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"EMPATHY TRAINING AND STRESS: THEIR ROLE IN MEDICAL STUDENTS' RESPONSES TO EMOTIONAL PATIENTS by HEATHER MARIE HIGGINS  ,A.  B.Sc. Mount A l l i s o n U n i v e r s i t y , 1974 The U n i v e r s i t y o f B r i t i s h Columbia, 1979  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE  FACULTY OF GRADUATE STUDIES  (Interdisciplinary  Studies)  We accept t h i s t h e s i s as conforming to the required  THE  standard  UNIVERSITY OF BRITISH COLUMBIA A p r i l 1990 \u00AEHeather Marie H i g g i n s , 1990  \u000CIn  presenting this  degree  at the  thesis  in  University of  partial  fulfilment  of  of  department  this thesis for or  by  his  or  requirements  British Columbia, I agree that the  freely available for reference and study. I further copying  the  representatives.  an advanced  Library shall make it  agree that permission for extensive  scholarly purposes may be her  for  It  is  granted  by the  understood  that  head of copying  my or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department The University of British Columbia Vancouver, Canada  DE-6 (2/88)  \u000CAbstract  T h i s study i n v e s t i g a t e d the e f f e c t s of empathy t r a i n i n g medical  s t u d e n t s ' responses  on  to emotionally intense s i t u a t i o n s .  I t a l s o e x p l o r e d the i n t e r a c t i o n between empathy and  stress.  T h i r t e e n v o l u n t e e r s from a second-year medical c l a s s completed the study which u t i l i z e d a t w o - f a c t o r c r o s s o v e r d e s i g n .  In  the f i r s t of t h r e e t e s t i n g s i t u a t i o n s , each s u b j e c t p a r t i c i p a t e d i n a 15-minute v i d e o t a p e d who  i n t e r v i e w w i t h an a c t o r  p o r t r a y e d an angry, f e a r f u l , or g r i e v i n g p a t i e n t .  medical  Each  student then completed measures of empathic  understanding  and p e r c e i v e d s t r e s s r e g a r d i n g the encounter,  w e l l as s c a l e s of coping and h a r d i n e s s .  as  Each s i m u l a t e d  p a t i e n t r a t e d the medical s t u d e n t s l e v e l of empathic 1  understanding.  Two  r a t e r s , b l i n d t o the experimental  analyzed the tapes and r a t e d the medical s t u d e n t s communicated empathy. one of two  groups:  delayed t r a i n i n g .  1  design,  degree of  S u b j e c t s were then randomly a s s i g n e d t o  t r a i n i n g w i t h follow-up, or c o n t r o l w i t h The  f i r s t group r e c e i v e d f o u r 3-hour weekly  s e s s i o n s i n empathy t r a i n i n g w h i l e the second group served a wait-list control.  A l l s u b j e c t s then p a r t i c i p a t e d i n a  second taped i n t e r v i e w and completed a l l measures a g a i n . s u b j e c t s i n group two  as  r e c e i v e d the t r a i n i n g w h i l e the  group r e c e i v e d no f u r t h e r treatment. a t h i r d time which concluded  The  first  A l l s u b j e c t s were t e s t e d  the experimental  procedure.  \u000Ciii The  principal statistical  ANOVAS t e s t e d revealed  that,  a n a l y s e s comprised a s e r i e s o f 2 x 2  a t t h e .05 l e v e l o f s i g n i f i c a n c e . following  Results  the t r a i n i n g , s u b j e c t s l e a r n e d t o  i n t e r a c t i n a more empathic manner; e f f e c t s i z e s ranged from 1.08 t o 18.32.  Also,  subjects*  s t r e s s l e v e l s regarding the  e m o t i o n a l l y i n t e n s e encounters were reduced; t h e e f f e c t s i z e was -1.95.  As hypothesized, these changes i n empathy and  s t r e s s were not observed f o r t h e w a i t - l i s t c o n t r o l group, w h i l e t r a i n i n g e f f e c t s were maintained f o r s u b j e c t s i n t h e f o l l o w - u p group. statistically  Changes i n h a r d i n e s s and c o p i n g were not  significant.  An o u t l i n e i s p r e s e n t e d which  i l l u s t r a t e s t h e mediating f u n c t i o n stressful interactions.  o f empathic responding i n  A l s o addressed a r e i m p l i c a t i o n s f o r  empathy t r a i n i n g i n medical e d u c a t i o n and f o r communication i n the p h y s i c i a n - p a t i e n t  relationship.  \u000Civ Table of Contents  Page  Abstract  i i  Table of Contents  iv  L i s t of Tables  viii  L i s t of F i g u r e s  x  Acknowledgements  xi  Dedication  xii  CHAPTER I: Introduction Background  1  O b j e c t i v e s of the Study  4  Operational D e f i n i t i o n s Empathy Stress Coping  7 7 8 8  Assumptions and  9  Limitations  Overview of the Document  CHAPTER I I :  11  Literature Review  Introduction  12  Value of E f f e c t i v e Communication i n the  Medical  Interview  13  E f f e c t s of Miscommunication i n the M e d i c a l The  14  Emergence of Communication S k i l l s T r a i n i n g  i n Medical  Education  I n c r e a s i n g Humanism i n Medical The  Interview  15 Students  Concept of Empathy  Empathy i n the P h y s i c i a n - P a t i e n t R e l a t i o n s h i p Intense Emotions as Sources of S t r e s s f o r M e d i c a l Practitioners Need f o r Empathy T r a i n i n g  19 21 26 29 32  \u000CV  Page E f f e c t i v e n e s s o f Empathy i n E m o t i o n a l l y - I n t e n s e Situations  34  P r e v i o u s Research Examining Empathy and S t r e s s  37  Hypotheses R e l a t e d t o Empathy and S t r e s s  41  P r e v i o u s Research R e l a t e d t o E x p l o r a t o r y Analyses ... Hardiness Ways o f Coping M e t h o d o l o g i c a l Issues I d e n t i f i e d i n Relevant P r e v i o u s Research  42 42 45  CHAPTER I I I :  Method  Introduction Experimental  47  54 Design  54  Subjects P o p u l a t i o n s and Samples . . .-. Recruitment and S e l e c t i o n  60 60 60  S e l e c t i o n o f t h e T r a i n e r , Raters, and Simulated P a t i e n t s Selection of the Trainer S e l e c t i o n o f t h e Raters S e l e c t i o n o f t h e Simulated P a t i e n t s  61 61 62 62  S u p e r v i s i o n o f t h e T r a i n e r and Raters  62  Research Measures Carkhuff Empathy R a t i n g S c a l e Barrett-Lennard Relationship Inventories Perceived Stress Questionnaire Hardiness S c a l e Ways o f Coping S c a l e S e s s i o n and O v e r a l l T r a i n i n g E v a l u a t i o n  63 63 65 66 66 67 69  Experimental Procedure The Experimental Treatment - Empathy T r a i n i n g . . Equipment and F a c i l i t i e s Scenarios f o r Testing S i t u a t i o n s T r a i n i n g o f t h e Simulated P a t i e n t s Emotion and Gender Combinations d u r i n g T e s t i n g Occasions Pre-Testing of Subjects ' Assignment t o Group A d m i n i s t r a t i o n o f T r a i n i n g and P o s t - T e s t i n g ....  69 69 70 70 72 73 74 75 76  \u000Cvi Page S t a t i s t i c a l Considerations Designs Used t o T e s t t h e Hypotheses A d d i t i o n a l E x p l o r a t o r y Questions  77 84 90  Data A n a l y s i s Procedures  90  CHAPTER IV:  Results  Introduction  91  Subject  91  Characteristics  Implementation Check o f Simulated  Patients  Inter-rater R e l i a b i l i t y Analyses of T r a i n i n g E f f e c t s Hypothesis 1A and IB Hypothesis 2 A i through 2 B i i i Hypothesis 3A and 3B Summary  91 92 92 95 103 108 I l l  R e s u l t s o f E x p l o r a t o r y Analyses Hardiness S c a l e B e h a v i o u r a l Coping Measures  112 112 115  Effect Sizes  121  S e s s i o n and T r a i n i n g E v a l u a t i o n  123  Summary o f F i n d i n g s  130  CHAPTER V:  Discussion  Introduction  132  Summary  132  D i s c u s s i o n o f R e s u l t s o f Dependent Measures Percentage o f L e v e l 3 Responses BLRI ( P a t i e n t Ratings o f Empathy Scale) BLRI (Medical Student Ratings o f Empathy Scale) Perceived Stress Questionnaire Hardiness B e h a v i o u r a l Coping S t r a t e g i e s Effect Sizes  13 3 133 134 135 13 6 138 139 140  \u000Cvii Page I m p l i c a t i o n s f o r Empathy S k i l l T r a i n i n g i n Medical Education  14 0  I m p l i c a t i o n s f o r Communication i n the Physician-Patient Relationship  149  Suggestions f o r F u r t h e r Research  157  References  160  Appendix A  178  Appendix B . . Appendix C  180 183  \u000Cviii L i s t of Tables Table 1.  Page Gender of Medical Student and Simulated Patient by Emotion of Scenario  73  2.  Means and Standard Deviations for Dependent Measures (N = 13)  93  3.  Summary of Analyses of Variance f o r Dependent Measures (Hypotheses (1A &amp; IB: Comparison of C e l l s 1 &amp; 2 with 4 &amp; 5, N = 13)  96  4.  5. 6.  7. 8.  9.  10. 11. 12.  Summary of Analyses of Variance f o r Dependent Measures (Hypotheses 2 A i &amp; 2 B i : Comparisons of C e l l s 2 &amp; 3 with 4 &amp; 5, N = 13)  104  Results of the T-Tests for Carry-Over and Wait-List E f f e c t s  107  Summary of Analyses of Variance f o r Dependent Measures (Hypotheses 3A &amp; 3B: Comparison of C e l l s 1 &amp; 2 with 5 &amp; 6, N = 13)  109  Summary of Analyses of Variance f o r Hardiness Scale (N = 13)  113  Summary of Analyses of Variance f o r Emotion-Focused Coping Scale (Number of Strategies Used) N = 13  116  Summary of Analyses of Variance f o r Problem-Focused Coping Scale (Number of Strategies Used) N = 13  117  Behavioural Coping Strategies Used by a l l Subjects Pre- and Post-Training (N = 13). ...  12 0  E f f e c t Sizes f o r Measures (N = 13, 2 Groups Pooled)  121  Fequency of Responses from Session Feedback  124  \u000Cix  Table 13.  Page Number o f Responses t o E v a l u a t i o n f o r A l l Sessions  127  14.  Suggestions f o r Improvements t o t h e Course. .  128  15.  Summary o f S i g n i f i c a n t R e s u l t s from A n a l y s e s of V a r i a n c e f o r t h e Main Hypotheses  130  \u000CX  L i s t of Figures Figure 1.  Page  A t r a n s a c t i o n a l model i l l u s t r a t i n g some p o s s i b l e f a c t o r s involved i n the process of poor p h y s i c i a n - p a t i e n t communication  4  2.  T e s t i n g room arrangement  71  3.  T r a i n i n g room arrangement  VI  4.  Experimental d e s i g n  79  5.  C e l l s used i n ANOVAS t o t e s t 1A and IB  hypotheses  C e l l s used i n ANOVAS t o t e s t 2Ai through 2 B i i i  hypotheses  C e l l s used i n ANOVAS t o t e s t 3A and 3B  hypotheses  6. 7. 8. 9. 10. 11.  86 87 89  Means f o r percentage o f l e v e l 3 responses r a t e d on t h e Carkhuff Empathy S c a l e  98  Means f o r s i m u l a t e d p a t i e n t r a t i n g s on the Empathy S c a l e o f t h e BLRI  99  Means f o r medical student r a t i n g s on t h e Empathy S c a l e o f t h e BLRI  100  Means f o r medical student r a t i n g s on t h e Perceived Stress Scale  101  12.  Means f o r Hardiness S c a l e  114  13.  Means f o r Emotion-Focused  14. 15.  Means f o r Problem-Focused Coping S c a l e O u t l i n e o f d i f f e r e n c e s i n medical students emotions and coping behaviours b e f o r e and a f t e r empathy t r a i n i n g  Coping S c a l e  118 119 138  \u000Cxi Acknowledgements  I wish t o express my h e a r t f e l t g r a t i t u d e t o the members of my  d i s s e r t a t i o n committee, Dr. Don  Herbert, and Dr. Doug Willms s u g g e s t i o n s throughout project. Dr. B i l l  Dutton,  Dr. C a r o l  f o r t h e i r time, p a t i e n c e , and  the p r e p a r a t i o n of t h i s r e s e a r c h  My deep a p p r e c i a t i o n goes t o my  chairman,  Borgen, f o r h i s c o n s t a n t support, encouragement,  and a s s i s t a n c e . Dr. K e i t h Dobson and Dr. P e t e r Grantham o f f e r e d v a l u a b l e i d e a s d u r i n g the d e s i g n stage of t h i s I am g r a t e f u l t o the 13 graduate psychology who raters.  My  study. students i n c o u n s e l l i n g  served as s i m u l a t e d p a t i e n t s , t r a i n e r ,  thanks go a l s o t o the medical students who  t h e i r time f o r t h i s  study.  and devoted  \u000CIn l o v i n g memory o f my Mother, Mary Kathleen  \"In the earliest the mother  . . . initiates  whereby the child  days and weeks of l i f e , an empathic  can, in turn,  relationship.  be empathic  \u2014Gladstein,  with  1987: 122  . . others.  \u000C1 CHAPTER I Introduction  Background The i n t e r a c t i o n between p h y s i c i a n s and t h e i r p a t i e n t s has been s a i d t o be t h e keystone o f medicine (Engel, 1973).  An  i n t e g r a l aspect o f t h i s i n t e r p e r s o n a l encounter i s communication.  I t i s through communication w i t h p a t i e n t s t h a t  p h y s i c i a n s a r e a b l e t o e l i c i t and convey i n f o r m a t i o n which may have an impact upon t h e e f f e c t i v e d e l i v e r y o f h e a l t h c a r e (White, 1988).  Indeed, C a s s e l l  (1985) suggested t h a t  e f f e c t i v e communication r e p r e s e n t s t h e c e n t r a l s k i l l on which a l l other a b i l i t i e s  i n t h e p r a c t i c e o f medicine depend.  Even though e f f e c t i v e communication i s v i t a l  i n medicine,  o n l y r e c e n t l y has much emphasis has been p l a c e d on communication s k i l l s  (Badenoch, 1986; W a i t z k i n , 1984).  Most  medical s c h o o l s , u n t i l t h e l a s t decade, d i d not o f f e r i n t e r p e r s o n a l communication s k i l l s t r a i n i n g Jason, 1979).  (Kahn, Cohen, &amp;  The assumptions appeared t o be t h a t e i t h e r a  person had t h e i n s t i n c t s t o be a good communicator  o r not, and  t h a t t h e s e s k i l l s would be developed w i t h e x p e r i e n c e through intuition or.imitation  ( R i c c a r d i &amp; K u r t z , 1983).  Recent  r e s e a r c h , however, i n d i c a t e s t h a t more a t t e n t i o n needs t o be g i v e n t o t h e development o f communication s k i l l s students and p h y s i c i a n s 1985; White, 1988).  i n medical  ( B e r n s t e i n &amp; B e r n s t e i n , 1985; C a s s e l l ,  \u000C2 One  aspect of communication s k i l l s t r a i n i n g which has  been i d e n t i f i e d as l a c k i n g i n medical s c h o o l s i s the t e a c h i n g of  empathy s k i l l s  (Sanson-Fisher  purpose of t h i s study was  &amp; Maguire, 1980).  The main  t o examine the e f f e c t i v e n e s s of  empathy s k i l l s t r a i n i n g f o r medical  students,  particularly  when they are c h a l l e n g e d by e m o t i o n a l l y i n t e n s e  encounters  with simulated p a t i e n t s . Empathy, which i s a core i n g r e d i e n t of the h e l p i n g p r o c e s s i n c o u n s e l l i n g and psychotherapy Egan, 1986), may to  understand  illness.  (e.g., Rogers,  help physicians i n t h e i r c l i n i c a l  p a t i e n t s ' emotional  1957;  interviews  needs which o f t e n accompany  D e a l i n g w i t h such emotional  needs o f t e n i n v o l v e s  working w i t h i n t e n s e a f f e c t r e l a t e d t o s u f f e r i n g , f e a r and death  (McCue, 1982).  A l s o , p a t i e n t s o f t e n expect c o u n s e l l i n g  and h e l p from t h e i r p h y s i c i a n s i n d e a l i n g w i t h p s y c h o s o c i a l i s s u e s (Baker &amp; Cassata, C l e a r y , 1987;  1978;  their  Good, Good, &amp;  Hansen, Bobula, Meyer, Kushner, &amp; Pridham,  Herbert, Cooke, Gutman &amp; Schechter,  1987;  1986).  Working w i t h such i n t e n s e l y emotional  a s p e c t s of p a t i e n t  c a r e has been i d e n t i f i e d as a source of s t r e s s f o r p r a c t i s i n g physicians  (Herbert &amp; Grams, 1986;  McCranie, Hornsby, &amp; C a l v e r t , 1982).  May  &amp; Revicki,  1985;  M e d i c a l students a l s o  r e p o r t e d t h a t coping w i t h i n t e n s e emotions i n t h e i r i n t e r a c t i o n s with p a t i e n t s contributes to t h e i r high s t r e s s levels  ( F i r t h , 1986;  Knight,  1983).  Firth  (1986)  concluded  t h a t t h e r e i s a need t o i d e n t i f y means which can h e l p  \u000C3 a l l e v i a t e medical s t u d e n t s ' d i s t r e s s when d e a l i n g w i t h s t r e s s f u l a s p e c t s o f p a t i e n t c a r e such as s u f f e r i n g . Branch  (1987) suggested t h a t t h e reason p h y s i c i a n s  e x p e r i e n c e d i s c o m f o r t i n d e a l i n g w i t h t h e emotional needs o f p a t i e n t s i s t h a t they l a c k t r a i n i n g i n t h i s a r e a .  Heavy  (1988) p o i n t e d out t h a t p h y s i c i a n s , f e e l i n g a sense o f f a i l u r e i n t h e c u r i n g r o l e , may a v o i d d e a l i n g w i t h p a t i e n t s ' i s s u e s and so may appear a l o o f o r i n s e n s i t i v e .  She concluded t h a t i t  i s necessary f o r medical p r a c t i t i o n e r s t o r e c e i v e empathy t r a i n i n g f o r t h e sake o f both themselves  and t h e i r p a t i e n t s .  P h y s i c i a n s themselves have i n d i c a t e d a need f o r t r a i n i n g i n d e a l i n g w i t h p s y c h o s o c i a l needs o f p a t i e n t s . In a survey o f 151 p h y s i c i a n s from a v a r i e t y o f s p e c i a l t i e s , Lewis, W e l l s , and Ware (1986) found t h a t 85 p e r c e n t o f them agreed  that  c o u n s e l l i n g p a t i e n t s was important; however, o n l y 12 p e r c e n t s a i d they were e f f e c t i v e i n c o u n s e l l i n g .  M e d i c a l students  a l s o have i n d i c a t e d a need f o r t r a i n i n g i n d e a l i n g w i t h emotional i s s u e s .  Batenburg  and G e r r i t s m a  (1983) found t h a t  medical s t u d e n t s i n d i c a t e d a need f o r f u r t h e r e x p e r i e n c e i n coping w i t h p a t i e n t s ' emotions even though they had a b a s i c i n t e r v i e w i n g s k i l l s course.  I t i s important, then, f o r  medical s t u d e n t s t o r e c e i v e empathy communication  skills  t r a i n i n g because they spend c o n s i d e r a b l e time, both as s t u d e n t s and as p r a c t i s i n g p h y s i c i a n s , i n e m o t i o n a l l y i n t e n s e involvement w i t h p a t i e n t s which can be a s i g n i f i c a n t source o f stress.  \u000C4  F i g u r e 1 i l l u s t r a t e s some o f t h e consequences o f l a c k o f t r a i n i n g and ensuing s t r e s s experienced by medical  students  and p h y s i c i a n s when they a r e presented w i t h e m o t i o n a l l y intense  interactions.  Presentation of intense emotional issue by patient ^  Expectations by patient of ^ physician to deal ^ with intense emotional issue  Lack of training. in communication ^ skills by physician ^ to respond effectively to intense emotional issue  Strong emotional discomfort by physician ^ and possible 4 ^ avoidance of patient's emotional issue  Stress for both physician and patient ensues, which may result in an unsatisfactory physician-patient relationship  F i g u r e 1. A t r a n s a c t i o n a l model i l l u s t r a t i n g some p o s s i b l e f a c t o r s i n v o l v e d i n t h e p r o c e s s o f poor p h y s i c i a n p a t i e n t communication.  O b j e c t i v e s o f t h e Study The r e c o g n i t i o n o f t h e importance  o f good p h y s i c i a n -  p a t i e n t communication h i g h l i g h t s t h e need f o r r e s e a r c h t o determine  the effectiveness of interpersonal  s k i l l s training i n this setting &amp; Mumford, 1984).  ( B e t c h a r t , Anderson, Thompson,  Poole and Sanson-Fisher  t h a t t r a i n i n g i n empathic  communication  (1979) recommended  s k i l l s be p r o v i d e d , but o n l y w i t h  continual evaluation of i t s effectiveness.  