6.26), and mean SWBS was 80.58 (18.89). By JSPE-S, the mean empathy score decreased from the 3rd year and was lower in the final year (P = 0.00002). By TEQ, the empathy score was higher in the 2nd year followed by 3rd and 1st and was lower in the final year (P = 0.002). Females had higher empathy than males (P < 0.002 for JSPE-S and P < 0.00001 for TEQ). There was a significant positive relationship between spiritual well-being score with mean JSPE-S (r = 0.4429, P = 0.0012) and TEQ score (r = 0.5777, P = 0.00001).
Conclusion: Medical students had an average level of empathy and spiritual well-being. Clinical empathy decreased from the 3rd year and was lower in final-year students. Spiritual well-being had a positive significant relationship with empathy. There was a statistically significant association between mean empathy scores with demographic variables such as gender, parental education, habit of doing meditation, permanent residence area, and year of study.

Keywords: Empathy, medical students, spirituality

How to cite this article:
Dhedhi BJ, Gattavali R, Nadukuru GN, Macharapu R, Mallepalli PK. A level of empathy and spirituality among undergraduate medical students of a tertiary hospital in Telangana: A cross-sectional study. Telangana J Psychiatry 2022;8:46-52

How to cite this URL:
Dhedhi BJ, Gattavali R, Nadukuru GN, Macharapu R, Mallepalli PK. A level of empathy and spirituality among undergraduate medical students of a tertiary hospital in Telangana: A cross-sectional study. Telangana J Psychiatry [serial online] 2022 [cited 2022 Nov 28];8:46-52. Available from: https://tjpipstsb.org/text.asp?2022/8/1/46/346238

  Introduction Top

Empathy is a very important element in patient care.[1],[2] Empathy is the basis of all human interaction. Empathic is different from sympathy. Empathy is defined as predominantly a cognitive attribute; sympathy lacks a cognitive element.[3] Sympathy involves more toward emotion and the development of feelings for a patient.[4],[5] Both have different consequences in patient care.[5],[6] Sympathy could interfere in the objectivity required in medical assessment and treatment.[7]

Hojat et al. defined empathy as a cognitive attribute (rather than emotional) which involves an ability to understand (rather than feel) the patient's inner experiences and perspective and a capability to communicate this understanding and intention to help.[5],[6]

Medical students with higher empathy scores were significantly and positively linked with higher grades of clinical aptitude.[8] High quality of clinical empathy plays an important role in establishment of great rapport with their patients and acceptance clinical decisions.[9] Patient care with empathy leads to better patient adherence, increased patient satisfaction, more accurate prognosis, and decreased levels of stress in patients.[10] Physicians with higher empathy were found to have less burnout, higher clinical competence, and greater feeling of well-being.[11] Empathy was shown to have a positive impact on the ability to recognize social determinants and disparities in health care[12] and reduce prejudice.[13]

Empathy was found to have improved outcomes from both psychological and pharmacological interventions.[14],[15] Physicians with empathic approach were found to have good clinical outcomes in patients with diabetes.[16] Higher empathy scores were found to be associated with a lower risk of a cardiovascular event and all-cause mortality.[17] Patients' anxiety and discomfort are reduced when physicians consult with an empathic attitude.[18]

Low therapist empathy leads to high patient dropout and relapse rates.[19] A loss of empathy in doctors subsequently shows an increase in rate of major medical errors.[20] Lack of empathy could be one of the reasons for increasing agitation in society toward doctors, which can be said as threat of ethical misconduct for health-care professionals.[21]

There is now considerable evidence that levels of empathy tend to decline during medical school and beyond.[22] There are a few Indian studies that address empathy among medical students. We could not come across any Indian study that addresses spirituality among medical students. As mentioned above, empathy is important in the medical field. Hence, we thought of conducting a study.


  1. To assess the level of empathy among medical students
  2. To assess the level of spiritual well-being among medical students and its relationship with empathy.


  1. To assess empathy and spirituality among medical students
  2. To compare empathy and spirituality in 1st-year medical students to 4th-year medical students
  3. To assess empathy among various sociodemographic factors
  4. To know the relationship between spirituality and empathy.

  Materials and Methods Top

Study design and sample

A cross-sectional study was conducted from January 2021 to March 2021 for approximately 3-month period among undergraduate medical students enrolled at Mamata Medical College and Hospital, Khammam, Telangana. A total of 200 samples were collected from the study population by a convenient sample method, among them 50 1st-year, 50 2nd-year, 50 3rd-year, and 50 final-year medical students.

Students were approached during their lecture hour after the competition of the lecture. Some students were also approached at the college campus hostel who were not available at the lecture hall. All the participants were briefed about the aims and objectives of the study. Hard copies of the semi-structured pro forma and all scale questionnaires were handed over to students. They were also requested to contact the study taker if they had any doubts during filling out the questionnaire. Confidentiality of privacy was assured to all participants, and consent was taken from each participant.

Inclusion criteria

  • Those who are willing to participate in the study
  • Those who are able to understand the questionnaire.

Exclusion criteria

  • Those who are not willing to participate in the study
  • Those who are unable to comprehend the questionnaire
  • Those who are suffering from any psychiatric illness.

Data collection tool

The semi-structured pro forma includes sociodemographic information as well as other details such as the habit of doing meditation, the habit of watching holy TV channels, or spiritual videos.

The empathy level of the students was assessed with two different instruments: the Jefferson Scale of Physician Empathy Student version (JSPE-S) for clinical empathy and the Toronto Empathy Questionnaire (TEQ) for general empathy.

JSPE-S[5],[6],[23] – it is a 20-item scale with answer in 7-point Likert type scale (1 = strongly disagree to 7 = strongly agree). Half of the items are positively worded and directly scored, and the remaining half are negatively worded (reverse scored). The individual responses of the 20 items are added to get a total empathy score. The sum of total score ranges from 20 to 140. Higher score indicates a higher level of empathy. It is developed to measure clinical empathy for medical students. The scale has demonstrated good internal consistency and construct validity. The JSPE-Health Profession Student version has been validated in an Indian setting with good internal consistency (Cronbach's alpha of 0.70).[24]

TEQ[25] – it is a 16-item questionnaire with answer in five-point Likert type scale (0 = never, 1 = rarely, 2 = sometimes, 3 = often to 4 = always). Half of the items are positively worded (scored directly) and the remaining half of the items are negatively worded (scored reversely). The individual responses of the 16 items are added to get a total empathy score. The sum of the total score may range from 0 to 64. Higher score indicates a higher level of empathy. Scale has strong psychometric properties, including high internal consistency with Cronbach's = 0.85.

Spiritual Well-Being Scale (SWBS)[26],[27],[28] – it is a 20-item scale with answer in a 6-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = slightly agree, 5 = agree, and 6 = strongly agree). Out of 20 items, 10 were based on the religious well-being subscale, which has been indicated by odd numbers, and 10 were based on the existential well-being subscale, which has been indicated by even numbers. Among total 20, half of the items are adversely worded (scored reversely). Individual response of the 20 items is added together to get total spiritual well-being score. Individual response of “odd” item is added together to get total religious subscale score and individual response of “even” item is added together to get total existential subscale score. The total SWBS score may range from 20 to 120 and subscale score may range from 10 to 60. Higher total score indicates a higher level of spiritual well-being. Total scores are classified as low (20–40), moderate (41–99), and high (100–120). The scale has demonstrated good internal consistency and construct validity. The scale has been validated in India. Cronbach's alpha for the Hindi version of SWBS was 0.83.[29] However, we used the original English version of the scale.

Statistical analysis

Data were analyzed using SPSS (social science statistic) software version 22 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as percentages, and the results were expressed in terms of mean scores with standard deviations. A t-test was used for a comparison of the empathy of two study variables. The one-way analysis of variance test was used for the comparison of empathy and spirituality among all 4-year medical students, and it was also used for the comparison of empathy among more than two study variables. Pearson's correlation coefficient was used to measure the correlation between spiritual well-being and empathy by TEQ and JSPE-S. Statistical significance was set at P < 0.05.