However, a number  of m e t h o d o l o g i c a l i s s u e s have been i d e n t i f i e d which must be c o n s i d e r e d when determining t h e e f f e c t i v e n e s s o f a communication s k i l l s t r a i n i n g course. C a r r o l l and Munroe (1980) and Sanson-Fisher,  Fairbairn,  and Maquire (1981), i n t h e i r two reviews o f t h e methodologies  \u000C5  of  s t u d i e s used t o e v a l u a t e t h e e f f e c t s o f communication  s k i l l s t r a i n i n g , suggested  that the great majority of studies  have employed weak r e s e a r c h designs  (e.g., no c o n t r o l  group),  and so t h e v a l i d i t y o f t h e f i n d i n g s must be q u e s t i o n e d . suggested  r e p l i c a t i n g s t u d i e s w i t h more c o n t r o l  p o t e n t i a l l y confounding  They  over  factors.  Kahn e t a l . (1979) i n another review o f s t u d i e s r e p o r t e d t h a t w h i l e 95 p e r c e n t o f i n t e r v i e w i n g courses had an e v a l u a t i o n component, 87 p e r c e n t o f these used methods such as c l a s s attendance  indirect  o r student knowledge.  Few  used d i r e c t o b s e r v a t i o n o f s k i l l s o r c r i t e r i o n - r e f e r e n c e d instruments.  W o l r a i c h , Albanese,  and Stone (198 6)  p o i n t e d out  t h a t one o f t h e b a r r i e r s t o e v a l u a t i n g p h y s i c i a n - p a t i e n t i n t e r a c t i o n s i s t h e d e a r t h o f r e l i a b l e and v a l i d  instruments  to  L e s s a r , and  a s s e s s communication s k i l l s .  Millar  Gask, Goldberg,  (1988) suggested t h a t few communication t r a i n i n g  courses e v a l u a t e d t h e changes i n s k i l l s by a s s e s s i n g v i d e o t a p e d i n t e r v i e w s p r e - and p o s t - t r a i n i n g . The purpose o f t h e p r e s e n t study was t o examine t h e e f f e c t i v e n e s s o f empathy communication s k i l l s t r a i n i n g f o r medical students e s p e c i a l l y when they a r e c h a l l e n g e d by emotionally intense c l i n i c a l shortcomings  situations.  To a v o i d some o f the  o f p r e v i o u s r e s e a r c h i n t h e area, t h i s  employed a \" t r u e \" experimental d e s i g n d i r e c t observation of s k i l l s  study  (Cook &amp; Campbell,  1979),  from v i d e o t a p e d i n t e r v i e w s , and  r e l i a b l e and v a l i d r e s e a r c h instruments designed t o measure a s p e c t s t h a t t h e i n t e r v e n t i o n was meant t o a f f e c t .  \u000C6  Many s t u d i e s have attempted t o e v a l u a t e t h e e f f e c t i v e n e s s of  p h y s i c i a n s ' communication s k i l l s i n terms o f p a t i e n t  satisfaction.  However, one o f t h e common reasons why  communication s k i l l s t r a i n i n g i s n o t o f f e r e d i n medical s c h o o l s as suggested that i t w i l l  by Wakeford (1983) i s \"You haven't  h e l p t h e medical s t u d e n t s \"  (p. 245).  T h i s study i n v e s t i g a t e d whether empathy s k i l l s  training  would h e l p medical students by d e c r e a s i n g t h e i r s t r e s s i n emotionally intense s i t u a t i o n s . of  t h i s study was:  medical  proved  levels  The main r e s e a r c h q u e s t i o n  What i s t h e impact  o f empathy t r a i n i n g f o r  students, both i n terms o f i n c r e a s i n g t h e i r l e v e l s o f  empathy as w e l l as d e c r e a s i n g t h e i r l e v e l s o f p e r c e i v e d s t r e s s i n emotionally intense c l i n i c a l i n t e r a c t i o n s ? E x p l o r a t o r y q u e s t i o n s which, were addressed  also i n this  study i n c l u d e d : (1)  Do c e r t a i n p e r s o n a l i t y c h a r a c t e r i s t i c s and b e h a v i o u r a l coping s t r a t e g i e s change as a r e s u l t o f empathy t r a i n i n g ?  (2)  What k i n d s o f coping s t r a t e g i e s a r e most commonly used by medical students t o cope w i t h t h e s t r e s s o f medical  (3)  training?  What processes o f t h e t r a i n i n g do t h e t r a i n e e s l i k e the b e s t , t h e l e a s t , and l e a r n by t h e most?  \u000C7 Operational  Definitions  Empathy Barrett-Lennard  (1981) suggested  t h a t the p r o c e s s of  empathy i n v o l v e s t h r e e d i s t i n c t phases. the i n n e r p r o c e s s of empathic l i s t e n i n g the c l i n i c i a n . expressed  Phase two  Phase one r e f e r s t o and understanding  r e f e r s t o the communicated or  empathic understanding  by the c l i n i c i a n .  The  phase of the empathy c y c l e i s r e c e i v e d empathy by the Barrett-Lennard d i f f e r e d  from Truax and Carkhuff  r e g a r d t o the o p e r a t i o n a l d e f i n i t i o n Carkhuff  of empathy.  (19 67) h e l d the view t h a t empathy may  terms of the t h e r a p i s t ' s behavior alone. maintained  t h a t the c l i n i c i a n ' s  operational definition In t h i s  third  client. with  Truax and  be d e f i n e d i n  Barrett-Lennard  and c l i e n t ' s s u b j e c t i v e  e x p e r i e n c e p a r t l y d e f i n e s the empathic p r o c e s s , and i n c l u d e d the c l i n i c i a n ' s  by  and c l i e n t ' s  he  inner processing i n h i s  (Barrett-Lennard, 1962,  1981).  study, medical student experienced empathy, or  empathic understanding,  i s o p e r a t i o n a l l y d e f i n e d as a score on  the c l i n i c i a n form (MO)  of the Empathy s c a l e of the B a r r e t t -  Lennard R e l a t i o n s h i p Inventory  ( B a r r e t t - L e n n a r d , 1962).  Communicated empathy i s d e f i n e d as the degree t o which medical students  1  statements  expressed  measured by C a r k h u f f ' s empathy, or how medical  empathic understanding  (1969) 5-point s c a l e .  as  Received  empathic the simulated p a t i e n t p e r c e i v e d the  student t o be,  on the c l i e n t form (OS)  i s o p e r a t i o n a l l y d e f i n e d as the score of the Empathy s c a l e of the B a r r e t t -  Lennard R e l a t i o n s h i p Inventory  ( B a r r e t t - L e n n a r d , 1962).  \u000C8  Stress Researchers who study s t r e s s have been unable t o reach g e n e r a l agreement r e g a r d i n g a d e f i n i t i o n o f s t r e s s . Lazarus  (1985) suggested  Monat and  that stress i s a general l a b e l f o r a  complex and i n t e r d i s c i p l i n a r y area o f study. r e f e r s t o \"any event i n which environmental  Stress generally demands, i n t e r n a l  demands, o r both t a x o r exceed t h e a d a p t i v e r e s o u r c e s o f an individual\"  (Monat &amp; Lazarus, 1985, p. 3 ) .  Folkman and Lazarus  (1980) d e f i n e d two important  p r o c e s s e s i n v o l v e d when a person i s a f f e c t e d by a s t r e s s f u l occurrence i n t h e environment. i s coping. to  One i s a p p r a i s a l and t h e other  A p p r a i s a l r e f e r s t o the c o g n i t i v e processes  used  e v a l u a t e t h e s t r e s s f u l s i t u a t i o n and t h e o p t i o n s a v a i l a b l e  to deal with i t .  In t h i s study, a p p r a i s a l by t h e s u b j e c t s o f  the e m o t i o n a l l y i n t e n s e i n t e r a c t i o n s w i t h t h e s i m u l a t e d p a t i e n t i s o p e r a t i o n a l l y d e f i n e d as s c o r e s on t h e P e r c e i v e d S t r e s s S c a l e which I developed  f o r t h e purposes  of t h i s  research.  Coping Coping r e f e r s t o an i n d i v i d u a l s response t o s t r e s s o r 1  one's e f f o r t s t o adapt i n s i t u a t i o n s which one a p p r a i s e s as b e i n g harmful, t h r e a t e n i n g , o r c h a l l e n g i n g (Lazarus &amp; Folkman, 1984).  There appears  study o f coping.  t o be two d i f f e r e n t approaches t o t h e  Some i n v e s t i g a t o r s have emphasized c o p i n g  t r a i t s or personality dispositions  ( G o l d s t e i n , 1973), w h i l e  \u000C9 o t h e r r e s e a r c h e r s have s t u d i e d a c t i v e , ongoing coping s t r a t e g i e s used i n p a r t i c u l a r s t r e s s f u l s i t u a t i o n s Lazarus,  1980).  Monat and Lazarus  (Folkman &amp;  (1985) suggested  t h a t the  study of coping, which i s t i e d t o the study of s t r e s s ,  should  focus on measuring both coping processes and p e r s o n a l i t y dispositions. In the p r e s e n t study, coping w i t h s t r e s s w i t h r e s p e c t t o p e r s o n a l i t y d i s p o s i t i o n was  o p e r a t i o n a l l y d e f i n e d by s c o r e s on  Kobasa's (1979) p e r s o n a l i t y - b a s e d Hardiness measure  comprised  of commitment, c o n t r o l and c h a l l e n g e . S t r e s s w i t h r e s p e c t t o coping behaviours w i t h the s t r e s s of medical t r a i n i n g was  used t o cope  operationally defined  as the number and types of coping s t r a t e g i e s used focused and emotion focused) Coping  (problem  as i n d i c a t e d on the Ways of  S c a l e (Donnelly, 1979).  Assumptions and L i m i t a t i o n s The  context f o r examining the r e s e a r c h q u e s t i o n was  an  i n t e r a c t i o n between a medical student and a s i m u l a t e d p a t i e n t . One  assumption of t h i s study was  t h a t the analog would be  s u f f i c i e n t l y s i m i l a r t o a s e s s i o n of an a c t u a l medical i n t e r v i e w t o enable the r e s u l t s t o be g e n e r a l i z e d t o such a s e s s i o n and t h a t simulated p a t i e n t s c o u l d be regarded s i m i l a r t o p a t i e n t s i n g e n e r a l , who and who  are f r e e of gross  Researchers  as  are f u n c t i o n i n g normally  psychopathology.  have found t h a t the use of s i m u l a t e d p a t i e n t s  has been e f f e c t i v e i n a s s e s s i n g medical  students'  \u000C10 communication s k i l l s Hannay, 198 0).  One  (e.g., Sanson-Fisher &amp; Poole, of the advantages of u s i n g  p a t i e n t s i n the study of p h y s i c i a n - p a t i e n t  Further,  simulated  simulated  interactions i s  t h a t i t i s p o s s i b l e t o have more c o n t r o l over s i m i l a r i n t e n s i t y l e v e l s and  1980;  maintaining  nature of emotions p r e s e n t e d .  p a t i e n t s were found t o be so a u t h e n t i c  that  medical s t u d e n t s and p h y s i c i a n s c o u l d not d i s t i n g u i s h them from r e a l p a t i e n t s O'Hagan, 1986;  (Norman, Tugwell, &amp; F e i g h t n e r ,  Sanson-Fisher &amp; Poole, 1980).  (1977) found, i n h i s mock p r i s o n r e s e a r c h ,  1982;  Also  Zimbardo  t h a t the guards and\u2022  p r i s o n e r s u b j e c t s developed a t t i t u d e s which were q u i t e i n d i s t i n g u i s h a b l e from r e a l guards and p r i s o n e r s .  Thus the  assumption t h a t r e s u l t s can be g e n e r a l i z e d t o r e a l p a t i e n t p h y s i c i a n i n t e r a c t i o n s has The  experiencing  some e m p i r i c a l  support.  of i n t e n s e emotions was  assumed t o be  u n i v e r s a l human experience which i s c o n s i s t e n t a c r o s s from a l l c u l t u r e s  t h a t o n l y those p r o f e s s i o n a l s  have p r o f e s s i o n a l t r a i n i n g and  experience i n i n t e r p e r s o n a l  s k i l l s are a b l e t o assess empathy a c c u r a t e l y Burstein,  persons  (Buck, 1984).  A f u r t h e r assumption was who  (Carkhuff  &amp;  1970).  Regarding l i m i t a t i o n s , the s u b j e c t s were a l l v o l u n t e e r s which may  have been a source o f b i a s i n the  P a r t i c i p a t i o n i n the study was s u b j e c t s who  a  sample.  time-consuming, so t h a t those  were most motivated t o l e a r n empathy  communication s k i l l s may  have  volunteered.  \u000C11 T h i s study was conducted w i t h s u b j e c t s from a second medical c l a s s .  Strictly  year  speaking, r e s u l t s may be g e n e r a l i z e d  t o those medical students i n t h i s c l a s s year.  However, i t  possesses i m p l i c a t i o n s f o r p h y s i c i a n - p a t i e n t i n t e r a c t i o n s i n general.  I assume t h a t empathy i s a c o r e  facilitative  c o n d i t i o n i n any h e l p i n g r e l a t i o n s h i p and t h a t h i g h l e v e l s of h e l p e r empathy may h e l p t o i n c r e a s e helpee s e l f awareness and r e l e a s e t h e p o t e n t i a l f o r t h e helpee t o make c o n s t r u c t i v e changes w i t h r e g a r d t o the problem presented.  O v e r v i e w o f t h e Document Chapter two c o n t a i n s a review o f t h e r e l e v a n t l i t e r a t u r e and a r a t i o n a l e f o r t h e r e s e a r c h problem.  Chapter t h r e e  p r o v i d e s d e t a i l s about t h e r e s e a r c h d e s i g n and experimental procedures.  R e s u l t s o f t h e s t a t i s t i c a l treatment o f t h e data  are p r e s e n t e d i n chapter f o u r .  Chapter f i v e i n c l u d e s a  d i s c u s s i o n o f t h e r e s u l t s and suggestions f o r f u r t h e r research.  \u000C12 CHAPTER I I L i t e r a t u r e Review  Introduction The p u r p o s e s o f t h e f i r s t p a r t o f t h i s l i t e r a t u r e are t o provide the research the value medical  a r a t i o n a l e f o r t h e study  problem.  The c h a p t e r  review  and t o c l e a r l y  define  opens w i t h a d i s c u s s i o n o f  o f e f f e c t i v e communication and s k i l l  training for  p r a c t i t i o n e r s . The t r e n d t o w a r d a d o p t i n g  a  b i o p s y c h o s o c i a l model o f m e d i c i n e and t r a i n i n g p h y s i c i a n s t o b e more humane i s e x a m i n e d .  A d i s c u s s i o n o f t h e concept o f  empathy i s f o l l o w e d by an e x p l o r a t i o n o f t h e i m p o r t a n c e o f empathy i n t h e p h y s i c i a n - p a t i e n t r e l a t i o n s h i p , e s p e c i a l l y i n emotionally  laden  e n c o u n t e r s w h i c h c a n be a s o u r c e o f s t r e s s  for medical  p r a c t i t i o n e r s . Previous  research  t o p i c s o f empathy and s t r e s s a r e examined.  linking the  Statements o f t h e  hypotheses addressed i n t h i s i n v e s t i g a t i o n a r e included. L i t e r a t u r e relevant t o the exploratory questions  i s also  reviewed. The s e c o n d p a r t o f t h i s c h a p t e r  contains  a review  of t h e e m p i r i c a l studies relevant t o t h e research  o f some  problem and  a d i s c u s s i o n o f i s s u e s i n v o l v e d i n empathy t r a i n i n g f o r p r a c t i c i n g p h y s i c i a n s and m e d i c a l  students.  \u000C13 Value o f E f f e c t i v e Communication i n the Medical  Interview  E f f e c t i v e communication between p h y s i c i a n s and  their  p a t i e n t s i s an important component o f medical c a r e . value  and  appreciate  Matthews, Sledge, and e v a l u a t i o n of 27 valued  good communication w i t h t h e i r  physicians.  Lieberman (1987) found through  i n t e r n s by 212  i n p a t i e n t s t h a t the  i n t e r p e r s o n a l s k i l l s and  B u l l e r and  Patients  clinical  skills  communication competence were s t r o n g l y  patients  equally.  B u l l e r (1987) a l s o found t h a t p a t i e n t s '  of medical care and p a t i e n t s ' e v a l u a t i o n s  an  evaluations  of t h e i r  physicians'  associated.  P o s i t i v e communication i n f l u e n c e s not o n l y p a t i e n t s ' s u b j e c t i v e e v a l u a t i o n s , but b i o c h e m i c a l  p r o c e s s e s as w e l l .  Kaplan, G r e e n f i e l d , and Ware (1989) found t h a t p a t i e n t s ' h e a l t h outcomes whether measured p h y s i o l o g i c a l l y , behaviourally,  or s u b j e c t i v e l y were a l l r e l a t e d t o a s p e c t s of  the i n t e r a c t i o n s between p h y s i c i a n s and  their patients.  Indeed s c h o l a r s have concluded t h a t the p r o c e s s of h e a l i n g i s p a r t i a l l y i n t e r p e r s o n a l , and  i s greatly influenced  p h y s i c i a n - p a t i e n t communication Friedman and  (Cousins,  1982).  by According  to  DiMatteo (1979), t o ignore t h i s f a c t i s a  s c i e n t i f i c error. Physicians  a l s o recognize  w i t h p a t i e n t s i s important. general  t h a t e f f e c t i v e communication  For i n s t a n c e ,  p r a c t i t i o n e r s concerning  system, 92.9%  i n a survey of  t h e i r r o l e i n the h e a l t h  of the respondents i n d i c a t e d t h e i r  387 care  strong  support of the view t h a t communication i s important  (Cockburn,  \u000C14 Killer,  Campbell, &amp; Sanson-Fisher, 1987).  The advantages o f  e f f e c t i v e communication a r e not l i m i t e d t o s p e c i a l t i e s such as family practice.  I n surgery, f o r i n s t a n c e ,  effective  communication reduces p o s t - o p e r a t i v e c o m p l i c a t i o n s and a n a l g e s i c requirements (Richards &amp; McDonald, 1985).  E f f e c t s o f Miscommunication i n t h e M e d i c a l I n t e r v i e w Poor communication i n t h e p h y s i c i a n - p a t i e n t can  l e a d t o n e g a t i v e consequences.  relationship  For instance,  miscommunication i n t h e medical i n t e r v i e w can l e a d t o poor r a p p o r t , p a t i e n t noncompliance and d i s s a t i s f a c t i o n , e r r o r s i n d i a g n o s i s and \"doctor-shopping\" (DiMatteo, P r i n c e , &amp; Hays, 1986; H a r r i g a n &amp; Rosenthal, 1986; J a r s k i , Gjerde, B r a t t o n , Brown, &amp; Matthes, 1985; L a v i n , 1983; Ley, 1982; R i c c a r d i &amp; K u r t z , 1983).  P a t i e n t s complain more about poor communication  w i t h t h e i r p h y s i c i a n s than about any t h i n g e l s e Elliott,  1987).  (Murtagh &amp;  I n f a c t , poor communication between p a t i e n t s  and t h e i r p h y s i c i a n s has been c i t e d as t h e most common cause of m a l p r a c t i c e l i t i g a t i o n  (Garr &amp; Marsh, 1986; Numann, 1988).  Because o f t h e p u b l i c d i s s a t i s f a c t i o n w i t h t h e q u a l i t y o f the  p h y s i c i a n - p a t i e n t r e l a t i o n s h i p , one remedy may be t o g i v e  more a t t e n t i o n t o t h e development o f communication s k i l l s i n medical s t u d e n t s and p h y s i c i a n s Cassell,  1985).  ( B e r n s t e i n &amp; B e r n s t e i n , 1985;  C a r r o l l and Monroe (1979) reviewed 73 s t u d i e s  on m e d i c a l i n t e r v i e w i n g and concluded t h a t \". . .. t h e importance o f m e d i c a l i n t e r v i e w i n g s k i l l s  i s demonstrated by  r e c e n t r e s e a r c h i d e n t i f y i n g i n t e r p e r s o n a l communication as a  \u000C15 major cause of v a r i a n c e i n p a t i e n t s a t i s f a c t i o n , p a t i e n t compliance,  and  the incidence of malpractice l i t i g a t i o n \"  (p.  498) .  The  Emergence o f Communication S k i l l s T r a i n i n g i n Medical  Education  In s p i t e of the f a c t t h a t communication between p h y s i c i a n s and important, has  p a t i e n t s has  i t has  been acknowledged as  being  o n l y b e e n i n r e c e n t y e a r s t h a t any  emphasis  b e e n p l a c e d on t e a c h i n g o r r e s e a r c h i n g t h e e f f e c t i v e n e s s  of communication s k i l l s  training.  A number o f r e a s o n s c a n be have not until  focused  recently.  i d e n t i f i e d why  medical  a t t e n t i o n on t e a c h i n g c o m m u n i c a t i o n F i r s t o f a l l , t h e r e seemed t o be  schools skills  the  a s s u m p t i o n t h a t t h e a b i l i t y t o communicate e f f e c t i v e l y i n n a t e and  that these  i n t u i t i o n or i m i t a t i o n  s k i l l s w o u l d be d e v e l o p e d (Riccardi  r e c e n t s t u d y by K r a m e r , B e r ,  through  &amp; K u r t z , 1983).  