  Results Top

The total study sample was 200. The mean age for all medical students was 20.73 (2.02). In total 200 students, 25% of the students from each year were selected [Table 1]. Among total study population, females were 55% and males were 45%. Students whose mother and father studied intermediate and below (low educated) were 39% and 20%, respectively [Table 2].
Table 1: Mean empathy score and year of study and student's position among siblings

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Table 2: Sociodemographic variable of study sample and mean empathy score

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Students whose mother and father were graduate or postgraduate (higher educated) were 61% and 80%, respectively. Majority of the students (83%) were from urban area and 17% were from rural area. Only a few 10% of students were having habit of doing meditation daily. Forty-two percent of the students were having habit of watching holy TV channels or spiritual videos on YouTube or social media [Table 2].

The mean JSPE-S score was 108.41 (14.19) and mean TEQ score was 44.89 (6.26). By JSPE-S, 1st and 2nd years had higher empathy score, and it decreased from the 3rd year and was lower in final-year medical students. It was significant statistically (P = 0.00002) [Table 1].

By TEQ, the 2nd year had a higher mean empathy score of 46.6 (6.32) followed by 3rd year and 1st year with a mean score of 45.72 (5.77) and 45.08 (5.96), respectively, and again was lower in final-year students with a mean score of 42.16 (6.26). It was significant statistically (P = 0.002) [Table 1].

By JSPE-S, females had higher empathy with a mean score of 110.91 (13.23) than males with a mean score of 105.36 (14.78) (P = 0.002). By TEQ also, females had higher empathy with a mean score of 46.65 (6.21) than males with a mean score of 42.73 (5.65) (P < 0.00001) [Table 2].

Pre- and paraclinical students had a higher mean empathy score than clinical-year medical students. It was significant statistically [Table 2]. Students whose father and mother studied graduate or postgraduate (higher educated) had significantly higher mean empathy score than whose parents were studied intermediate and below (low educated) [Table 2].

Students with habit of doing meditation daily had significantly higher mean empathy score than those who had no such habits [Table 2]. Students who belong to urban area had higher empathy than rural area. It was statistically significant by TEQ (0.0001) but not by JSPE-S.

In position among siblings by JSPE-S, students who are elder had higher empathy with a mean score of 111.46, followed by single only (110.9) and middle (109.75), and lower empathy in younger position with a mean score of 105.38 (P = 0.0395) [Table 2].

The total mean spiritual well-being score was 80.58 (18.89), with subscale of existential well-being mean score of 41.77 (9.10) and religious well-being mean score of 38.81 (12.1). There was a decrease in mean spiritual well-being score from the first to final year (P = 0.0016), same for existential well-being (P = 0.0002) and spiritual well-being (P = 0.048) [Table 3].
Table 3: Spiritual well-being and its subscale score among all year medical students

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There was a positive significant correlation of mean total spiritual well-being score with mean total JSPE-S (r = 0.4429, P = 0.0012) and TEQ score (r = 0.5777, P = 0.00001) [Table 4].
Table 4: Spiritual well-being relationship with empathy of study population using Pearson correlation coefficient calculator

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  Discussion Top

The aim of the present study is to assess the level of empathy among medical students. In the present study, the mean TEQ empathy score was 44.89 and the mean JSPE-S score was 108.41, which was quite similar to the study conducted by Youssef et al.,[30] who showed a mean empathy TEQ score of 47.06 and a JSPE-E score of 106.00. A study conducted by Akgün et al.[31] found a mean TEQ score of 52.8 and a mean JSPE-S score of 80.3.

The mean TEQ score in this study was 44.89, which was lower than the study by Akgün et al.[31] (52.8), but close to the studies by Riaz et al.[32] (42.57), Haque et al.[33] (45.78), and Pantović-Stefanović et al.[34] 2015 (45.23).

In the present study, the mean JSPE-S was 108.41, which was higher than the studies conducted by Nair et al.[35] (100.5), Kulkarni and Pathak[36] (99.25), Biswas et al.[37] 2017 (98.5), and Hasan et al.[38] 2013 (104.6). It was quite close to the study conducted by Mostafa et al.[39] 2014 (110.41) and Wen et al.[40] 2013 (109.60). It was lower than studies conducted by Chen et al.[41] 2007 (114.82), Guilera et al.[42] 2018 (121), and Hojat et al.[6] 2009 (115).