However, a  and M o o r e (1989) r e v e a l e d t h a t i n  order f o r students t o l e a r n communication s k i l l s , participate  i n t r a i n i n g ; being taught  i n s t r u c t o r s who m o d e l s was  was  t h e y had  regular classes  r e c e i v e d t h e t r a i n i n g and who  not e f f e c t i v e i n improving  medical  to  by  a c t e d as  role  students'  skills. Another reason  t h a t communication s k i l l s  i s t h a t t h e b i o m e d i c a l model w h i c h has c l i n i c a l method i n m e d i c i n e primarily  f o r over  on t h e p h y s i c a l a s p e c t s  were not o f f e r e d  been the  100  years  of i l l n e s s .  dominant focuses I t i s purely  \u000C16 o b j e c t i v e and  does not  focus on such s u b j e c t i v e p r o c e s s e s as  i n t e r p e r s o n a l r e l a t i o n s h i p s and  f e e l i n g s (McWhinney, 198 6).  T r a d i t i o n a l medical t r a i n i n g has t e c h n i c a l and  c o n c e n t r a t e d on  teaching  s c i e n t i f i c m a t e r i a l , t a k i n g a more m e c h a n i s t i c  approach (Cockburn e t a l . , 1987; Jacob, &amp; James e t a l . , 1988).  Numann, 1988;  Further,  Putnam, S t i l e s ,  t h e r e have been many  advances i n technology and medical knowledge (Schwartz &amp; Wiggins, 1985).  Consequently, the t r a d i t i o n a l b i o m e d i c a l  method, which was  based on the n o t i o n of C a r t e s i a n  dualism,  r e s u l t e d i n the s p l i t i n focus between the psyche and (Carek, 1987).  Unfortunately,  what seems t o have o c c u r r e d  a p o l a r i t y between the s c i e n c e and between \"compassion and  human f a c t o r s  As a r e s u l t of t h i s mind-body s p l i t the r e l a t i o n s h i p has recognizing  suffered.  Physicians  and  (Cousins,  1988).  physician-patient  themselves  are  the consequences of the imbalance i n focus between  t e c h n o l o g i c a l advances and s t a t e d by G o r l i n and New  England J o u r n a l  emotional a s p e c t s of c u r i n g .  of Medicine:  (1987) f u r t h e r e l a b o r a t e s  physician-patient  As  Zucker (1983) i n a s p e c i a l a r t i c l e i n the  Something has gone wrong i n the p r a c t i c e of medicine, and we a l l know i t . I t i s i r o n i c t h a t i n t h i s e r a , dominated by t e c h n i c a l prowess and r a p i d b i o m e d i c a l advances, p a t i e n t and p h y s i c i a n each f e e l s i n c r e a s i n g l y r e j e c t e d by the other. Clearly, one r o o t of the problem l i e s i n the p a t i e n t - d o c t o r r e l a t i o n s h i p , (p. 1059) Lipkin  is  the a r t of medicine,  competence,\" between c a r i n g  c u r i n g , between technology and  soma  relationships:  on the breakdown i n  \u000C17  P a t i e n t s have been a l i e n a t e d by t h e growing schism between t h e human and t h e m e d i c a l . The p r e s t i g e o f the p h y s i c i a n has appeared t o dwindle: i n c r e a s i n g l y , people f e e l t h a t t h e i r d o c t o r s do not o r cannot listen . . . The s k i l l s o f i n t e r v i e w i n g and p h y s i c a l examination t h a t once l i n k e d t h e d o c t o r and the p a t i e n t have r u s t e d . There has been a breakdown i n communication here. (p. 363) There appears t o be an e f f o r t towards f i n d i n g a balance between n a t u r a l s c i e n c e and humanism.  Recent attempts t o  c o n j o i n n a t u r a l s c i e n c e s and humanism have been c a l l e d t h e \"doctor's dilemma\" (Moulyn 1988, p.149) and t h e \" c h a l l e n g e f o r the 1980's and beyond\" (Arnold, Povar, &amp; Howell, 1987, p . 3 ) . Questions ensuing  from t h i s c h a l l e n g e i n c l u d e :  humanism t o be i n c o r p o r a t e d w i t h t h e t r a d i t i o n a l  \"How i s biomedical  model?\" and \"How can humanism be taught?\" There have been some attempts t o i n t r o d u c e a l t e r n a t i v e s t o t h e t r a d i t i o n a l b i o m e d i c a l model i n order t o i n c r e a s e physicians*  s e n s i t i v i t i e s t o p a t i e n t s ' emotional  concerns.  For i n s t a n c e , B a l i n t i n t h e l a t e 1950's i n t r o d u c e d h i s n o t i o n of p a t i e n t - c e n t r e d medicine as opposed t o d i s e a s e - c e n t r e d medicine, and he began t o o f f e r groups f o r g e n e r a l p r a c t i t i o n e r s i n order t o focus on p h y s i c i a n s ' f e e l i n g s about i n t e r a c t i o n s with p a t i e n t s (Balint, L a t e r , i n 1977, Engel  1957).  i n t r o d u c e d an a l t e r n a t i v e model t o  the t r a d i t i o n a l one, which he termed t h e b i o p s y c h o s o c i a l model.  He proposed t h a t p s y c h o l o g i c a l and s o c i a l a s p e c t s o f a  person be c o n s i d e r e d  i n medical  i n t e r a c t i o n s because t h e  c u r r e n t b i o m e d i c a l model was inadequate i n t h i s r e g a r d .  More  r e c e n t l y , L e v e n s t e i n , McCracken, McWhinney, Stewart, and Brown  \u000C18  (1986) i n t r o d u c e d the p a t i e n t - c e n t r e d c l i n i c a l method f o r f a m i l y medicine.  In t h i s model i n c l u s i o n i s made of not  d o c t o r s ' agendas, as i s the case i n d i s e a s e - c e n t r e d but o f p a t i e n t s ' agendas as w e l l .  medicine,  These s c h o l a r s encouraged  p h y s i c i a n s t o make e f f o r t s t o understand p a t i e n t s of t h e i r  only  1  experiences  illnesses.  With the emergence of new  trends  i n medicine,  and  v a l u e b e i n g p l a c e d on p o s i t i v e p h y s i c i a n - p a t i e n t communication, medical educators are now  p l a c i n g focus  a c q u i r i n g e f f e c t i v e communication s k i l l s  (Bernstein &amp;  Bernstein,  1986;  C a s s e l l , 1985).  As R e i s e r p o i n t e d  on  out  i n C a s s e l l (1985): I t i s c r u c i a l f o r modern medicine t o e s t a b l i s h a balance between understanding g e n e r a l b i o l o g i c processes t h a t make us i l l and understanding the i l l n e s s as experienced and produced by the p a t i e n t . To l e a r n of the l a t t e r , the v e r b a l and nonverbal elements of human communication i n medical care must be understood and mastered, (p., x) A c o n c l u s i o n r e s u l t i n g from a conference i n which p h y s i c i a n s and  other s c h o l a r s met  to discuss  b i o p s y c h o s o c i a l model of h e a l t h and \" a c q u i s i t i o n of i n t e r v i e w i n g and  a p p r e c i a t i n g and disease\"  d i s e a s e was  that i s not  the o n l y means, f o r both  a p p l y i n g a more i n c l u s i v e model of h e a l t h  (White, 1988,  conference was  the  communications s k i l l s  o n l y a d e s i r a b l e means, but probably  40  p. 37).  A recommendation made a t t h i s  t h a t f u r t h e r r e s e a r c h u s i n g sound e m p i r i c a l  methods i s needed t o support i n c l u s i v e medical model.  and  the adoption  of the more  To date, much of the evidence  has  \u000C19 been a n e c d o t a l and d e s c r i p t i v e .  In p a r t i c u l a r , more r e s e a r c h  i s needed which demonstrates t h e e f f e c t i v e n e s s o f communication s k i l l s t r a i n i n g of  (White, 1988).  One o f the g o a l s  the p r e s e n t study i s t o p r o v i d e such r e s e a r c h .  I n c r e a s i n g Humanism i n M e d i c a l Students In  o r d e r t o improve the q u a l i t y o f the p h y s i c i a n - p a t i e n t  r e l a t i o n s h i p so t h a t good communication can occur, attempts are  b e i n g made by medical educators t o enhance h u m a n i s t i c  q u a l i t i e s such as compassion and c a r i n g i n m e d i c a l students (Henderson, 1981; Robinson &amp; B i l l i n g s ,  1985).  In 1980, the  American Board o f I n t e r n a l M e d i c i n e Committee on the D e f i n i t i o n o f C l i n i c a l Competence i d e n t i f i e d s i x b a s i c elements o f c l i n i c a l  competence,  two o f which were h u m a n i s t i c  q u a l i t i e s and communication s k i l l s 1985).  The Committee,  (Blurton, &amp; Mazzaferri,  concluded i n 1983 t h a t m e d i c a l t r a i n i n g  programs had a major r e s p o n s i b i l i t y t o s t r e s s human q u a l i t i e s , e s p e c i a l l y i n t e g r i t y , r e s p e c t , and compassion i n t h e physician-patient relationship Board now  (Benson e t a l . ,  1983).  The  r e q u i r e s t h a t a l l r e s i d e n t s be assessed f o r t h e i r  h u m a n i s t i c q u a l i t i e s and b e h a v i o r i n order f o r them t o be certified  (Krevans, 1983).  A l s o , i n 1987, the m e d i c a l e t h i c s  subcommittee o f t h e American Board o f P e d i a t r i c s p u b l i s h e d a paper i n d i c a t i n g t h a t i n t e r p e r s o n a l s k i l l s was one o f the s u b j e c t areas i n which t h e i r c a n d i d a t e s would be examined f o r certification.  Included was the requirement t h a t p h y s i c i a n s  should have some knowledge o f and s k i l l s  i n counselling  \u000C20 techniques  t o enhance p o s i t i v e communication w i t h p a t i e n t s and  t h e i r f a m i l i e s (Daeschner, 1987). Harvard U n i v e r s i t y has begun a new  Pathway Program w i t h  the g o a l s of c r e a t i n g more humane and c a r i n g p h y s i c i a n s t h a t r e l a t i o n s h i p s with p a t i e n t s can be improved 1986).  Herbert  Medical  School  (Stark,  (1986) s t a t e d t h a t \"the approach a t U.B.C. c i r c a 1986  model o f d i s e a s e and and treatment\"  so  i s t o emphasize the b i o p s y c h o s o c i a l  i l l n e s s as the context  (p. 537).  I t was  f o r a l l teaching  recommended by a U.B.C.  F a c u l t y of Medicine Subcommittee t h a t b e h a v i o r a l s c i e n c e as i t a p p l i e s t o medicine, i n c l u d i n g the s k i l l  area of the  doctor-  p a t i e n t r e l a t i o n s h i p , be i n t e g r a t e d i n t o a l l medical disciplines  (Herbert,  1986).  In h i s P r e s i d e n t ' s address t o  the American M e d i c a l A s s o c i a t i o n i n June, 1989,  Nelson urged  t h a t r e s e a r c h be done t o i n v e s t i g a t e ways t o i n c r e a s e such v a l u e s as humanism and a l t r u i s m i n medicine and a l s o t o develop ways t o measure humanism i n attempts t o meet the c h a l l e n g e of r e d u c i n g the imbalance between the a r t and s c i e n c e of medicine.  Nelson (1989) suggested, \"The  ability  to  p r o v i d e the s c i e n t i f i c m i r a c l e s of the f u t u r e w i l l depend on our understanding  and a p p l i c a t i o n of the a r t of medicine\"  (p.  1230). While t h e r e appears t o be widespread agreement t h a t attempts must be made t o c r e a t e more humane p h y s i c i a n s , s c h o l a r s i n the area have r e c o g n i z e d t h a t t h e r e i s a l a c k of agreement as t o the d e f i n i t i o n of humanism.  Arnold et a l .  (1987) suggested t h a t a humane p h y s i c i a n possesses not  only  \u000C21 t e c h n i c a l competence, but a l s o humanistic a t t i t u d e s , and knowledge of humanistic concepts. and Robbins,  behavior  L i n n , DiMatteo,  Cope,  (1987) suggested t h a t humanism be measured i n  terms of a t t i t u d e s , v a l u e s and b e h a v i o r s . i n v e s t i g a t e the way  In o r d e r t o  i n which \"humanism\" was  measured, L i n n e t a l . (1987) conducted  d e f i n e d and  both a l i t e r a t u r e  review and a survey of r e s e a r c h e r s and c l i n i c i a n s who  were  i n t e r e s t e d i n the area of p a t i e n t - p h y s i c i a n r e l a t i o n s h i p s . They found t h a t t h e r e were 132 d i f f e r e n t d e f i n i t i o n s of \"humanism\"; however, the most f r e q u e n t l y mentioned q u a l i t y of a h u m a n i s t i c p h y s i c i a n was  empathy.  S i m i l a r l y , Kramer,Ber,  and Moore (1987) d e f i n e d \"dehumanization\" r e d u c t i o n of empathic b e h a v i o r s .  i n p a r t as the  Empathy, then, may  c o n s i d e r e d t o be one key dimension  of \"humanism\".  Also  r e s e a r c h has shown a l i n k e x i s t s between empathy and (Batson, F u l t z , &amp; Schoenrade, 1987). humanism and a l t r u i s m t h e r e f o r e may communication s k i l l s t r a i n i n g .  One  way  be  altruism  to increase  be t o o f f e r empathy  Before a d i s c u s s i o n of i s s u e s  i n v o l v e d i n empathy t r a i n i n g however, the t o p i c o f d e f i n i n g the concept of empathy w i l l be  addressed.  The C o n c e p t o f Empathy The word \"empathy\" was E.B.  t r a n s l a t e d i n the e a r l y 1900s by  T i r c h e n e r from the German word \" E i n f u h l u n g \" which means  \" f e e l i n g together with\"  ( G o l d s t e i n &amp; M i c h a e l s , 1985).  The  e a r l y Greek word \"empatheia\" means a s t r o n g f e e l i n g o f c o n n e c t i o n w i t h another person, w i t h a q u a l i t y of s u f f e r i n g .  \u000C22  Empathy i n t h e g e n e r a l sense may r e f e r t o t h e p r o c e s s o f understanding  o t h e r s ( A l l p o r t , 1963) o r t o a \" c o n n e c t i o n a l  q u a l i t y \" which has t o do w i t h t h e meaning o f b e i n g human ( B a r r e t t - L e n n a r d , 1981).  F o r example, one person may  imagine  another who has s u f f e r e d a tragedy as f e e l i n g sad, because she h e r s e l f has f e l t sad, although t h e circumstances  f o r t h e two  i n d i v i d u a l s which g i v e r i s e t o t h e f e e l i n g may be v e r y different.  T h i s f e l t sense o f \" p u t t i n g o n e s e l f i n another's  shoes and understanding how t h e o t h e r i s t h i n k i n g and f e e l i n g \" can occur without two people n e c e s s a r i l y  interacting.  O b s e r v a t i o n a l empathy ( i . e . , b e i n g e m o t i o n a l l y moved w h i l e o b s e r v i n g o t h e r s and not n e c e s s a r i l y i n t e r a c t i n g w i t h them), i s a common everyday  experience, and \"may make t h e  d i f f e r e n c e between a world o f profound a l i e n a t i o n o r danger for of  humankind, and a p r o g r e s s i o n toward t h e common experience humanity as f a m i l i a r \"  ( B a r r e t t - L e n n a r d , 1981, p. 98).  Indeed, some people h o l d t h e view t h a t empathy can h e l p t o r e s o l v e t e n s i o n s not o n l y between i n d i v i d u a l s , but among n a t i o n s and t e r r o r i s t groups as w e l l ( G l a d s t e i n , 1987). In  t h e e a r l y 1950s, C a r l Rogers p r e s e n t e d t h e f i r s t  t h e r a p e u t i c a p p l i c a t i o n o f t h e word \"empathy\" a t t h e time when he l e d t h e humanistic movement i n psychology.  The term became  w e l l known a f t e r Rogers i n t r o d u c e d empathic understanding as one c o r e a t t i t u d i n a l c o n d i t i o n o f h i s c l i e n t - c e n t e r e d known as person-centered)  psychotherapy.  (later  His d e f i n i t i o n of  empathy was \" t o p e r c e i v e t h e i n t e r n a l frame o f r e f e r e n c e o f another w i t h accuracy, and w i t h t h e emotional components and  \u000C23 meanings which p e r t a i n t h e r e t o , as i f one were the person, but without ever l o s i n g the p. 210).  According  other  'as i f c o n d i t i o n \" (1959,  t o Rogers, empathy i s not o n l y a b a s i c  element of e f f e c t i v e i n t e r p e r s o n a l r e l a t i o n s h i p s , but a l s o  one  of the t h r e e e s s e n t i a l c h a r a c t e r i s t i c s o f a s u c c e s s f u l t h e r a p e u t i c r e l a t i o n s h i p , along w i t h h e l p e r genuineness  and  u n c o n d i t i o n a l p o s i t i v e regard.  Although Rogers suggested t h a t  the t h r e e are e s s e n t i a l , he was  of the o p i n i o n t h a t empathy  was  of prime importance. From Roger's p e r s p e c t i v e , empathy i s v i t a l  therapeutic interaction.  for  any  I f a h e l p e r i s empathic, t h a t i s ,  acknowledges the helpee's i n n e r world of f e e l i n g s and meanings, and f e e l s accepted  communicates t h i s understanding, then the helpee and  s a f e enough t o continue s e l f - e x p l o r a t i o n ,  thus a l l o w i n g p o s i t i v e change t o occur. when the helpee experiences p o t e n t i a l of any  t h i s c a r i n g \".  individual will  (Meador &amp; Rogers, 1982,  Rogers b e l i e v e d t h a t  p.131).  . . the  growthful  tend t o be r e l e a s e d Research has  ...\"  revealed  that  e f f e c t i v e t h e r a p i s t s , r e g a r d l e s s of t h e i r t h e o r e t i c a l o r i e n t a t i o n or t r a i n i n g , convey empathic understanding t o their clients  (Baruth  &amp; Huber, 1985).  c r u c i a l element which has  Empathy, then, i s a  application i n interpersonal helping  r e l a t i o n s h i p s where the h e a l t h y p s y c h o l o g i c a l growth of individuals i s a goal. Elliott most w i d e l y  (1982) observed t h a t \"empathy i s probably c i t e d and  s t u d i e d process  and psychotherapy l i t e r a t u r e \"  the  variable in counselling  (p. 379) .  However, as a number  \u000C24  of  s c h o l a r s have noted, the concept o f empathy i s both complex  and e l u s i v e  (e.g., Batson e t a l . ,  G o l d s t e i n , &amp; M i c h a e l s , 1985).  1987; G l a d s t e i n ,  Batson e t a l .  1987;  (1987) have s a i d  \" P s y c h o l o g i s t s are noted f o r u s i n g terms l o o s e l y , but i n our use o f empathy we have outdone o u r s e l v e s , \"  (p. 19).  Hackney  (1978) p o i n t e d out t h a t by 1968, i n the c o u n s e l l i n g psychology l i t e r a t u r e alone, t h e r e were 21 d e f i n i t i o n s o f empathy. While Rogers' d e f i n i t i o n focused more on t h e empathic s t a t e o r c o n d i t i o n o f a h e l p e r , Truax and C a r k h u f f  (1967)  i n c l u d e d emphasis on the communication o f empathic understanding, t h a t i s , b e h a v i o r a l and v e r b a l e x p r e s s i o n s by the  h e l p e r , i n t h e i r d e f i n i t i o n of empathy.  Thus t h e r e was a  s h i f t o f emphasis from i n t e r n a l s t a t e t o e x t e r n a l s k i l l , qualitative condition to quantifiable s k i l l  from  (Hackney, 1978).  As t h e d e f i n i t i o n s o f empathy s i n c e the i n t r o d u c t i o n o f the  t h e r a p e u t i c meaning o f the term by Rogers e v o l v e d and  moved away from a q u a l i t a t i v e a t t i t u d e toward a q u a n t i f i a b l e p r o c e s s , t r a i n i n g procedures changed i n t h i s d i r e c t i o n  also.  Empathy t r a i n i n g models began t o focus l e s s on h e l p e r a t t i t u d e s and more on b e h a v i o u r a l h e l p i n g s k i l l s M a r s h a l l , 1982).  (Kurtz &amp;  Although the c o r e c o n d i t i o n s o f Rogers'  t h e o r y have been emphasized as key elements i n w i d e l y p r a c t i s e d h e l p i n g models such as those o f C a r k h u f f (1969), Gazda, Walters, and C h i l d e r s  (1975) and Egan  (1986), the  emphasis o f these t r a i n i n g models appears t o be on d e v e l o p i n g h e l p e r communication  skills.  \u000C25  Barrett-Lennard  (1981) suggested t h a t , i n o r d e r t o  understand the concept of empathy, i t must be viewed p r o c e s s , not o n l y as v e r b a l communication by the  fully  as a  clinician.  The p r o c e s s o f empathy i n v o l v e s t h r e e d i s t i n c t phases. one r e f e r s t o the i n n e r p r o c e s s of empathic understanding by the c l i n i c i a n .  Phase two  communicated or expressed empathic clinician.  listening  Phase and  r e f e r s t o the  understanding by the  The t h i r d phase of the empathy c y c l e i s r e c e i v e d  empathy by the c l i e n t .  T h i s empathy c y c l e takes i n t o  account  both a f f e c t and c o g n i t i o n as w e l l as the e x p e r i e n c e of both c l i e n t and  clinician.  S e v e r a l instruments have been developed designed t o measure the v a r i o u s a s p e c t s of empathy.  Barrett-Lennard  developed the Empathic Understanding S c a l e s which are p a r t of the R e l a t i o n s h i p Inventory t h a t measures the f i r s t and phase of empathy c y c l e s . completed three). may  third  These s u b j e c t i v e s c a l e s are  by both the h e l p e r (phase one)  and helpee  (phase  Truax and Carkhuff (1967) h o l d the view t h a t empathy  be d e f i n e d i n terms of the h e l p e r ' s behaviour alone, and  they developed a 5 - p o i n t r a t i n g s c a l e which measures phase  two  of the empathy c y c l e . The r a t i n g s c a l e s developed by B a r r e t t - L e n n a r d and  Truax  and C a r k h u f f are the two most common instruments used t o measure empathy.  Together they are e f f e c t i v e i n measuring  the  e f f e c t i v e n e s s of an empathy t r a i n i n g model because they measure a l l components of the empathy c y c l e .  L i t t l e research  however, has been done t o t e s t the v a l i d i t y of the empathy  \u000C26 c y c l e , and the e f f e c t s of empathy t r a i n i n g f o r medical students  on the t h r e e phases has not been examined.  Gladstein evidence  (1987) i s of the o p i n i o n t h a t well-founded  fact,  empirical  i n the area of empathy i s l a c k i n g .  Empathy One  In  i n the Physician-Patient  Relationship  of the g o a l s of both the b i o p s y c h o s o c i a l model  and  the p a t i e n t - c e n t r e d c l i n i c a l method i n f a m i l y p r a c t i c e appears t o be f o r p h y s i c i a n s t o achieve experiences  of t h e i r i l l n e s s e s  an understanding  of p a t i e n t s '  ( L e v e n s t e i n e t a l . , 1986;  Weston, Brown, &amp; Stewart, 1989)  and t o g a i n some i n s i g h t i n t o  p a t i e n t s ' \" l i f e w o r l d s \" (White, 1988).  Understanding p a t i e n t s  from t h e i r p o i n t of view g i v e s i n f o r m a t i o n t o p h y s i c i a n s about the f a c t o r s i n v o l v e d i n i l l n e s s .  L e v e n s t e i n e t a l . (1986)  have p o i n t e d out t h a t the i d e a of a p a t i e n t - c e n t r e d approach i s s i m i l a r t o Rogers' person-centred One  approach i n c o u n s e l l i n g .  of the g o a l s of both i s t o understand p a t i e n t s from t h e i r  p o i n t of view.  One  of the most important  ways t o  accomplish  t h i s g o a l would appear t o be t o develop a s t r o n g sense of empathy f o r p a t i e n t s because, a c c o r d i n g t o Rogers, empathy i s the a b i l i t y t o understand the \" i n t e r n a l frame of r e f e r e n c e of another\" and communicate t h i s understanding f e e l i n g s and meanings.  Carkhuff  i n terms of  (1969) wrote of the  importance of empathy i n the h e l p i n g  process:  general  \u000C27 Empathy i s the key i n g r e d i e n t of h e l p i n g . Its e x p l i c i t communication, p a r t i c u l a r l y d u r i n g e a r l y phases of h e l p i n g i s c r i t i c a l . Without an empathic understanding of the helpee's world and h i s d i f f i c u l t i e s as he sees them t h e r e i s no b a s i s f o r h e l p i n g , (p. 173)  The  a b i l i t y . o f p h y s i c i a n s t o p r o j e c t empathic  understanding may reasons.  be p a r t i c u l a r l y  important f o r a number of  F i r s t of a l l , p a t i e n t s are now  responsibility  t a k i n g more  f o r t h e i r h e a l t h and they have i d e a s and  are  making more d e c i s i o n s about what k i n d of medical treatment they want (Tuckett e t a l . , 1986). p h y s i c i a n s t o show c a r i n g , support, (Ben-Sira,  1980;  Campion, 1987,  Wolinsky &amp; S t e i b e r , 1982).  and  concern towards them  Korsch &amp; Negrete,  A study of 800  between p h y s i c i a n s and mothers who pediatric  P a t i e n t s want t h e i r  interactions  brought t h e i r c h i l d r e n t o a  c l i n i c showed t h a t the main reasons f o r mothers'  d i s s a t i s f a c t i o n were p h y s i c i a n s ' l a c k of warmth and show i n t e r e s t 1972).  1972;  i n the mothers' concerns (Korsch  Empathy i s a way  f a i l u r e to  &amp; Negrete,  of demonstrating i n t e r e s t  and  support  towards p a t i e n t s . A second reason p h y s i c i a n s need empathy s k i l l s i s t h a t many p a t i e n t s expect help from p h y s i c i a n s i n managing t h e i r p s y c h o s o c i a l concerns.  S t u d i e s have shown t h a t p a t i e n t s want  t o be asked about (Yaffe &amp; Stewart, 1986)  and p r o v i d e d  help  w i t h t h e i r p s y c h o s o c i a l problems by t h e i r f a m i l y p h y s i c i a n s . Indeed a h i g h percentage of p a t i e n t v i s i t s i n primary s e t t i n g s have a p s y c h o s o c i a l component Good e t a l . , 1987;  Hansen e t a l . , 1987;  care  (Baker &amp; Cassata, Herbert  1978;  e t a l . , 1986).  \u000C28 Psychosocial  problems may  be the primary or secondary  complaint  (Frowick, Schank, Doherty, &amp; Powell, 1986  Bernstein  and  Bernstein  (1985) wrote:  \"As Rakel  ).  (1977) p o i n t s  out, primary care p h y s i c i a n s need t o be prepared t o d e a l w i t h emotional problems s i n c e p a t i e n t s tend t o c a s t them i n the c o u n s e l l o r r o l e , prepared or not\" I t has  137).  been documented t h a t p h y s i c i a n s need t r a i n i n g i n  counselling s k i l l s Gall,  (p.  1988).  (Hansen e t a l . , 1987;  J a f f e , Radius, &amp;  A group of p a r t i c i p a n t s a t the 1979  National  Conference of Family P r a c t i c e R e s i d e n t s ranked c o u n s e l l i n g skills  as the area  from b e h a v i o r a l  r e l e v a n t t o f a m i l y medicine 1979)  .  s c i e n c e s which was  (Shienvold,  most  Asken, &amp; C i n c o t t a ,  Agras (1982) suggested t h a t p h y s i c i a n s must be  able  t o i d e n t i f y those s i t u a t i o n s i n which p a t i e n t s need counselling. P h y s i c i a n s have i d e n t i f i e d t h a t they do not have the skills  t o counsel  need them.  p a t i e n t s , but they have acknowledged they  For i n s t a n c e ,  i n a survey conducted on  p h y s i c i a n s , which i n c l u d e d 45 g e n e r a l 44  i n t e r n i s t s , 49 surgeons, and  85 percent  and  family  11 o b s t e t r i c i a n - g y n e c o l o g i s t s ,  agreed t h a t p h y s i c i a n s have an o b l i g a t i o n t o  counsel  and  i s a core s k i l l  87  percent  counsel.  agreed t h a t p h y s i c i a n s knew how  o n l y 12 percent  effective in counselling  physicians  physicians,  agreed t h a t c o u n s e l l i n g i s important and  However, o n l y 21 percent  151  to  agreed t h a t they themselves were  (Lewis e t a l . , 1986).  Empathy, which  i n most c o u n s e l l i n g models, can be u s e f u l t o  i n situations requiring counselling.  \u000C29 A t h i r d reason t h a t i t i s important f o r p h y s i c i a n s t o convey empathic clinical of  understanding t o p a t i e n t s i s t h a t many  encounters a r e a f f e c t i v e l y laden such as i n t h e c a r e  t e r m i n a l l y i l l people and i n communicating w i t h g r i e v i n g  families  (Cassidy, 1986; F l e t c h e r &amp; S a r i n , 1988; F u l l e r &amp;  G e i s , 1985; T o l l e , Bascom, Hickam, &amp; Benson, 1986).  Effective  communication i s a l s o important when i n t e r a c t i n g w i t h patients.  angry  F o r example, i n a survey o f p h y s i c i a n s c o n c e r n i n g  the r i s k and i n c i d e n t s o f abuse by a g g r e s s i v e p a t i e n t s , t h e respondents  i n d i c a t e d t h a t good i n t e r p e r s o n a l s k i l l s were t h e  most important f a c t o r s i n l i m i t i n g a g g r e s s i v e i n c i d e n t s (D'Urso &amp; Hobbs, 1989).  Empathy has been s p e c i f i c a l l y  suggested as a v a l u a b l e communication s k i l l p h y s i c i a n s can use when i n t e r a c t i n g w i t h t e r m i n a l l y i l l cancer p a t i e n t s ( K i n z e l , 1988), depressed p a t i e n t s (Peteet, 1979), and angry p a t i e n t s (Lane,  1986).  Intense Emotions as Sources o f S t r e s s f o r Medical  Practitioners  Working w i t h h i g h l y emotional a s p e c t s o f p a t i e n t c a r e such as g r i e f , anger, for  f e a r , and death i s a source o f s t r e s s  p h y s i c i a n s (Herbert St Grams, 1986; McCranie e t a l . , 1982;  McCue, 1982).  Intense emotions have been found t o be  s t r e s s f u l f o r medical students as w e l l .  For instance, F i r t h  (1986), i n a study o f f o u r t h year medical students, found t h a t two  o f t h e f o u r c a t e g o r i e s most commonly r e p o r t e d as s t r e s s f u l  \u000C30  were t a l k i n g t o p s y c h i a t r i c p a t i e n t s , and d e a l i n g w i t h death and  suffering. The s t r e s s caused as a r e s u l t o f working w i t h h i g h l y  emotional a s p e c t s o f p a t i e n t c a r e can evoke i n t e n s e emotions f o r p h y s i c i a n s and medical s t u d e n t s . t h a t problem  Powers (1985) suggested  p a t i e n t s can evoke n e g a t i v e f e e l i n g s such as  f r u s t r a t i o n and apathy on t h e p a r t o f p h y s i c i a n s .  Medical  s t u d e n t s have d i f f i c u l t y a d d r e s s i n g emotional i s s u e s w i t h p a t i e n t s as w e l l as coping w i t h t h e i r own emotions d u r i n g such interactions  (Batenburg &amp; G e r r i t s m a , 1983).  Knight  (1983)  found t h a t medical students experienced f e e l i n g s o f i n s e c u r i t y , a n x i e t y , h o s t i l i t y , and d e s t r u c t i v e argumentativeness,  as w e l l as a sense o f g u i l t and  h e l p l e s s n e s s when c o n f r o n t e d w i t h s e r i o u s l y i l l  or dying  patients. I f p h y s i c i a n s and medical students have not l e a r n e d t o d e a l w i t h e m o t i o n a l l y i n t e n s e encounters, they may a l s o embarrassed  and i l l  a t ease  ( S l e v i n , 1987).  feel  Buckman (1984),  i n h i s d i s c u s s i o n o f p h y s i c i a n s ' f e e l i n g s o f inadequacy  when  d e a l i n g w i t h p a t i e n t s ' emotional r e a c t i o n s t o medical treatment  stated:  Not knowing how t o d e a l w i t h t h e consequences o f what we do breaks one o f t h e most important r u l e s o f accepted medical behaviour. I t makes us inadequate i n our own eyes and those o f o t h e r s . There i s a l s o the embarrassment. . . . (p. 1598)  Other r e a c t i o n s t h a t p h y s i c i a n s might have when p r e s e n t e d w i t h h i g h l y emotional and s t r e s s f u l aspects o f p a t i e n t c a r e i n c l u d e  \u000C31  denying t h e i r p a i n (Buckman, 1984;  S l e v i n , 1987), appearing  a l o o f or i n s e n s i t i v e , a v o i d i n g the o b v i o u s l y p a i n f u l  issues,  or b e i n g i n a p p r o p r i a t e l y o p t i m i s t i c  They  (Heavey, 1988).  may  i n t e r a c t w i t h p a t i e n t s or f a m i l y members i n a v e r y h a r s h manner or be o v e r l y hasty i n emotional s i t u a t i o n s because of t h e i r discomfort (Fletcher &amp; Sarin,  1988).  A f u r t h e r reason which c o n t r i b u t e s t o e m o t i o n a l l y i n t e n s e encounters b e i n g s t r e s s f u l f o r p h y s i c i a n s i s t h a t they may have had any t r a i n i n g t o cope w i t h t h e i r own  reactions.  b e i n g t r a i n e d i n the t r a d i t i o n a l medical model they may been taught t o not show emotion. overwhelmed by t h e i r own  Thus, they may  not  By have  be  f e e l i n g s such as g u i l t , shame or a  sense of f a i l u r e i f they are not a b l e t o o f f e r a cure f o r a situation  (Heavey, 1988).  C a s s i d y (1986) p o i n t e d out t h a t  p a r t of the d i s t r e s s caused by d e a l i n g w i t h i n t e n s e emotions associated with terminal i l l n e s s  (e.g. f e a r , g r i e f , anger) i s  due t o the f a c t t h a t c a r e g i v e r s are reminded o f t h e i r  own  mortality. Such s t r e s s may students.  l e a d t o emotional impairment  For i n s t a n c e , Smith, Denny, and Witzke  r e p o r t e d t h a t , over a 5 year p e r i o d , 55.5%  o f medical (1986)  of i n t e r n a l  medicine t r a i n i n g programs granted l e a v e s of absence t o medical r e s i d e n t s due mainly t o d e p r e s s i o n .  Girard et a l .  (1986) a l s o found t h a t d e p r e s s i o n and f a t i g u e i n c r e a s e d w h i l e s a t i s f a c t i o n w i t h the d e c i s i o n t o become a p h y s i c i a n decreased during education.  Firth  (1986) concluded t h a t \" s t r e s s among  \u000C32 medical students should be acknowledged and attempts made t o alleviate i t \"  (p. 1177).  Need f o r Empathy T r a i n i n g ; There i s a need t o t r a i n medical p r a c t i t i o n e r s i n communication s k i l l s t o use when i n t e r a c t i n g w i t h p a t i e n t s i n emotionally intense situations Branch  (Herbert &amp; Grams, 1986).  (1983) suggested t h a t t h e reason p h y s i c i a n s f e e l so  uncomfortable  i n e m o t i o n a l l y i n t e n s e s i t u a t i o n s i s t h a t they  have not r e c e i v e d enough t r a i n i n g t o d e a l w i t h encounters.  such  M e d i c a l students should a l s o r e c e i v e s y s t e m a t i c  t r a i n i n g i n how t o d e a l s p e c i f i c a l l y w i t h e m o t i o n a l l y laden encounters  (Hornblow, Kidson, &amp; I r o n s i d e , 1988; Sanson-Fisher  and Maguire, 1987).  1980) and i n c o u n s e l l i n g s k i l l s  Poole &amp; Sanson-Fisher  (Lewis &amp; Freeman,  (1979) suggested t h a t empathy i s  not b e i n g a c q u i r e d by medical students o r r e s i d e n t s and they concluded t h a t t h e s k i l l o f empathic n e c e s s a r i l y develop w i t h e x p e r i e n c e . Saltzman,  communication does not In f a c t E n g l e r ,  Walker, and Wolf (1981) found t h a t as medical  s t u d e n t s advanced through t r a i n i n g , t h e i r m e d i c a l - t e c h n i c a l skill  i n c r e a s e d , but t h e a b i l i t y t o r e l a t e w e l l t o p a t i e n t s  i n t e r p e r s o n a l l y decreased i f students were not i n v o l v e d i n a p p r o p r i a t e communication t r a i n i n g . M e d i c a l students who have taken a b a s i c i n t e r v i e w i n g s k i l l s course have i n d i c a t e d they would l i k e f u r t h e r t r a i n i n g to  a c q u i r e s k i l l s t o use when d e a l i n g w i t h p a t i e n t s ' emotions  (Batenburg  &amp; G e r r i t s m a , 1983).  As was d i s c u s s e d e a r l i e r ,  \u000C33 coping w i t h e m o t i o n a l l y i n t e n s e encounters has been shown t o be a source of s t r e s s f o r medical s t u d e n t s ( F i r t h ,  1986).  And  Burnett and Thompson (1987) suggested t h a t the problems which medical students experience when t a l k i n g t o p a t i e n t s i n t h e i r e a r l y c l i n i c a l y e a r s w i l l not be r e s o l v e d i f the i s s u e s are not d e a l t w i t h then. Even though t h e r e seems t o be agreement i n the  literature  t h a t e f f e c t i v e p h y s i c i a n - p a t i e n t communication i s c r u c i a l , empathy i s a d e s i r a b l e c h a r a c t e r i s t i c of p h y s i c i a n s , and which can be developed, Wakeford  and  one  (1983) p o i n t e d out t h a t  i n t r o d u c i n g courses on communication s k i l l s i n t o  undergraduate  medical e d u c a t i o n i n the U n i t e d Kingdom i s o f t e n not supported.  A common reason f o r t h i s , he suggested,  i s that  t h e r e i s l i t t l e p r o o f t h a t t e a c h i n g such s k i l l s w i l l h e l p the medical s t u d e n t s (p. 245). suggested how  There have been a r t i c l e s which  p a t i e n t s b e n e f i t from e f f e c t i v e p h y s i c i a n -  p a t i e n t communication, and how s a t i s f a c t i o n or compliance.  i t can l e a d t o i n c r e a s e d  There i s l i t t l e  evidence,  however, which suggests t h a t t e a c h i n g communication b e n e f i t s medical students d i r e c t l y . study, i n a d d i t i o n t o measuring s t u d e n t s ' empathic  One  skills  of the aims of t h i s  the development of medical  responses, was  t o examine whether t h e i r  s t r e s s l e v e l s i n e m o t i o n a l l y i n t e n s e encounters would decrease, as a r e s u l t of empathy s k i l l s  training.  \u000C34  E f f e c t i v e n e s s o f Empathy i n E m o t i o n a l l y - I n t e n s e  Situations  Empathic responding may be a p a r t i c u l a r l y u s e f u l and r e l e v a n t i n t e r v e n t i o n f o r medical p r a c t i t i o n e r s t o use i n emotionally  laden encounters.  By u s i n g t h e s k i l l s o f empathic  communication, medical students and p h y s i c i a n s may c o n f i d e n t knowing t h a t , i n s i t u a t i o n s where no  feel  concrete  medical treatment can s o l v e a p a t i e n t ' s problem, they have u s e f u l s k i l l s which can h e l p p a t i e n t s .  As one s u b j e c t  i n this  study wrote \"The t h r u s t o f medicine i s t o do something.\" study by Putnam e t a l . (1988) i n which i n t e r v i e w i n g were taught t o medical r e s i d e n t s , t h e r e s i d e n t s f e e l i n g worried  techniques  reported  t h a t p a t i e n t s would b r i n g up emotional  w i t h which they c o u l d not d e a l . found t h a t t h e u n d e r l y i n g  However, these  In a  issues  researchers  reason f o r t h e r e s i d e n t s *  anxiety  was t h a t t h e r e s i d e n t s were concerned t h a t they c o u l d not \"do something\", t o s o l v e p a t i e n t s ' p s y c h o s o c i a l  concerns.  Even though empathic responding may not seem as concrete as a b i o c h e m i c a l  event o r a medical procedure, which may be  used t o h e a l a p h y s i c a l wound, i t may be t h e r a p e u t i c when p a t i e n t ' s have an \"emotional wound\" ( C P . Herbert, communication, 1989).  In e m o t i o n a l l y  personal  i n t e n s e s i t u a t i o n s when  the p a t i e n t knows t h a t t h e p h y s i c i a n cannot s o l v e h i s o r h e r problems, t h e p a t i e n t may be a p p r e c i a t i v e o f t h e o p p o r t u n i t y t o express f e e l i n g s and r e c e i v e some empathic understanding ( L i d z , 1976). a therapeutic  Rogers b e l i e v e d t h a t empathy conveyed through r e l a t i o n s h i p was c u r a t i v e and t h a t \" i t i s t h e  \u000C35  experience of f e e l i n g understood i t s e l f t h a t e f f e c t s g r o w t h f u l change\" (Meador &amp; Rogers, In  1979,  p.  152).  a d d i t i o n t o b e l i e v i n g t h a t they are doing  something  h e l p f u l f o r t h e i r p a t i e n t s , medical p r a c t i t i o n e r s may  also  f i n d they can remain more o b j e c t i v e i n e m o t i o n a l l y i n t e n s e encounters.  One  s t r e s s o r f o r p h y s i c i a n s appears t o be  attempting t o prevent themselves  from becoming too deeply  emotionally involved with t h e i r p a t i e n t s 1972).  The p r a c t i c e of empathic  (Korsch and  Negrete,  responding means \" p u t t i n g  y o u r s e l f i n the o t h e r person's shoes\" w h i l e never l o s i n g your own  perspective.  