In the present study, females had higher mean empathy scores compared to males on both the TEQ and the JSPE-S. Various studies found that women had higher empathy than men.[30],[31],[32],[33],[34],[35],[36],[43],[44],[45] Women are more receptive to emotional signals, which could lead to better understanding and make women more empathic in cognition and emotion.[8]

In the present study, using the TEQ scale, we found that there was a fluctuation in empathy as education progressed, and finally, a decrease in empathy in the last year. Previous studies have shown that empathy decreases from the 1st to 3rd year, then increases in the 4th year, and finally decreases in the final year.[30],[32]

In the present study, by JSPE-S, it was found that empathy scores were higher in the initial years but decreased from the 3rd year and were lower in the final year. Many studies show that empathy decreases with increasing study periods and educational processes.[30],[35],[37],[41],[44],[46] The decrease in empathy in medical students could be due to a lack of role models, overreliance on computer-based diagnostic as well as therapeutic technology, pressure of time, and experiencing demanding and hostile environmental factors.[6] Other causes could be high academic workload, burnout, low quality of life, insomnia, and stress.[47]

Preclinical students had a higher empathy score compared to clinical year students. Several other studies found similar results.[41],[44],[45]

In the present study, on both scales, the student's mother and father, who had a higher education (graduate or postgraduate), had significantly higher empathy compared to the student's parents, who were less educated (intermediate and less). According to Hasan et al.'s[38] study, medical students whose mothers did not complete high school had less empathy than their more educated mothers. In contrast to our study, a study done by Yi et al.[43] showed that students' parents with low education had a higher level of empathy than higher educated parents.

In the present study, we found that students belonging to urban areas were more empathic than those in rural areas. Riaz et al.[32] discovered that students with permanent residences in urban areas were more empathic than those with permanent residences in rural areas. Contrary to the present study, Biswas et al.'s[37] study found that students belonging to rural areas had higher empathy than students from urban areas.

In the present study, medical students with the habit of doing meditation daily had significantly higher empathy compared to those who had no habit of doing meditation. In this study by JSPE-S, medical students with the habit of watching holy TV channels or spiritual videos on YouTube or social media had significantly higher empathy than those who had no such habit. We could not find any studies regarding such an association.

The aim of the present study was also to assess the relationship between spirituality and empathy among medical students. In the present study, the mean spiritual well-being score of medical students was 80.58, the existential well-being score was 41.77, and the religious well-being score was 38.81. Students had a moderate level of spiritual health. A study done by Salehi et al.[48] found a mean spiritual well-being score of 89.54, a mean religious score of 46.17, and an existential score of 43.37.

The mean spiritual well-being and subscale scores in the present study decreased significantly as the study year progressed. The previous study also discovered a decrease in spiritual, religious, and existential well-being scores from 1st- to 3rd-year students.[48]

In the present study, we found a positive and significant relationship between empathy, measured by TEQ and JSPE-S, and spiritual well-being. A study conducted by Angela Hamidia et al.[49] revealed a strong positive relationship between a student's perspective and clinical empathy and spiritual well-being. Spiritual well-being and religiosity were significant predictors of empathy in medical students.[50]

The culture of medicine and of medical training may be such that empathy is undervalued and undertaught.[51] Empathy could be maintained and increased by educational interventions in medical students, interventions such as workshops on role-playing and well-being, interpersonal skills, literature and medicine, spirituality, and communication skills.[52]

  Conclusion Top

Medical students had a moderate level of empathy and spiritual well-being. Clinical empathy decreased from the third to the final years. Female students were more empathic than males. Pre- and paraclinical students had higher levels of empathy than clinical students. Students' parents with a high education had more empathy than low-educated parents. Students with the habit of doing meditation daily were more empathic than those who had no such habit. There is a decrease in spiritual well-being as the study year increases. Spiritual well-being had a positive, significant correlation with empathy. Another research study needs to identify a cause for the decreasing empathy levels in medical students, so we can implement various interventions in the medical curriculum to improve empathy among students, which in turn will produce future empathic doctors, which benefits patients' care.


There was limited sample size. The study was conducted in a single institute, so result could not be generalized to all students of nation. As the study was cross-sectional, a longitudinal study could have accurately measured the decrease in empathy over a period of time. Empathy scale instruments were self-reported questionnaires, which might have caused some participants to respond in a socially desirable way by hiding personal beliefs or behaviour.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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