Empathy i s not sympathy which i s f e e l i n g  s o r r y f o r the o t h e r person, nor i s i t i d e n t i f i c a t i o n which i s f e e l i n g the same as the o t h e r person.  Rather, empathy i s a  f e e l i n g w i t h another person, which means having a continuous awareness your own  experience (Muldary, 1983).  Rogers  1  spoke  about e x p e r i e n c i n g another person's f e e l i n g s as i f they were your own, skill  but never l o s i n g the \"as i f \" a s p e c t .  o f empathic  responding may  enable p h y s i c i a n s and medical  s t u d e n t s t o acknowledge p a t i e n t s ' d i f f i c u l t emotions w h i l e keeping t h e i r own decrease t h e i r s t r e s s  Thus, the  and i n t e n s e  p e r s p e c t i v e , which may  help  levels.  During the p a s t decade, much has been w r i t t e n  about  p a t i e n t s ' reactions concerning a f f e c t i v e aspects,of i n t e r a c t i o n s with t h e i r physicians.  However, r e l a t i v e l y  l i t t l e emphasis seems t o have been p l a c e d on emotional r e a c t i o n s of p h y s i c i a n s i n such e m o t i o n a l l y - l a d e n encounters (Buckman, 1984).  P h y s i c i a n s themselves are s u g g e s t i n g t h a t ,  \u000C36 i t may  be h e l p f u l f o r p h y s i c i a n s t o become aware of t h e i r  f e e l i n g s i n c l i n i c a l encounters (Longhurst, 1988; and  t h i s may  be another way  s t a t e d by G o r l i n and f e e l i n g s and  t o i n c r e a s e humanism.  As  1988) was  Zucker (1983) \"awareness of one's  own  the a b i l i t y t o cope w i t h them c o n s t r u c t i v e l y i s  an e s s e n t i a l aspect Indeed Longhurst neglected  Zinn,  own  of humanistic medical t e a c h i n g \"  (p. 1061).  (1988) suggested t h a t s e l f - a w a r e n e s s i s \"the  i n s i g h t \" (p. 121),  and he suggested t h a t  self  awareness b u i l d s compassion which i s so h e l p f u l i n the physician-patient relationship. One  advantage of empathy t r a i n i n g may  r o l e - p l a y i n g and  be t h a t through  other e x e r c i s e s , t r a i n e e s l e a r n t o become  aware of emotions, both t h e i r own  and p a t i e n t s ' .  By  attending  t o p a t i e n t s ' f e e l i n g s through both r o l e r e v e r s a l and  empathic  responses, t r a i n e e s a t t e n d t o a f f e c t i n a d d i t i o n t o medical a s p e c t s of the i n t e r v i e w s .  Through awareness of t h e i r  own  f e e l i n g s , p h y s i c i a n s ' a b i l i t i e s t o l e a r n empathic responding may  be enhanced.  of e m o t i o n a l l y  A l s o i t might h e l p t o a l l e v i a t e the  intense s i t u a t i o n s for physicians  acknowledge t h e i r own suppress them. p h y s i c i a n s may  to  f e e l i n g s r a t h e r than t o t r y t o deny or  By being be  stress  aware of t h e i r own  feelings,  i n a p o s i t i o n t o b e t t e r cope w i t h p a t i e n t s '  emotional r e a c t i o n s . addition to teaching  A l s o Smith (1986) suggested t h a t , i n c o g n i t i v e aspects of improving  the  p h y s i c i a n - p a t i e n t r e l a t i o n s h i p , t h e r e i s a need t o develop t e a c h i n g methods i n order t o h e l p medical s t u d e n t s become aware of and manage t h e i r emotional responses t o p a t i e n t s .  \u000CHowever, as Mengel and Mauksch (1989) p o i n t e d out, i t remains t o be e m p i r i c a l l y demonstrated t h a t s e l f - e v a l u a t i o n by p h y s i c i a n s of t h e i r own  the  f e e l i n g s would be r e l a t e d t o  improvements i n t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s .  P r e v i o u s Research Examining Empathy and While a number of s t u d i e s were found  Stress  i n the l i t e r a t u r e  on  the s u b j e c t s of e i t h e r empathy o r s t r e s s , few attempted t o l i n k the two  topics.  which examined how  A l s o , no i n t e r v e n t i o n s t u d i e s were noted  the two  c o n s t r u c t s may  be c a u s a l l y  connected. Letourneau  (1981) compared the l e v e l s of s t r e s s of  mothers who  were p h y s i c a l l y abusive w i t h t h e i r c h i l d r e n with  mothers who  were i d e n t i f i e d as not abusive.  were measured by the Schedule Of Recent L i f e d e v i s e d by Holmes and Rahe (1969).  Two  Levels of s t r e s s Experiences  i n d i c e s were used t o  measure empathy i n the s u b j e c t s , the Hogan Empathy T e s t (Hogan, 1969) Epstein  and a q u e s t i o n n a i r e d e v i s e d by Mehrabian  (1972).  experienced  Letourneau p r e d i c t e d t h a t mothers  who  h i g h empathy and low s t r e s s would be much l e s s  abusive than mothers who stress.  and  experienced  low empathy and  high  T - t e s t s r e v e a l e d t h a t the more abusive mothers scored  s i g n i f i c a n t l y lower on measures of empathy.  However, the  abusive mothers d i d not score s i g n i f i c a n t l y h i g h e r on measures of s t r e s s .  F u r t h e r , Letourneau found t h a t empathy  was  n e g a t i v e l y c o r r e l a t e d with a g g r e s s i o n , a f i n d i n g which  \u000C38  supported h e r t h e o r y t h a t empathy s e r v e s as a mediator  f o r the  s t r e s s - abuse r e l a t i o n s h i p . Letourneau a l s o compared t h e c a t e g o r i e s o f h i g h empathy and h i g h s t r e s s t o low empathy and low s t r e s s t o a s s e s s whether empathy o r s t r e s s was t h e more important p r e d i c t o r o f abuse.  F o l l o w i n g t h e c a t e g o r i z a t i o n o f s u b j e c t s around t h e  grand mean, F i s h e r ' s exact t e s t was used t o examine t h e c o n d i t i o n s under which abuse was more l i k e l y t o occur and t o examine t h e i n t e r a c t i o n between empathy and s t r e s s . Letourneau  found t h a t t h e percentage o f abusive mothers i n the  c a t e g o r y o f low empathy and low s t r e s s was much h i g h e r t h a t these mothers i n t h e category o f h i g h empathy and h i g h s t r e s s . F u r t h e r , f o r mothers who s c o r e d low i n empathy, t h e percentages o f abusive mothers i n t h e c a t e g o r i e s o f h i g h and low s t r e s s were not s i g n i f i c a n t l y d i f f e r e n t . which mothers were empathic  The degree t o  as opposed t o how much s t r e s s they  e x p e r i e n c e d seemed t o be t h e more c r i t i c a l p r e d i c t i n g abusive behaviour.  Letourneau  factor i n concluded t h a t \"the  f a c t t h a t many mothers a p p a r e n t l y f u n c t i o n adequately i n t h e presence o f h i g h s t r e s s , o r i n a d e q u a t e l y even when e x p e r i e n c i n g low l e v e l s o f s t r e s s , suggests t h a t empathy and s t r e s s somehow i n t e r a c t and t h a t empathy s e r v e s a m e d i a t i n g function\"  (p. 387).  In Letourneau's  study, however, o n l y t h e s t r e s s f u l  events i n d i c a t e d by t h e s u b j e c t s were measured.  life  Coping  d i s p o s i t i o n s o r s t r a t e g i e s were not i n v e s t i g a t e d as suggested by Monat and Lazarus  (1985).  Nor was a b e h a v i o u r a l l y - b a s e d  \u000C39  measure o f empathy u s e d ; H o g a n s empathy s c a l e i s a  self-  1  assessed t r a i t scale. of  J a r s k i e t a l . (1985), i n a  comparison  f o u r empathy i n s t r u m e n t s i n s i m u l a t e d p a t i e n t - m e d i c a l  student interactions,  f o u n d t h a t empathy w h i c h was  a s s e s s e d on  the  Hogan's S c a l e d i d n o t c o r r e l a t e s i g n i f i c a n t l y w i t h any  the  b e h a v i o r - b a s e d measures.  The p r e s e n t s t u d y u s e d  of  empathy  m e a s u r e s w h i c h a r e recommended i n t h e l i t e r a t u r e t o e x a m i n e p h y s i c i a n - p a t i e n t i n t e r a c t i o n s i n an a t t e m p t t o g a i n a b e t t e r u n d e r s t a n d i n g o f t h e r e l a t i o n s h i p b e t w e e n empathy a n d B a t s o n e t a l . (1987) (i.e.,  s u g g e s t e d t h a t empathy a n d  stress. distress  t h e emotion e x p e r i e n c e d as a r e s u l t o f s t r e s s )  q u a l i t a t i v e l y v e r y d i f f e r e n t emotions. p e r c e i v e s a n o t h e r who reactions. distress  One  are  When a p e r s o n  i s s u f f e r i n g , h e / s h e c a n h a v e one o f  two  response can i n v o l v e f e e l i n g s of p e r s o n a l  ( e . g . , u p s e t , w o r r i e d ) and t h e o t h e r r e s p o n s e  can  i n v o l v e f e e l i n g s o f empathy ( e . g . , c o m p a s s i o n , t e n d e r n e s s ) . D i s t r e s s may  be v i e w e d a s e v o k i n g a n e g o i s t i c m o t i v a t i o n t o  h e l p a n o t h e r i n need. r e d u c e o n e ' s own  That i s , t h e d e s i r e d consequence  a v e r s i v e response.  evoke an a l t r u i s t i c  Empathy, however,  motivation to help another.  i s to may  That i s , the  u l t i m a t e g o a l i s t o h e l p t h e o t h e r person i n need;  to  o n e ' s own  Empathy  d i s t r e s s i s not the primary motivation.  be v i e w e d a s more o t h e r - f o c u s e d , w h i l e d i s t r e s s may  be  reduce may  viewed  a s more s e l f - f o c u s e d .  T h i s t w o - p a r t model i s s i m i l a r t o t h e  v i e w h e l d by M c D o u g a l l  (1908).  by H u l l  (1943) was  A more r e c e n t v i e w p r e s e n t e d  t h a t empathy a n d d i s t r e s s a r e s i m i l a r i n  t h a t the u l t i m a t e g o a l of both emotions  i s t o reduce one's  own  \u000C40  l e v e l o f a r o u s a l whether o r not t h i s p r o c e s s i n v o l v e s h e l p i n g another person i n need. Batson e t a l . (1987, 1988) p r o v i d e d e m p i r i c a l evidence i n support o f t h e view t h a t empathy and d i s t r e s s a r e q u a l i t a t i v e l y d i f f e r e n t emotions and t h a t e x p e r i e n c i n g empathy toward a person i s a s s o c i a t e d w i t h t h e u l t i m a t e g o a l o f h e l p i n g t h a t person.  They suggested t h a t f u r t h e r r e s e a r c h i s  needed t o support t h e view t h a t d i s t r e s s l e a d s t o e g o i s t i c and empathy l e a d s t o a l t r u i s t i c m o t i v a t i o n t o h e l p . L i t t l e i s known about the f u n c t i o n o f empathy i n t h e i n t e r a c t i o n o f empathy and s t r e s s as suggested (1981).  Folkman and Lazarus  (1988) suggested  by Letourneau t h a t coping  a f f e c t s emotion p o s s i b l y by a c t i n g as a mediator. T r a d i t i o n a l l y , t h e o r y and r e s e a r c h focused on how emotion a f f e c t s coping, but l i t t l e a t t e n t i o n has been g i v e n t o s t u d y i n g whether t h e r e v e r s e i s t r u e . suggested  Folkman and Lazarus  t h a t c o p i n g a f f e c t s emotion i n a b i - d i r e c t i o n a l  manner, t h a t i s , each a f f e c t s t h e o t h e r . a p p r a i s e d as s t r e s s f u l .  First a situation i s  T h i s generates emotion which i n t u r n  i n f l u e n c e s coping processes which a l t e r s t h e personenvironment r e l a t i o n s h i p .  T h i s r e a p p r a i s e d person-environment  r e l a t i o n s h i p r e s u l t s i n a change i n emotion.  Empathic  responding may be e v a l u a t e d by medical students as an e f f e c t i v e means o f coping which, i n t u r n , decreases t h e s t r e s s f u l n e s s o f t h e encounter.  Thus empathic responding may  be viewed as a mediator t o reduce t h e s t r e s s o f e m o t i o n a l l y i n t e n s e c l i n i c a l encounters.  More r e s e a r c h however, i s needed  \u000C41 t o c l a r i f y t h e nature o f t h e b u f f e r i n g a s p e c t s o f empathy i n stressful  situations.  H y p o t h e s e s R e l a t e d t o Empathy a n d S t r e s s The f o l l o w i n g hypotheses were t e s t e d i n t h e p r e s e n t study. Hypothesis  1A:  S u b j e c t s who r e c e i v e empathy  skill  t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y h i g h e r s c o r e s on measures o f empathy than w i l l s u b j e c t s who a r e i n a w a i t - l i s t (delayed-treatment) Hypothesis  c o n t r o l group.  IB:  S u b j e c t s who r e c e i v e empathy  skill  t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y lower s c o r e s on a measure o f p e r c e i v e d s t r e s s than w i l l s u b j e c t s who a r e i n a wait-list  (delayed-treatment)  Hypothesis  2Ai:  c o n t r o l group.  S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  follow-up group w i l l demonstrate s i g n i f i c a n t l y h i g h e r s c o r e s on measures o f empathy than w i l l s u b j e c t s i n t h e w a i t - l i s t c o n t r o l group. Hypothesis  2Aii:  S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  group w i l l m a i n t a i n s c o r e s on measures o f empathy d u r i n g t h e follow-up time p e r i o d . Hypothesis  2Aiii:  (delayed-treatment)  S u b j e c t s who a r e i n t h e w a i t - l i s t  c o n t r o l group w i l l not i n c r e a s e i n s c o r e s  on measures o f empathy d u r i n g t h e w a i t - l i s t c o n t r o l  time  period. Hypothesis  2Bi:  S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  follow-up group w i l l demonstrate s i g n i f i c a n t l y  lower s c o r e s on  \u000C42 a measure of p e r c e i v e d s t r e s s than w i l l  s u b j e c t s i n the w a i t -  l i s t c o n t r o l group. Hypothesis  2Bii:  S u b j e c t s who  are i n the p o s t - t r a i n i n g  group w i l l m a i n t a i n s c o r e s on a measure of p e r c e i v e d s t r e s s d u r i n g the follow-up time p e r i o d . Hypothesis  2Biii:  (delayed-treatment)  S u b j e c t s who  are i n the w a i t - l i s t  c o n t r o l group w i l l not decrease  i n scores  on a measure of p e r c e i v e d s t r e s s d u r i n g the w a i t - l i s t  control  time p e r i o d . Hypothesis  3A;  S u b j e c t s who  r e c e i v e empathy s k i l l s  t r a i n i n g a t d i f f e r e n t p o i n t s i n time w i l l  increase i n scores  on measures of empathy. Hypothesis  3B:  S u b j e c t s who  r e c e i v e empathy s k i l l s  t r a i n i n g a t d i f f e r e n t p o i n t s i n time w i l l decrease of  i n scores  a measure of p e r c e i v e d s t r e s s .  P r e v i o u s Research  Related to  E x p l o r a t o r y Analyses Hardiness Antonovsky (1979) suggested i l l n e s s has begun t o s h i f t  that research i n stress  and  toward the study of r e s i s t a n c e  r e s o u r c e s which h e l p a person cope w i t h s t r e s s f u l  events.  Folkman and Lazarus  processes  (1980), d e f i n e d two  important  i n v o l v e d when a person i s a f f e c t e d by a s t r e s s f u l i n the environment.  One  occurrence  i s a p p r a i s a l which r e f e r s t o the  c o g n i t i v e p r o c e s s e s used t o e v a l u a t e the s t r e s s f u l and the o p t i o n s a v a i l a b l e t o d e a l w i t h i t .  situation  A p p r a i s a l or  \u000C43  e v a l u a t i o n of the s t r e s s f u l s i t u a t i o n has been d i s c u s s e d i n terms o f the P e r c e i v e d S t r e s s Q u e s t i o n n a i r e . The second process i n v o l v e s the c o p i n g approach t o the a p p r a i s a l s of s t r e s s .  The c o p i n g responses may  a c t u a l p r o c e s s e s used,  such as problem-focused  focused e f f o r t s or  o r emotion-  (Folkman, Lazarus, Gruen, &amp; DeLongis,  they can r e f e r t o antecedents  (Kobasa,  1979).  and R e v i c k i (1985) have i l l u s t r a t e d a s t r e s s and  coping  model f o r primary c a r e p h y s i c i a n s i n which two moderators of s t r e s s mentioned, which may or  1986),  of coping such as p e r s o n a l i t y  c h a r a c t e r i s t i c s or t r a i t s such as h a r d i n e s s May  refer to  determine s u c c e s s f u l  u n s u c c e s s f u l coping, were coping s k i l l s  style.  May  of the f o u r  and  personality  and R e v i c k i (1985) s p e c i f i c a l l y s t a t e d t h a t  h a r d i n e s s i s one example of a p e r s o n a l i t y s t y l e which may c r i t i c a l moderating medical p r a c t i c e .  be a  f a c t o r i n c o p i n g w i t h the s t r e s s of F a i n and S c h r e i e r (1989) recommended t h a t  the p e r s o n a l i t y v a r i a b l e of h a r d i n e s s should be c o n s i d e r e d i n the s e l e c t i o n of medical personnel f o r d i s a s t e r or emergency situations. Hardiness was  c o n c e p t u a l i z e d by Kobasa (1979) as having  t h r e e components; commitment, c o n t r o l and c h a l l e n g e . Commitment r e f e r s t o being a c t i v e l y i n v o l v e d i n one's growth and b e i n g i n touch w i t h one's own  f e e l i n g s and v a l u e s as  opposed t o b e i n g a l i e n a t e d from one's s e l f . having a b e l i e f t h a t one  Control r e f e r s to  i s a b l e t o i n f l u e n c e one's  environment r a t h e r than b e i n g t o t a l l y i n f l u e n c e d by o t h e r s .  \u000C44 C h a l l e n g e r e f e r s t o viewing l i f e as having o p p o r t u n i t i e s f o r change and growth r a t h e r than t h r e a t s t o s e c u r i t y . Kobasa's (1982) r e s e a r c h  suggested t h a t the p e r s o n a l i t y  c h a r a c t e r i s t i c of psychological hardiness r e s i s t a n c e resource events.  f u n c t i o n s as a  i n b u f f e r i n g the e f f e c t s o f s t r e s s f u l  Kobasa, Maddi, and Kahn (1982) viewed t h i s concept  from an e x i s t e n t i a l p e r s p e c t i v e .  Hardiness was c o n s i d e r e d  to  be a moderator o f s t r e s s because s t r e s s f u l events would not be appraised  t o be u n c o n t r o l l a b l e o r meaningless.  J u s t as empathic s k i l l  can be l e a r n e d ,  Kobasa  (1982)  suggested t h a t the p e r s o n a l i t y c h a r a c t e r i s t i c o f h a r d i n e s s \" s t r e s s r e s i s t a n c e \" c o u l d be developed.  or  She recommended t h a t  r e s e a r c h be conducted t o g a i n an understanding o f how hardiness devise  develops, and i n d i c a t e d t h a t t h e r e  i n t e r v e n t i o n s t o develop t h i s t r a i t .  i s a need t o Although s t u d i e s -  have examined whether h e a l t h p r o f e s s i o n a l s who have h i g h l e v e l s of hardiness stress  allowed them t o b e t t e r cope w i t h work  (e.g. Maloney &amp; B a r t z ,  1983), no s t u d i e s were found  which examined whether an i n t e r v e n t i o n (designed  t o reduce the  s t r e s s o f medical s i t u a t i o n s ) was a s s o c i a t e d w i t h a change i n hardiness  or \" s t r e s s - r e s i s t a n c e . \"  One o f the g o a l s o f t h i s  study was t o i n v e s t i g a t e whether h a r d i n e s s medical students who r e c e i v e d empathy  would develop i n  skills training.  \u000C45  Ways o f C o p i n g I n o r d e r t o i n v e s t i g a t e t h e t y p e o f r e s p o n s e s used by i n t e r n s t o cope w i t h t h e s t r e s s o f i n t e r n s h i p , D o n n e l l y  (1979)  d e v i s e d a Ways o f C o p i n g S c a l e b a s e d o n t h e c o p i n g s t r a t e g i e s which were r e p o r t e d by t h e i n t e r n s . the  The s t r a t e g i e s f e l l  into  t w o c a t e g o r i e s o f (a) n o n - p a l l i a t i v e o r p r o b l e m - f o c u s e d  coping  (problem-solving actions t o t r yt o a l l e v i a t e the stress  o r a l t e r t h e e n v i r o n m e n t ) a n d (b) p a l l i a t i v e o r e m o t i o n focused coping (actions t o t r yt o a l l e v i a t e the emotional d i s t r e s s caused by t h e s i t u a t i o n ) .  Donnelly found t h a t t h e  i n t e r n s who h a d h i g h e r e g o d e v e l o p m e n t  used s t r a t e g i e s  from  both categories i n coping with the stress of internship. S u b j e c t s who h a d l o w e r e g o d e v e l o p m e n t palliative  used m a i n l y non-  (problem-focused) coping s t r a t e g i e s .  Further, the  i n t e r n s who h a d a c o m b i n a t i o n o f h i g h e g o d e v e l o p m e n t  and used  b o t h p r o b l e m - f o c u s e d and emotion-focused c o p i n g s t r a t e g i e s r e c e i v e d t h e h i g h e s t c l i n i c a l performance r a t i n g s by a group of u n i v e r s i t y f a c u l t y and house m e d i c a l o f f i c e r s . The  s u b j e c t s w i t h l o w ego d e v e l o p m e n t  who u s e d m a i n l y  p r o b l e m - f o c u s e d c o p i n g w e r e more c o n c e r n e d w i t h t r y i n g t o a l t e r t h e environment t o cope w i t h s t r e s s because,  perhaps,  t h e y v i e w e d s t r e s s a s b e i n g c a u s e d more b y e x t e r n a l e v e n t s . The  s u b j e c t s w i t h h i g h ego development  who u s e d b o t h t y p e s o f  c o p i n g s t r a t e g i e s , on t h e o t h e r hand, t r i e d t o a l t e r themselves as w e l l as t h e environment.  The i n t e r n s  i n the  h i g h p e r f o r m a n c e group were f l e x i b l e i n t h e i r u s e o f c o p i n g s t r a t e g i e s and had a w i d e r range o f responses t o s t r e s s .  \u000C46 Donnelly suggested t h a t medical e d u c a t i o n should make attempts  t o t r y t o d e s i g n ways t o reduce t h e s t r e s s o f medical  e d u c a t i o n and t o i n c r e a s e coping a b i l i t i e s o f s t u d e n t s .  She  recommended t h a t f u r t h e r r e s e a r c h examine c o p i n g s t y l e s o f students and t h e c o n t r i b u t i o n o f c o p i n g s t r a t e g i e s t o t h e stages o f medical education, because coping s t r a t e g i e s  used  d u r i n g medical t r a i n i n g may p r e d i c t a f u t u r e a b i l i t y t o d e a l w i t h s t r e s s i n medical  practice.  No f u r t h e r s t u d i e s were found which used Donnelly's Ways of Coping S c a l e .  However, t h e problem o f s t r e s s among medical  students i s t h e s u b j e c t o f r e c e n t r e s e a r c h . S p i e g e l , Smolen, and Hopfensperger  For instance,  (1986) who examined medical  student s t r e s s and how i t r e l a t e d t o c l i n i c a l performance found an i n v e r s e r e l a t i o n s h i p between medical  students'  r a t i n g s o f i n t e r p e r s o n a l c o n f l i c t s and measures o f t h e i r academic performance. understand  They suggested  that, i n order t o  t h i s r e l a t i o n s h i p f u r t h e r , r e s e a r c h i s needed on  how c o p i n g r e s o u r c e s , among o t h e r f a c t o r s , c o n t r i b u t e t o s t u d e n t s ' performance i n medical s c h o o l .  V i t a l i a n o , Masuro,  M i t c h e l l , and Russo (1989) p o i n t e d out t h a t w h i l e many s t u d i e s have examined t h e r e a c t i o n s o f medical students t o s t r e s s f u l situations,  (e.g., s u i c i d e , drug abuse),  few have examined  i n d i v i d u a l v u l n e r a b i l i t i e s and i n t e r n a l r e s o u r c e s o f medical students which i n f l u e n c e how they cope w i t h t h e s t r e s s o f medical t r a i n i n g .  These s c h o l a r s recommended t h a t  i n t e r v e n t i o n s should be designed t o a s s i s t medical cope w i t h s t r e s s .  One o f t h e purposes  students  of t h i s present  study  \u000C47  was  t o i n v e s t i g a t e whether the number of c o p i n g s t r a t e g i e s  changed f o r medical students who empathy s k i l l s  r e c e i v e d the i n t e r v e n t i o n of  training.  Methodological Issues I d e n t i f i e d i n Relevant Previous Research In  1980,  C a r r o l l and Munroe p u b l i s h e d a review of the  e m p i r i c a l r e s e a r c h on i n s t r u c t i o n a l programs f o r t e a c h i n g clinical of  interviewing.  They r e p o r t e d t h a t the g r e a t m a j o r i t y  t h e s e s t u d i e s had employed weak r e s e a r c h d e s i g n s .  T h e r e f o r e , the v a l i d i t y of r e p o r t e d f i n d i n g s must be questioned.  Many of the s t u d i e s were One  Group P r e t e s t -  P o s t t e s t Designs, t h a t i s , pre-experimental d e s i g n s , and were s u s c e p t i b l e t o many confounding used nonequivalent c o n t r o l groups,  factors.  thus  Studies often  t h a t i s , the assignment of  students t o the experimental c o n d i t i o n was  by means of i n t a c t  groups r a t h e r than by random assignment. Only f i v e out of twenty-seven s t u d i e s which compared i n t e r p e r s o n a l s k i l l s t r a i n i n g w i t h no i n t e r p e r s o n a l s k i l l s t r a i n i n g i n c o r p o r a t e d t r u e experimental d e s i g n s .  In these  s t u d i e s , p a r t i c i p a n t s were randomly a s s i g n e d t o groups, were t e s t e d b e f o r e and a f t e r i n s t r u c t i o n . suggested  and  C a r r o l l and Monroe  t h a t t h e r e i s a need t o r e p l i c a t e s t u d i e s and  c o n t r o l f o r p o t e n t i a l confounding  f a c t o r s such as h i s t o r y ,  p r a c t i c e , maturation and i n t e r a c t i o n Sanson-Fisher  effects.  e t a l . (1981) a l s o p u b l i s h e d a review of  the methodology of s t u d i e s designed t o t e a c h communication  \u000C48  skills specifically  t o medical s t u d e n t s .  They conducted a  survey o f experienced r e s e a r c h e r s i n o r d e r t o determine what c o n s t i t u t e d adequate methodology f o r such s t u d i e s . criteria  Among t h e  i n d i c a t e d f o r adeguate s t u d i e s o f t h e t e a c h i n g o f  communication s k i l l s were: c o n t r o l group,  a) random a l l o c a t i o n o r matched  b) assessments  o f medical s t u d e n t s '  abilities  u s i n g d i r e c t methods (e.g., i n t e r v i e w s and r e l i a b l e t e s t shown to measure s k i l l ) v e r s u s i n d i r e c t measures such as p e n c i l and paper t e s t s , o r comments, and c) e s t i m a t e s o f r e l i a b i l i t y o f ratings. To examine how adequately s t u d i e s were designed t o teach communication s k i l l s t o medical students u s i n g t h e c r i t e r i a listed  above, Sanson-Fisher e t a l . reviewed 4 6 s t u d i e s .  They  found t h a t 28 (61 percent) o f t h e s t u d i e s were d e s c r i p t i v e , c o n t a i n i n g no experimental evidence t h a t t h e t e a c h i n g methods improved  communication s k i l l s .  determined  Of t h e 18 s t u d i e s which were  t o be experimental, few met t h e c r i t e r i a .  For  i n s t a n c e , out o f t h e 18 experimental s t u d i e s , o n l y h a l f used a c o n t r o l group,  and o n l y 39 p e r c e n t used random a l l o c a t i o n o r a  matched c o n t r o l group.  Only 11 p e r c e n t p r e s e n t e d and  described a s t a t i s t i c a l  index o f r e l i a b i l i t y .  et  a l . concluded t h a t \"those who advocate new approaches  demonstrate methods.  must  t h a t they a r e e f f e c t i v e and s u p e r i o r t o e x i s t i n g  They can o n l y do t h i s i f they adopt an adeguate  methodology\" (p.37). of  Sanson-Fisher  DiMatteo  (1979) echoed t h e s u g g e s t i o n s  Sanson-Fisher e t a l . (1981), as he a l s o r e p o r t e d t h a t many  s t u d i e s l a c k e d sound e v a l u a t i o n techniques due t o such  factors  \u000C49 as inadequate He suggested  experimental designs and l a c k o f c o n t r o l  groups.  t h a t f u t u r e r e s e a r c h must be designed t o p r o v i d e  p h y s i c i a n s w i t h e f f e c t i v e methods o f d e v e l o p i n g i n t e r p e r s o n a l a s p e c t s o f p a t i e n t c a r e such as empathy. suggested  DiMatteo  (1989)  t h a t medical educators w i l l p r o b a b l y c o n s i d e r t h e  recommendations o f s o c i a l s c i e n t i s t s c o n c e r n i n g such t h i n g s as communication s k i l l s o n l y i f t h e i n f o r m a t i o n i s grounded upon \" m e t h o d o l o g i c a l l y sound r e s e a r c h f i n d i n g s \"  (p. 29).  Recommendations have been made by o t h e r r e s e a r c h e r s about c o n s i d e r a t i o n s when d e s i g n i n g r e s e a r c h t o e v a l u a t e t h e e f f e c t i v e n e s s o f communication s k i l l s t r a i n i n g f o r medical students and p h y s i c i a n s .  F o r i n s t a n c e , t h e r e i s a need t o  i n v e s t i g a t e t h e e f f e c t s o f t r a i n i n g on r a t i n g s o f both t h e t r a i n e e s and t h e s i m u l a t e d p a t i e n t s ( C a r r o l l &amp; Munroe, 1980). Such e v a l u a t i o n outcome measures should be d i r e c t l y r e l e v a n t to  p a t i e n t v a r i a b l e s such as s a t i s f a c t i o n  1980,  DiMatteo,  1979).  ( C a r r o l l &amp; Munroe,  A s u g g e s t i o n made by o t h e r  investigators included the objective evaluation of s k i l l s of trainees  (Betchart e t a l . ,  1984).  Kahn e t a l . (1979) i n t h e i r  review o f i n t e r v i e w i n g s k i l l courses found t h a t 87 p e r c e n t used i n d i r e c t methods such as student s a t i s f a c t i o n , w h i l e o n l y a few used c r i t e r i o n - r e f e r e n c e d instruments o r d i r e c t observation of s k i l l s .  Gask e t a l . (1988) suggested  t h a t few  s t u d i e s e v a l u a t e d change i n i n t e r v i e w i n g by t h e r a t i n g o f s k i l l s using videotaped sessions with r e a l or simulated patients.  J a r s k i e t a l . (1985) suggested  that studies  designed t o examine changes i n empathy should have o b j e c t i v e  \u000C50  measures by e x t e r n a l r a t e r s which can be compared w i t h t h e p e r c e p t i o n s o f p a t i e n t s because p a t i e n t s  1  ratings are closely  r e l a t e d t o t h e r a p e u t i c outcomes. Another was  recommendation made by Shore and Franks  t h a t w h i l e most instruments examine p a t i e n t s '  (1986)  satisfaction  r e g a r d i n g encounters w i t h p h y s i c i a n s , t h e examination and study o f p h y s i c i a n s a t i s f a c t i o n has been n e g l e c t e d . s a t i s f a c t i o n with c l i n i c a l  Physician  encounters would be an important  outcome measure s i n c e i t would p r o v i d e a more analysis of physician-patient interactions.  complete Such a measure  would l e n d e m p i r i c a l support i n response t o Wakeford's s u g g e s t i o n t h a t t h e reason communication s k i l l s courses a r e not taught more f r e q u e n t l y i s t h a t t h e r e i s no evidence which shows how programs h e l p medical s t u d e n t s . I reviewed t h e l i t e r a t u r e t o examine i f s t u d i e s employed methodology which i n c l u d e d t h e c r i t e r i a  d i s c u s s e d above.  While s e v e r a l o f these s t u d i e s examined l e v e l s o f empathy i n medical s t u d e n t s and p h y s i c i a n s and c o r r e l a t e d them w i t h other measures through a one-time t e s t i n g o c c a s i o n (e.g., Dornbush et  a l . 1984; Evans, K i e l l e r u p , S t a n l e y , Burrows, &amp; Sweet,  1987;  Hornblow, Kidson, &amp; Jones,  1977; L i n n e t a l . 1987), few  i n t e r v e n t i o n s t u d i e s designed t o i n c r e a s e empathy l e v e l s u s i n g pre-  and post-measures were noted. Some s t u d i e s (e.g., D i c k i n s o n , Huels, &amp; Murphy, 1983;  Wolf, W o o l l i s c r o f t , Calhoun,  &amp; Boxer, 1987) r e p o r t e d t h e  e f f e c t s o f a g e n e r a l communication s k i l l s t r a i n i n g courses on measures o f empathy.  F o r i n s t a n c e Wolf e t a l . ,  1987, i n a  \u000C51 study of communication s k i l l s  t r a i n i n g f o r f i r s t year medical  s t u d e n t s , i n c l u d e d i n t h e i r course s t r a t e g i e s f o r responding empathically.  They found t h a t average s c o r e s on an  understanding s c a l e which measured p r e f e r e n c e s f o r w r i t t e n empathic  responses of p a t i e n t s emotional needs i n c r e a s e d  significantly after training. skills  was  not examined.  However, d i r e c t o b s e r v a t i o n of  D i c k i n s o n e t a l . (1983) examined  empathy of p e d i a t r i c house o f f i c e r s as r a t e d by o b s e r v e r s on the C l i n i c a l Assessment S c a l e f o r P e d i a t r i c I n t e r v i e w i n g b e f o r e and a f t e r an i n t e r v i e w i n g course.  They found t h a t  empathy s c o r e s d i d not i n c r e a s e . Weihs and Chapados (1986) conducted e f f e c t s o f an i n t e r v i e w i n g s k i l l s  a study of the  course, based on C a r k h u f f ' s  model, on v e r b a l responses by f i r s t year medical s t u d e n t s . The study i n v o l v e d a treatment group (n = 16) and a c o n t r o l group (n = 16).  Scores based on C a r k h u f f * s 5-point model were  s i g n i f i c a n t l y h i g h e r a f t e r t r a i n i n g f o r the treatment group as compared w i t h the c o n t r o l group.  These r e s u l t s are s i m i l a r t o  the ones p r e s e n t e d by Poole and Sanson-Fisher demonstrated  (1979)  a s i g n i f i c a n t i n c r e a s e i n empathy by  who  objective  r a t e r s based on Truax and C a r k h u f f ' s 9-point s c a l e a f t e r an empathy t r a i n i n g program f o r p r e c l i n i c a l medical s t u d e n t s as compared w i t h a c o n t r o l  group.  Kramer e t a l . (1989) used an o b s e r v a t i o n a l schedule developed by A l r o y , Ber, and Kramer (1984) t o observe v e r b a l and non-verbal s u p p o r t i n g behaviours of which responses were a p a r t .  empathic  F i f t h year I s r a e l i medical  students  \u000C52  were observed b e f o r e and a f t e r a course i n empathy t r a i n i n g and r e s u l t s showed t h a t t h e r e was  a s i g n i f i c a n t and  lasting  i n c r e a s e over time i n the number of s u p p o r t i n g behaviours  and  a s i g n i f i c a n t decrease i n number of r e j e c t i n g b e h a v i o u r s . r e v e r s e was  t r u e f o r the c o n t r o l  The  group.  E l i z u r and Rosenheim (1982) conducted  a study a l s o of  I s r a e l i medical students t o determine whether a p s y c h i a t r i c c l e r k s h i p combined w i t h group e x p e r i e n c e , compared t o a c l e r k s h i p w i t h no group experience had any impact on l e v e l s of empathy.  These r e s e a r c h e r s used Mehrabian's Emotional  Empathic Tendency S c a l e (Mehrabian  &amp; E p s t e i n , 1972)  as a  w r i t t e n s e l f - r a t e d empathy s c a l e as w e l l as r a t i n g s by u s i n g a s o c i o m e t r i c technique. who  peers  They found t h a t the students  p a r t i c i p a t e d i n a group experience had  significantly  h i g h e r s c o r e s on the Empathic Tendency S c a l e than those had the c l e r k s h i p alone. was  who  F u r t h e r , a f t e r the c l e r k s h i p , t h e r e  a s i g n i f i c a n t c o r r e l a t i o n between s e l f - r e p o r t e d and o t h e r -  r e p o r t e d empathy f o r the students w i t h group e x p e r i e n c e .  The  authors concluded t h a t the group experience c o n t r i b u t e d t o i n c r e a s e d s e n s i t i v i t y and a deepening  of empathy.  None of the f o u r s t u d i e s mentioned above nor any study was  other  found which e v a l u a t e d the e f f e c t s of an empathy  t r a i n i n g program u s i n g s t u d e n t s ' s e l f - a s s e s s m e n t of s k i l l s i n comparison  t o the assessments  of s i m u l a t e d p a t i e n t s .  important because p a t i e n t s ' responses may  This i s  be l i n k e d t o outcome  and t h e r e f o r e have important i m p l i c a t i o n s f o r the understanding of p h y s i c i a n - p a t i e n t r e l a t i o n s h i p s .  \u000C53  J a r s k i e t a l . (1985) presented an argument t h a t should  \"studies  be d e v i s e d where the r e s u l t s of empathy r a t i n g s by  e x t e r n a l o b s e r v e r s can be compared w i t h the p e r c e p t i o n s  of  p a t i e n t s and  Based  o b j e c t i v e t h e r a p e u t i c outcomes\" (p. 550).  on h i s f i n d i n g s , he recommended the R e l a t i o n s h i p Inventory f o r use  Barrett-Lennard  i n medicine.  He  a l s o suggested  t h a t o b j e c t i v e r a t i n g s of empathy, such as C a r k h u f f s ,  1969  r a t i n g s c a l e , be completed by p r o f e s s i o n a l s t r a i n e d i n s c o r i n g them.  In s p i t e of J a r s k i e t a l . ' s suggestions,  t h a t the B a r r e t t - L e n n a r d  and  Carkhuff's  e x t e n s i v e l y used s u b j e c t i v e and (Barrett-Lennard  and  the  fact  S c a l e s are the most  o b j e c t i v e measures of empathy  1981), no study was  found where they were a l l  used as outcome measures t o determine the e f f e c t i v e n e s s of empathy t r a i n i n g programs f o r medical students o r In view of the above d i s c u s s i o n and based recommendations of p r e v i o u s designed t o i n c o r p o r a t e  researchers,  physicians.  on  t h i s study  recommended m e t h o d o l o g i c a l  was features  i n c l u d i n g u s i n g a c o n t r o l group, d i r e c t assessments of communication s k i l l s w i t h c r i t e r i o n - r e f e r e n c e d instruments, students'  assessments of t h e i r own  communication s k i l l s  using  r e l i a b l e instruments which c o u l d be compared t o assessments by simulated  p a t i e n t s , and  students'  responses t o the  as measures of the impact of empathy t r a i n i n g .  interview  \u000C54  CHAPTER I I I Method  Introduction T h i s chapter opens w i t h the r a t i o n a l e and d e t a i l s of the experimental d e s i g n chosen t o t e s t the hypotheses study.  I n f o r m a t i o n about people who  in this  p a r t i c i p a t e d i n the study  i s f o l l o w e d by a d e s c r i p t i o n of measures and o t h e r m a t e r i a l s r e q u i r e d f o r the e x e c u t i o n of the r e s e a r c h . c o n c e r n i n g the experimental procedures  Details  are i n c l u d e d and a  d e s c r i p t i o n of data analyses c l o s e the chapter.  Experimental  Design  The d e s i g n employed i n t h i s study was d e s i g n f o r two  e q u i v a l e n t groups.  a crossover control  In Campbell and  (1963) t e r m i n o l o g y the d e s i g n i s i l l u s t r a t e d R R  X 0  4  0  2  0  5  Stanley's  as:  \u00B03 X  0  6  where R i n d i c a t e s random assignment of s u b j e c t s , X i n d i c a t e s t r a i n i n g , and 0 r e p r e s e n t s t e s t i n g u s i n g the r e s e a r c h measures.  In t h i s d e s i g n a l l s u b j e c t s are measured on the  dependent v a r i a b l e s and randomly a s s i g n e d t o one of groups.  The  f i r s t group r e c e i v e s the treatment  two  (experimental  group), w h i l e the second group serves as a w a i t - l i s t Measures are then c o l l e c t e d f o r a l l s u b j e c t s , halfway the study.  The treatment  control. through  c r o s s o v e r then takes p l a c e and  \u000C55 s u b j e c t s i n group two r e c e i v e treatment.  The f i r s t  group  r e c e i v e s no f u r t h e r i n t e r v e n t i o n and so serves as a c o n t r o l o r follow-up group. completing  Measures a r e c o l l e c t e d a t h i r d  time,  t h e procedure.  The c r o s s o v e r d e s i g n a l l o w s f o r an examination e f f e c t s o f treatment for a l l subjects. Stanley  compared w i t h a no-treatment c o n d i t i o n  ( E p s t e i n &amp; T r i p o d i , 1977).  design.  T h i s type o f d e s i g n i s r e f e r r e d t o  a l s o a s . a \"change-over d e s i g n \" a \"cross-over design\"  (Gill,  (Cochran  Wasserman, 1974), and a time-lagged comparative The First,  Campbell and  (1963) p l a c e such a d e s i g n under t h e heading o f  \"counterbalanced\"  1974)  of the  experimental  design  1978; Neter  &amp; Wasserman,  &amp; Cox, 1957, Neter &amp; crossover or crossover  (Epstein &amp; T r i p o d i ,  1977).  c r o s s o v e r c o n t r o l d e s i g n has s e v e r a l advantages.  i t i s a \" t r u e \" experimental  randomly a s s i g n e d t o treatments.  d e s i g n because s u b j e c t s a r e Random assignment h e l p s a  r e s e a r c h e r make c a u s a l i n f e r e n c e s because i t i s t h e b e s t way t o ensure t h a t t h e groups a r e g e n u i n e l y comparable.  I n other  words, i t can be assumed t h a t t h e f e a t u r e s o f s u b j e c t s i n one group w i l l be counterbalanced identical,  by comparable, but not  f e a t u r e s o f s u b j e c t s i n t h e o t h e r group (Cook &amp;  Campbell, 1979).  A l s o because one o f t h e \"treatments\"  used i n  t h i s c r o s s o v e r d e s i g n i s a no-treatment c o n t r o l , and because s u b j e c t s a r e randomly a s s i g n e d t o t h e two groups, t h r e a t s t o internal validity  (i.e.,  f a c t o r s i d e n t i f i e d by Campbell and  S t a n l e y , 1963) a r e c o n t r o l l e d 1985).  ( E p s t e i n &amp; T r i p o d i , 1977; Cates,  For i n s t a n c e , t h e e f f e c t s o f contemporary h i s t o r y and  \u000C56  maturation processes are l i m i t e d and the e f f e c t s of t e s t i n g are reduced by assessing the control group. Cook and Campbell (1979) i d e n t i f y four threats to internal v a l i d i t y that randomization does not r u l e out. These threats w i l l now be i d e n t i f i e d and suggestions given as to why they are probably not v a l i d threats to t h i s study. (1)  Imitation of Treatment - While i t i s true that there  was no c e r t a i n method to prevent the p o s s i b i l i t y of subjects who were involved i n the second t r a i n i n g period from learning about the d e t a i l s of the empathy t r a i n i n g , the subjects who received the t r a i n i n g f i r s t were asked not to reveal the nature of the t r a i n i n g to the people i n the delayed t r a i n i n g group.  Imitation of treatment i s more l i k e l y to be a threat  i f two d i f f e r e n t types of t r a i n i n g were to be used i n the study. (2)  Compensatory equalization - There was no need f o r  compensation since every subject received the treatment; thus no inequality resulted from random assignment. (3)  Compensatory Rivalry - A l l subjects received the  same t r a i n i n g .  Each subject was tested i n d i v i d u a l l y i n a one-  to-one therapeutic i n t e r a c t i o n .  Further, the type of emotion  presented at each t e s t i n g occasion was counterbalanced so that each subject had experience with each type of emotion. I t would seem u n l i k e l y , then, e s p e c i a l l y since subjects were asked not to discuss d e t a i l s about the t r a i n i n g to subjects i n the w a i t - l i s t group, that subjects would want to prove that t h e i r t r a i n i n g group s performance was superior over the 1  \u000Cother.  I b e l i e v e t h a t because the one-to-one encounters of  the t e s t i n g o c c a s i o n s  were somewhat s t r e s s f u l , t h a t  d i d the b e s t they c o u l d g i v e n t h e i r t r a i n i n g . f a c t , no v e r b a l e x p r e s s i o n s  subjects  Demoralization  There were, i n  of such r i v a l r y by the c o n t r o l  s u b j e c t s d u r i n g the t e s t i n g (4)  subjects  occasions.  i n Groups - T h i s may  happen i f  i n a group l e a r n t h a t they w i l l r e c e i v e a l e s s  d e s i r a b l e treatment and  thus they become r e s e n t f u l .  Certainly  i n d i v i d u a l s u b j e c t s want t o r e c e i v e the more d e s i r a b l e treatment or e l s e they may other group. all  f e e l deprived  when compared t o  the  However, i n t h i s study s u b j e c t s knew they would  r e c e i v e the same t r a i n i n g . In summary, Cook and  Campbell  (1979) s t a t e d t h a t these  f o u r t h r e a t s r e s u l t from the \"focused  inequities that  i n e v i t a b l y accompany experimentation because some people r e c e i v e one  treatment and  or no treatment a t a l l \"  others  (pp 56-57).  v i o l a t i o n of what i s f a i r and t h i s crossover  design,  r e c e i v e d i f f e r e n t treatments  and  just.  In other words t h e r e One  of the advantages of  something t h a t a l l s u b j e c t s were  t o l d d u r i n g the p r e t e s t i n t e r v i e w , was receive equivalent  is a  treatment.  t h a t they were t o  That i s , a l l s u b j e c t s  p a r t i c i p a t e d i n the same empathy t r a i n i n g and  three t e s t i n g  occasions. Cook and  Campbell  (1979) suggested t h a t t h r e a t s  i n t e r n a l v a l i d i t y are caused by a t y p i c a l behaviour o f  to subjects  i n a no-treatment c o n t r o l group or groups t h a t r e c e i v e l e s s d e s i r a b l e treatments.  They suggested the b e s t way  t o ensure  \u000C58 t h a t t h e s e t h r e a t s do n o t o p e r a t e i n a n e x p e r i m e n t i s t o h a v e d i r e c t measures f o r a l l t r e a t m e n t was connection.  groups of t h e p r o c e s s t h a t  t o e f f e c t i n o r d e r t o make a v a l i d  the  causal  Such measures were t a k e n i n t h i s s t u d y , as  i n d i c a t e d by t h e s e v e r a l dependent  measures o f empathy  d i s t r e s s w h i c h t h e empathy t r a i n i n g was  meant t o  influence.  A l s o t h e b e h a v i o u r o f t h e no-treatment c o n t r o l group examined  to control f o r i m i t a t i o n of treatment.  s t a t i s t i c a l p r o c e d u r e s examined e f f e c t t o a s s e s s whether between groups.  and  was  Furthermore,  t h e presence o f a group  t h e r e was  compensatory  Thus, a f u r t h e r advantage  main  rivalry  of the crossover  c o n t r o l d e s i g n i s t h a t t o some e x t e n t i t c o n t r o l s f o r t h e s e f o u r t h r e a t s t o i n t e r n a l v a l i d i t y t h a t r a n d o m i z a t i o n does not r u l e outA s e c o n d a d v a n t a g e , a s Cook a n d C a m p b e l l o u t , i s t h a t d e s i g n s i n w h i c h an e f f e c t c a n be  (1979)  pointed  demonstrated  w i t h two s a m p l e s a t d i f f e r e n t moments i n t i m e h a v e t h e potential  f o r e x t e n d i n g c o n s t r u c t and e x t e r n a l v a l i d i t y .  The  b u i l t - i n r e p l i c a t i o n o f the experiment i n t h e second group t h e c r o s s o y e r d e s i g n makes i t p o s s i b l e t o i n f e r t h a t  of  findings  f r o m t h e e x p e r i m e n t c a n be g e n e r a l i z e d t o o t h e r s i m i l a r subject populations.  A f u r t h e r advantage  replication i n t h i s design i s that, s m a l l sample overcome.  of the  built-in  f o r s t u d i e s which have a  s i z e , t h e p r o b l e m o f low power i s p a r t i a l l y  Providing the treatment at d i f f e r e n t times f o r the  two s i m i l a r s a m p l e s d r a w n f r o m t h e same p o p u l a t i o n c o n f i r m s the findings  (Cates, 1985).  \u000C59 A t h i r d advantage o f t h i s d e s i g n receive the intervention.  i s that a l l subjects  The d e n i a l o f an i n t e r v e n t i o n t o  s u b j e c t s , e s p e c i a l l y i n f i e l d s t u d i e s , may be e t h i c a l l y and p r o f e s s i o n a l l y unacceptable instance,  ( E p s t e i n &amp; T r i p o d i , 1977).  For  i n t h i s study, t h e r e may have been some emotional  discomfort  on t h e p a r t o f t h e medical s t u d e n t s when they took  the p r e t e s t s because o f t h e i n t e n s i t y o f t h e emotions and s u b j e c t matter.  Therefore  I thought t h a t i t would be u n f a i r  t o have s u b j e c t s complete t e s t i n g o n l y and not r e c e i v e t h e training.  In summary, E p s t e i n and T r i p o d i (1977) s t a t e d t h a t  \"the unique advantage o f t h i s that i t provides  (crossover c o n t r o l ) d e s i g n i s  t h e s c i e n t i f i c r i g o r o f a c o n t r o l group  experiment without r e q u i r i n g any s e r v i c e d e n i a l t o any agency clients\"  (p.  165).  As a number o f s c h o l a r s have i n d i c a t e d (e.g., Armitage &amp; Hills,  1982; M i l l a r ,  1983), t h e c r o s s o v e r  d e s i g n has f u r t h e r  advantages i n c l u d i n g economy o f s u b j e c t s and i n c r e a s e d power. Because each s u b j e c t p r o v i d e s  more than one o b s e r v a t i o n ,  subjects are required f o r a within-subjects between-groups d e s i g n . i n the present  design  fewer  than f o r a  And not o n l y does the c r o s s o v e r  design  study have t h e advantage o f having a c o n t r o l  group, each s u b j e c t a l s o a c t s as h i s o r h e r own c o n t r o l . Therefore, subjects  t h e source o f e r r o r due t o d i f f e r e n c e s between  i s removed as comparisons a r e made w i t h i n  subjects.  H i l l s and Armitage (1979) s t a t e d , \"A comparison o f treatments on t h e same s u b j e c t  i s expected t o be more p r e c i s e than a  \u000C60  comparison  between s u b j e c t s and t h e r e f o r e t o r e q u i r e  s u b j e c t s f o r t h e same p r e c i s i o n \"  fewer  (p. 7 ) .  A l i t e r a t u r e r e v i e w r e v e a l e d t h a t few s t u d i e s e v a l u a t i n g the e f f e c t s o f t r a i n i n g u t i l i z e d t h e crossover design. R e p e a t e d m e a s u r e s d e s i g n s a r e . t h e m o s t commonly u s e d  designs  when t h e e f f e c t s o f l e a r n i n g o r t r a n s f e r o f t r a i n i n g i s o f interest.  Although  r e p e a t e d m e a s u r e s d e s i g n s a r e common i n  l e a r n i n g s t u d i e s , c r o s s o v e r d e s i g n s may b e u n d e r - u t i l i z e d i n research evaluating the effects of training.  Given t h e  advantages d i s c u s s e d above, t h i s d e s i g n s h o u l d perhaps be e m p l o y e d more o f t e n .  Subjects P o p u l a t i o n s and Samples The The  t a r g e t p o p u l a t i o n i n t h i s s t u d y was m e d i c a l  a c c e s s i b l e p o p u l a t i o n c o n s i s t e d o f second  s t u d e n t s a t U.B.C. from t h e second  year  students.  medical  The a c t u a l s a m p l e c o n s i s t e d o f v o l u n t e e r s  year medical  class.  Recruitment and S e l e c t i o n F o l l o w i n g p e r m i s s i o n b e i n g g r a n t e d b y t h e U.B.C. M e d i c a l F a c u l t y , t h e B e h a v i o r a l S c i e n c e s S c r e e n i n g Committee, and Research  S e r v i c e s , s t u d e n t s were r e c r u i t e d  year medical c l a s s .  from t h e second  A p r e s e n t a t i o n was made t o t h e e n t i r e  c l a s s i n v i t i n g t h e students t o take part i n a study, t h e p u r p o s e o f w h i c h was t o e x a m i n e t h e v a r i o u s ways i n w h i c h medical students respond  t o emotionally intense physician-  \u000C61 patient interactions.  They were t o l d they would have an  o p p o r t u n i t y t o r e c e i v e t r a i n i n g i n communication s k i l l s which would p o t e n t i a l l y enhance t h e i r a b i l i t y t o communicate w i t h p a t i e n t s who  were f e a r f u l , angry or g r i e v i n g .  i n d i v i d u a l s i n d i c a t e d i n t e r e s t i n the study.  Forty-one However, because  the f o l l o w - u p component of another study on communication s k i l l s t r a i n i n g was  b e i n g conducted  concurrently, I  r e q u i r e d t o e l i m i n a t e 17 s u b j e c t s who the p r e v i o u s study.  were p a r t i c i p a t i n g i n  Of 24 v o l u n t e e r s who  the p r e s e n t study, 18 were s t i l l when the t r a i n i n g began.  was  were a v a i l a b l e f o r  interested i n participating  During the t r a i n i n g 5 s t u d e n t s  i t n e c e s s a r y t o withdraw c i t i n g demands of medical (e.g., exams) as the reasons.  felt  training  A t - t e s t revealed that scores  on the b l o c k i n g v a r i a b l e f o r those s u b j e c t s who  withdrew d i d  not d i f f e r from the p r e - t e s t s c o r e s f o r the 13 s u b j e c t s who completed  the study  (p = .76).  i n the study completed  The 13 s u b j e c t s who  remained  a l l three t e s t i n g occasions.  S e l e c t i o n o f the T r a i n e r , R a t e r s , and Simulated P a t i e n t s S e l e c t i o n o f the T r a i n e r A male who  was  a r e c e n t graduate of the U.B.C. master's  program i n C o u n s e l l i n g Psychology was trainer.  the empathy  skills  He had r e c e i v e d a t l e a s t 100 hours of i n t e n s i v e  t r a i n i n g i n empathic t e a c h i n g empathic t r a i n e r was  responding, and he had had  experience  communication s k i l l s t o groups.  The same  employed f o r a l l t r a i n i n g s e s s i o n s so t h a t  trainer  \u000C62  would not be an experimental v a r i a b l e which c o u l d confound t h e results.  S e l e c t i o n o f The Raters One male d o c t o r a l student and one female master's  student  i n C o u n s e l l i n g Psychology were t h e r a t e r s o f empathic responding as measured by t h e Carkhuff s c a l e .  Both had  r e c e i v e d a t l e a s t 100 hours o f t r a i n i n g i n empathic  responding  and were experienced i n r a t i n g t r a n s c r i p t s u s i n g t h e Carkhuff method.  The r a t e r s were b l i n d as t o which group t h e s u b j e c t s  were i n and b l i n d t o t h e nature o f t h e experimental d e s i g n .  S e l e c t i o n o f t h e Simulated P a t i e n t s I n d i v i d u a l s who were e n r o l l e d i n t h e d o c t o r a l and master's  programs i n t h e C o u n s e l l i n g Psychology  Department a t  U.B.C. were t h e a c t o r s i n t h e s i m u l a t e d p h y s i c i a n - p a t i e n t t e s t situations.  From t h e d o c t o r a l program t h e r e were f o u r males  and t h r e e females and from t h e master's t h r e e females and one male.  program t h e r e were  Some o f t h e same a c t o r s were used  a c r o s s groups a t each t e s t i n g time, although t h e a c t o r s sometimes d i f f e r e d a t each t e s t i n g o c c a s i o n .  S u p e r v i s i o n o f t h e T r a i n e r and R a t e r s I observed a l l t r a i n i n g s e s s i o n s and met w i t h t h e t r a i n e r b e f o r e and a f t e r a l l s e s s i o n s t o d i s c u s s t h e t r a i n i n g p r o c e s s . I a l s o met w i t h t h e r a t e r s s e p a r a t e l y and reviewed  the  Carkhuff s c a l e w i t h them b e f o r e t h e r a t i n g procedure began.  \u000C63 Both r a t e r s r a t e d a l l u t t e r a n c e s i n the study. was  An u t t e r a n c e  d e f i n e d as a medical student response of a t l e a s t  sentence  separated by two  sentences.  s i m u l a t e d p a t i e n t phrases  one  or  The r a t e r s worked independently of one another  and  r a t e d the tapes a t d i f f e r e n t p o i n t s i n time.  Research  Measures  C a r k h u f f Empathy R a t i n g S c a l e Communicated empathy was Empathic Understanding A l e v e l 1 response  measured by C a r k h u f f ' s  i n I n t e r p e r s o n a l Process 5-point S c a l e .  r e f e r s t o one  i n which a h e l p e r o b v i o u s l y  does not show any s e n s i t i v i t y t o another's expressed or  experience.  helpee.  (1969)  feelings  I t d e t r a c t s from the e x p r e s s i o n s of the  L e v e l 2 r e f e r s t o a response which i n d i c a t e s t h a t the  h e l p e r shows some acknowledgement o f the helpee's  obvious  f e e l i n g s and/or e x p e r i e n c e s , but does so i n a way  which  d i s t o r t s the t r u e meaning of what the helpee i s e x p r e s s i n g . l e v e l 2 response  s u b t r a c t s from what the helpee i s attempting  to  L e v e l 3 r e f e r s t o a h e l p e r ' s response  communicate.  A  which  i s i n t e r c h a n g e a b l e w i t h t h a t of the helpee i n t h a t i t a c c u r a t e l y expresses e s s e n t i a l l y the same f e e l i n g and  content.  Responses a t l e v e l 3 are c o n s i d e r e d t o be m i n i m a l l y f a c i l i t a t i v e empathic responses.  A l e v e l 4 response  adds t o  the e x p r e s s i o n s of the helpee i n t h a t i t acknowledges deeper f e e l i n g s of which the helpee may  have been unaware.  Level 5  r e f e r s t o a h i g h l y a d d i t i v e h e l p e r response which l e a d s t o a  \u000C64 helpee e x p e r i e n c i n g h i s / h e r deepest f e e l i n g s which had been p r e v i o u s l y unexplored  (Carkhuff, 1969).  L e v e l 3 responses are c o n s i d e r e d t o be primary  empathic  statements and l e v e l s 4 and 5 responses are c o n s i d e r e d t o be advanced empathic  statements.  i n the p r e s e n t study was  The aim of the empathy t r a i n i n g  t o t e a c h the medical s t u d e n t s t o  respond t o p a t i e n t s u s i n g primary a c c u r a t e empathic ( i . e . , l e v e l 3).  responses  Responses a t l e v e l s 4 or 5 would be more  a p p r o p r i a t e l y covered i n c o u n s e l l o r t r a i n i n g because deep e x p l o r a t i o n of c l i e n t s ' thoughts and f e e l i n g s i s p a r t of a more e x t e n s i v e c o u n s e l l i n g p r o c e s s .  The percentage of the  responses which were a t l e v e l 3 or h i g h e r was  used i n the  analyses. The Carkhuff S c a l e i s the most commonly used  objective  s c a l e t o independently judge a c t u a l c o u n s e l l i n g s e s s i o n s ( G l a d s t e i n , 1987) expressed empathy.  and i s the b e s t a v a i l a b l e measure of Carkhuff and B u r s t e i n (1970) r e p o r t e d  r e l i a b i l i t i e s o f .90 and  .88 r e s p e c t i v e l y on i n t r a  i n t e r c o r r e l a t i o n s among r a t e r s .  and  There does not seem t o be  agreement on a t what p o i n t i n an i n t e r v i e w r a t i n g s should be taken, and many s t u d i e s randomly chose segments t o be r a t e d . However, i n t h i s study a l l u t t e r a n c e s were r a t e d by both raters. In  t h e i r review of the c o n s t r u c t v a l i d i t y of C a r k h u f f ' s  measure, F e l d s t e i n and G l a d s t e i n (1980) suggested t h a t because t h i s s c a l e i g n o r e s nonverbal communication and  affective  e x p e r i e n c e of the c o u n s e l l o r , i t should not be used alone i n  \u000C65  research.  Therefore,  other measures o f empathy were i n c l u d e d  i n t h i s study.  Barrett-Lennard Medical  Relationship Inventories  students  empathic understanding o r e x p e r i e n c e d  1  empathy and simulated  (BLRI)  p a t i e n t s ' r e c e i v e d empathy o r empathy  based on t h e experience o f simulated  p a t i e n t s were measured  u s i n g t h e two Empathic Understanding s u b s c a l e s Lennard R e l a t i o n s h i p I n v e n t o r i e s , (Barrett-Lennard,  1962).  of the Barrett-  forms MO and OS r e s p e c t i v e l y  Each item o f t h e s c a l e s has a  6-point s c a l e anchored w i t h -3 = \"no I s t r o n g l y f e e l t h a t i t i s n o t t r u e \" t o +3 = \"yes I s t r o n g l y f e e l t h a t i t i s t r u e . \" Each s c a l e has e i g h t negative To s c o r e t h e i n v e n t o r y ,  items and e i g h t p o s i t i v e items.  t h e p o s i t i v e and n e g a t i v e  items a r e  summed s e p a r a t e l y t o form s u b - t o t a l s ; t h e n e g a t i v e  sum score  i s m u l t i p l i e d by -1 and t h e two s u b - t o t a l s a r e then added t o obtain the t o t a l score.  Possible scores  ranged from -48 t o  +48. J a r s k i e t a l . (1985) suggested t h a t t h i s s c a l e i s t h e b e s t measure o f empathy f o r use i n medical r e s e a r c h  for a  number o f reasons, i n c l u d i n g t h e f a c t t h a t t h e s c a l e has known and  acceptable  v a l i d i t y and r e l i a b i l i t y ,  r e l e v a n t items.  Barrett-Lennard  split-half reliability .94,  face v a l i d i t y , and  (1962) r e p o r t e d  that the  o f these two forms ranged from .75 t o  and a t e s t - r e t e s t c o r r e l a t i o n over a two t o s i x week  p e r i o d was .92.  The B a r r e t t - L e n n a r d  Relationship  have been v a l i d a t e d w i t h a v a r i e t y o f p o p u l a t i o n s  Inventories and have  \u000C66 been used i n over 100 s t u d i e s , i n c l u d i n g a t l e a s t two w i t h medical  personnel  ( J a r s k i e t a l . , 1985).  Perceived Stress Questionnaire I devised a s c a l e c o n s i s t i n g o f four questions i t u s i n g a 7-point  L i k e r t s c a l e (see Appendix A ) .  gave an i n d i c a t i o n o f t h e s t r e s s f u l n e s s o f t h e w i t h t h e s i m u l a t e d p a t i e n t as experienced  and scored This scale  interaction  by t h e s u b j e c t s .  To  compute t h e p e r c e i v e d s t r e s s score, t h e f i r s t two items were p o s i t i v e l y scored and t h e l a s t two items ( i . e . , q u e s t i o n s 4 and  5) were r e v e r s e d scored.  The items were summed f o r t h e  t o t a l p e r c e i v e d s t r e s s score and t h e maximum p o s s i b l e s c o r e was  28.  I n t e r n a l c o n s i s t e n c i e s as measured by Gronbach's  alpha f o r t h e 4-item s c a l e were .69 (scores f o r p r e - t r a i n e d S's,  n = 19),  .68 (scores f o r p o s t - t r a i n e d S's, n = 20), .84  (combined, N = 39).  A f i f t h q u e s t i o n concerning  p e r c e p t i o n o f t h e l e v e l o f emotional  the subject's  d i s t r e s s o f t h e simulated  p a t i e n t was i n c l u d e d i n t h e middle o f t h e q u e s t i o n n a i r e . was  This  a measure t o ensure t h a t t h e r e was no s i g n i f i c a n t  d i f f e r e n c e i n t h e amount o f d i s t r e s s p o r t r a y e d by t h e s i m u l a t e d p a t i e n t s over t h e d i f f e r e n t t e s t i n g p e r i o d s .  Hardiness The  Scale c o n s t r u c t o f p s y c h o l o g i c a l h a r d i n e s s was measured  u s i n g t h e s c a l e s employed by Kobasa e t a l . (1982). instrument six  This  i s a composite q u e s t i o n n a i r e made up o f items from  instruments,  a l l o f which were chosen f o r t h e i r  \u000C67 t h e o r e t i c a l r e l e v a n c e and e m p i r i c a l r e l i a b i l i t y .  The  h a r d i n e s s measure was scored u s i n g t h e 4-point s c a l e l a b e l e d 0, 1, 2 , 3 f o r t h e items i n t h e f i r s t suggested  by S.C. Kobasa and S.R. Maddi  communication, November 1, 1982). n e g a t i v e l y keyed.  1 = 2.5.  (personal  The m a j o r i t y o f items a r e  The b i n a r y s c o r e d items from t h e R o t t e r  E x t e r n a l Locus o f C o n t r o l S c a l e and  f o u r s c a l e s , as  (1966), were s c o r e d as 0 = .5  The maximum p o s s i b l e s c o r e was 102.5.  Kobasa and Maddi (1982) r e p o r t e d t h a t e s t i m a t e s o f i n t e r n a l c o n s i s t e n c y f o r t h e h a r d i n e s s measure have been i n the  . SO's  was .61.  and t e s t - r e t e s t r e l i a b i l i t y over a f i v e - y e a r p e r i o d The shortened,  r e f i n e d form o f t h e h a r d i n e s s s c a l e ,  which was used i n t h i s study,  showed i n t e r n a l  consistency  ( c o e f f i c i e n t alpha o f .86), and c o r r e l a t e d .89 w i t h t h e l o n g e r composite.  Kobasa and Maddi r e p o r t e d t h a t t h i s  refined  composite d u p l i c a t e s a l l t h e major f i n d i n g s r e p o r t e d w i t h t h e l o n g e r one. control  The h a r d i n e s s q u e s t i o n n a i r e measures a degree o f  ( i n t e r n a l r a t h e r than e x t e r n a l ) , commitment  r a t h e r than a l i e n a t i o n from s e l f ) ,  and c h a l l e n g e  (to s e l f  (vigorousness  r a t h e r than v e g e t a t i v e n e s s ) .  Ways o f Coping S c a l e D i f f e r e n t i a l coping s t r a t e g i e s were examined u s i n g t h e items  from t h e Ways o f Coping C h e c k l i s t (Donnelly  which was based on a taxonomy developed  by Lazarus  1979),  1  (1966). The  \u2022'\u2022The Ways o f Coping items were used by p e r m i s s i o n o f J.C. Donnelly.  \u000C68  items l i s t e d were s t r a t e g i e s r e p o r t e d by i n t e r n s as the ones most u s e f u l i n c o p i n g w i t h s t r e s s f u l s i t u a t i o n s a s s o c i a t e d with t h e i r medical t r a i n i n g . Lazarus'  T h i s s c a l e was  chosen over  (1966) measure because i t appeared t o be more  r e l e v a n t and have more f a c e v a l i d i t y f o r a m e d i c a l student population. The 74 items on the s c a l e are c l a s s i f i e d i n t o categories: problem  problem-focused and emotion-focused.  two The  34  focused or n o n - p a l l i a t i v e items i n c l u d e such c o p i n g  s t r a t e g i e s as:  \"I l e f t the h o s p i t a l \" and \"I looked i t up\".  The 40 emotion-focused o r p a l l i a t i v e items i n c l u d e such c o p i n g measures as \"I b e l i e v e d i n myself\" and \"I p a i d a t t e n t i o n t o my feelings\".  These items were l i s t e d i n random o r d e r t o a v o i d a  s e t response t o e i t h e r category. s c o r i n g system  (i.e.,  Instead of using a binary  \"used\", \"not used\"), I chose t o use a  4-point s c a l e anchored w i t h 0 = \"not used\" t o 3 = \"used a g r e a t d e a l \" , i n o r d e r t o determine the e x t e n t t o which the c o p i n g s t r a t e g i e s were used. was  T h i s 4-point s c o r i n g procedure  used by Folkman e t a l . (1986).  Although Donnelly (1979)  d i d not compute r e l i a b i l i t y o r v a l i d i t y data on the s c a l e , the i n t e r n a l c o n s i s t e n c i e s were computed f o r the sample used i n t h i s study and were h i g h ( P a l , N = 39, a = .89; N = 39, a =  .87).  Nonpal,  \u000C69 S e s s i o n and O v e r a l l T r a i n i n g E v a l u a t i o n At  t h e end o f each i n d i v i d u a l t r a i n i n g s e s s i o n , t h e  s u b j e c t s were asked t o complete t h e f o l l o w i n g sentences: What I l e a r n e d today was . . . What I l i k e d most about today was ... . What I l i k e d l e a s t was . . . I thought i t was important t o have immediate  feedback on t h e  t r a i n i n g and t o i d e n t i f y those elements which s h o u l d be incorporated into future t r a i n i n g s . A f t e r t h e course was completed, s t u d e n t s were asked a l s o about any g e n e r a l feedback and s u g g e s t i o n s f o r improvement t o the  training.  Because one o f t h e aims o f t h i s r e s e a r c h i s t o  i d e n t i f y how empathy t r a i n i n g h e l p s medical s t u d e n t s , I thought t h i s i n f o r m a t i o n would be r e l e v a n t and u s e f u l .  Experimental Procedure The E x p e r i m e n t a l Treatment - Empathy T r a i n i n g S u b j e c t s r e c e i v e d f o u r weekly three-hour l o n g t r a i n i n g s e s s i o n s i n empathic communication  skills.  Twelve hours o f  empathic s k i l l s t r a i n i n g was chosen because t h i s has been the l e n g t h o f o t h e r communication health providers  s k i l l s t r a i n i n g programs f o r  ( C l i n e &amp; G a r r a r d , 1973; F r i e d r i c h ,  Schacht, 1985; Poole &amp; Sanson-Fisher, 1979).  Lively,  A v a r i e t y of  approaches were used - l e c t u r e s , m o d e l l i n g , f i l m s and videotaping, s e l e c t e d readings, r o l e p l a y i n g s i t u a t i o n s , e x e r c i s e s , feedback, and d i s c u s s i o n .  group  The s t a n d a r d s t e p s i n a  s k i l l s t r a i n i n g program as o u t l i n e d by Egan (1986) were used  \u000C70  i n c l u d i n g development  o f c o g n i t i v e and b e h a v i o r a l c l a r i t y  empathic communication,  p r a c t i c e of s k i l l s ,  evaluation  f e e d b a c k , a n d r e f l e c t i o n on t h e t r a i n i n g p r o c e s s . of  An  of  and outline  t h e t r a i n i n g p r o g r a m w h i c h I d e v e l o p e d c a n be f o u n d i n  Appendix  B.  Equipment and  Facilities  The U.B.C. D e p a r t m e n t o f F a m i l y P r a c t i c e p r o v i d e d t h e l a r g e t r a i n i n g room a s w e l l a s t h e t e s t i n g room, b o t h o f w h i c h h a d v i e w i n g rooms c o m p l e t e w i t h one way could monitor a l l sessions.  The  m i r r o r s so t h a t  I  room w h e r e t h e m e d i c a l  s t u d e n t - s i m u l a t e d p a t i e n t i n t e r a c t i o n t o o k p l a c e was  a  regular  /  m e d i c a l e x a m i n a t i o n room c o m p l e t e w i t h s u c h i t e m s a s a  sink  and an e x a m i n a t i o n t a b l e w h i c h i n c r e a s e d t h e m e d i c a l a t m o s p h e r e and r e a l i s m o f t h e e n c o u n t e r .  T h e s e rooms w e r e  a l s o equipped w i t h t h e audio v i s u a l equipment  (i.e.,  video  cameras and p l a y b a c k u n i t s ) n e c e s s a r y t o c o n d u c t t h i s  study.  F l o o r p l a n s o f t h e t e s t i n g and t r a i n i n g rooms c a n be s e e n i n F i g u r e s 2 and  3.  Scenarios f o r Testing The of  Situations  t h r e e t e s t s i t u a t i o n s i n c l u d e d p r e s e n t a t i o n s by t h e anger,  f e a r , and g r i e f  (see Appendix  C).  a d a p t a t i o n s o f s c e n a r i o s by C o o k e a n d H e r b e r t R i c c a r d i a n d K u r t z (1983) m e n t i o n e d  emotions  They were (1986). such as  a n g e r , and d e p r e s s i o n as ones f o r w h i c h p a t i e n t s supportive counselling.  actors  grief,  require  The d i f f e r e n t t e s t s i t u a t i o n s w e r e  \u000CTable w i t h c a s s e t t e r e c o r d e r and m i c r o p h o n e Simulat patient I\u2014^ L_r  Medical student  E l e c t r i c a l cord between rooms connect i n g v i d e o equipment  Camera on w a l l  one-way m i r r o r V i e w i n g and a u d i o v i s u a l c o n t r o l room for researcher -  Video recorder and p l a y b a c k unit S  -Table w i t h t i m e r  Figure 2.  T e s t i n g room arrangement.  Medical students \u2022 'Flip chart \u2022 \u2022  |  \u2014Trainer  \u2022 \u2022 |  \u2022  jg\u2014Video  Table w i t h l i t e r a t u r e and r e f r e s h m e n t s Video playback equipment  T  One-way m i r r o r y tn Researcher V i e w i n g room  Figure 3.  T r a i n i n g room arrangement.  \u000C72  counterbalanced t o e l i m i n a t e p o s s i b l e confounding o f o r d e r w i t h treatment e f f e c t s .  Each s u b j e c t i n t e r a c t e d w i t h t h r e e  s i m u l a t e d p a t i e n t s , one a t each t e s t i n g o c c a s i o n , each o f whom p r e s e n t e d a d i f f e r e n t emotion.  Every medical student  i n t e r a c t e d w i t h a c t o r s o f both sexes and a t each t e s t i n g each one i n t e r a c t e d w i t h a d i f f e r e n t a c t o r . exception t o t h i s  time  There was one  (One s u b j e c t saw t h e same a c t o r  t w i c e due  t o a l a s t minute c a n c e l l a t i o n o f another a c t o r ) ; however, n e i t h e r t h e medical student nor t h e s i m u l a t e d p a t i e n t made any acknowledgement o f t h i s .  T r a i n i n g o f t h e Simulated  Patients  The a c t o r s were asked t o read t h e s c e n a r i o d e s c r i b i n g the emotion and t h e type o f p a t i e n t they were t o p o r t r a y . They then f a m i l i a r i z e d themselves w i t h t h e t r i g g e r  sentences  and were asked t o use as many o f them as they c o u l d remember. The s i m u l a t e d p a t i e n t s then engaged i n a s h o r t r o l e p l a y w i t h me i n o r d e r t o ensure t h a t they c o u l d demonstrate t h e a p p r o p r i a t e emotion through t h e i r v e r b a l and non-verbal responses.  T h i s a l s o served as a warm-up f o r t h e a c t o r s .  They were asked not t o s p e c i f i c a l l y s t a t e t h e i r emotion a t t h e b e g i n n i n g o f t h e i n t e r v i e w but r a t h e r t o use t h e t r i g g e r sentences and non-verbal behaviours t o d i s p l a y t h e i r  emotion.  A c t o r s were t o l d t h a t i f t h e medical students acknowledged t h e emotion,  they were t o d e - e s c a l a t e t h e i n t e n s i t y o f t h e emotion  w h i l e a t t h e same time continue t o e x p l o r e t h e nature o f t h e problem.  In o t h e r words, t h e a c t o r s were t o c o n t i n u e t o g i v e  \u000C73  the medical students s u b j e c t matter t o which they c o u l d respond, but i n a l e s s i n t e n s e way.  A c t o r s were a l s o  i n s t r u c t e d not t o ask any medical q u e s t i o n s which may  have  been beyond the knowledge of second y e a r medical s t u d e n t s .  Emotion and Gender Combinations  during Testing  Occasions  T a b l e 1 o u t l i n e s the gender of both the medical student and the s i m u l a t e d p a t i e n t who  interacted  i n each of the  t e s t i n g o c c a s i o n s as w e l l as the type of emotion which  was  presented.  Gender o f M e d i c a l Student and Simulated by Emotion o f S c e n a r i o  T a b l e 1,  Patient  Group 1 T e s t i n g Occasion II  Gender of M e d i c a l Student  I  Subject Subj e c t Subj e c t Subject Subj e c t Subj e c t Subj e c t  F _ Grief M Grief M Anger M Anger M Fear F Fear F \u2014 Grief  1 2 3 4 5 6 7  M F M M F F F  -  M F F M M F F  -  Fear Anger Grief Fear Anger Grief Anger  III F F M F F M M  -  Anger Fear Fear Grief Grief Anger Fear  -  Grief Anger Grief Grief Fear Fear  Group 2 Gender of M e d i c a l Student Subject Subject Subj e c t Subj e c t Subj e c t Subj e c t  1 2 3 4 5 6  F F M M F M  T e s t i n g Occasion II  I M F F F M M  -  Anger Fear Fear Anger Grief Grief  F M F F F F  -  Fear Grief Anger Fear Anger Anger  III M M M M F F  \u000C74 I n summary, t h e n , t h e number o f t i m e s e a c h e m o t i o n was presented  i n t h e t e s t i n g s i t u a t i o n s b e f o r e and a f t e r  r e c e i v e d t h e t r a i n i n g a r e as f o l l o w s :  Fear:  subjects  6 pre, 7 post;  Anger: 7 p r e , 6 p o s t ; and G r i e f :  6 p r e , and 7 p o s t .  d e s i g n was f u l l y c o u n t e r b a l a n c e d  f o r the 3  Thus, t h e  emotional  c o n d i t i o n s on p r e a n d p o s t t r a i n i n g f o r e a c h g r o u p .  Pre-Testinq of Subjects I telephoned the p r e - t e s t .  a l l subjects t o arrange  I a l s o b r i e f l y e x p l a i n e d t o each s u b j e c t i n  what a c t i v i t i e s t h e y c o u l d e x p e c t test situation. medical  a s u i t a b l e time f o r  t o be i n v o l v e d d u r i n g t h e  The t y p i c a l t e s t i n g o c c a s i o n i n v o l v e d one  s t u d e n t a r r i v i n g a t t h e F a m i l y P r a c t i c e U n i t and  m e e t i n g w i t h me w h e r e I e x p l a i n e d f u r t h e r t h a t t h e f i r s t  part  of the t e s t i n g involved i n t e r a c t i n g with a simulated patient. The m e d i c a l  s t u d e n t s were n o t t o l d o f t h e e m o t i o n a l c o n d i t i o n ,  but t h e y were g i v e n a sheet w i t h g e n e r a l d e t a i l s about t h e p a t i e n t ' s concern had  (Appendix  C).  S u b j e c t s were t o l d t h a t  they  15 m i n u t e s t o e x p l o r e t h e n a t u r e o f t h e p a t i e n t ' s p r o b l e m ,  recognizing the l i m i t a t i o n s of t h e i r t r a i n i n g t o date. f a m i l i a r i z i n g themselves  After  with the s i t u a t i o n , the medical  s t u d e n t e n t e r e d t h e t e s t i n g room t o i n t e r a c t w i t h t h e s i m u l a t e d p a t i e n t who was s i t t i n g i n t e r v i e w was v i d e o t a p e d a d j a c e n t room.  i n t h e t e s t i n g room.  and o b s e r v e d  A f t e r 12 m i n u t e s ,  by m y s e l f  I tapped  The  from t h e  on t h e g l a s s o f t h e  one-way m i r r o r t o i n d i c a t e t h a t t h e r e w e r e up t o 3 m i n u t e s l e f t t o complete the i n t e r v i e w .  \u000C75 A f t e r the i n t e r v i e w , the medical s t u d e n t r e t u r n e d t o the o r i g i n a l examination room where he/she met w i t h me. s u b j e c t was  The  asked \"What was t h a t e x p e r i e n c e l i k e f o r you?\", i n  o r d e r t h a t they might have an o p p o r t u n i t y t o express any immediate  feelings.  No d e b r i e f i n g about the n a t u r e o f t h e  experimental hypotheses was g i v e n .  The s u b j e c t was then asked  t o complete t h e P e r c e i v e d S t r e s s Q u e s t i o n n a i r e , The BLRI, the Hardiness Q u e s t i o n n a i r e and the Ways o f Coping S c a l e .  I then  went t o the t e s t i n g room and requested t h a t the s i m u l a t e d p a t i e n t complete the c l i e n t form o f the BLRI. s u b j e c t completed a l l  When t h e  forms, I t o l d him/her t h a t  further  c o n t a c t would be made about when he/she c o u l d b e g i n t h e training.  Assignment t o Group To ensure t h a t assumptions o f group e q u i v a l e n c e had been met and t o ensure t h a t s i g n i f i c a n t i n i t i a l d i f f e r e n c e s would not confound the r e s u l t s , groups were equated b e f o r e random assignment t o groups.  In o t h e r words, w i t h such a s m a l l  number o f s u b j e c t s , i t was  important t h a t not a l l s u b j e c t s  who  r a t e d h i g h l y on the empathy p r e - t e s t s be i n one group. The b l o c k i n g procedure used was the one f o r e q u i v a l e n t groups recommended by Cook and Campbell  (1979).  Individuals  were ranked a c c o r d i n g t o p r e - t e s t s c o r e s on the c l i e n t form o f the BLRI, c o u n t e r b a l a n c e d f o r gender, and then randomly a s s i g n e d t o a group.  Because Mendez, Shymansky, and W o l r a i c h  (1986) found t h a t female p h y s i c i a n s demonstrated more frequent  \u000C76 r e f l e c t i o n o f f e e l i n g s than male p h y s i c i a n s , and Carney and Mitchell  (1986) found t h a t p a t i e n t s tended t o r a t e  female  medical s t u d e n t s h i g h e r than male m e d i c a l s t u d e n t s on a measure o f communication  skills,  and females i n each group.  I wanted a balance o f males  I wanted t o ensure a l s o t h a t not  a l l t h e s u b j e c t s who were r a t e d as h i g h l y empathic were i n one group. B l o c k i n g i s a procedure which i s encouraged by researchers.  F o r i n s t a n c e , Huck, Cormier, and Bounds (1974)  suggested t h a t randomization and matching can be combined and t h a t \"the combination o f f i r s t matching and then random assignment w i l l perhaps y i e l d g r e a t e r d e s i g n p r e c i s i o n than would randomization a l o n e \" (p. 244). I t i s p a r t i c u l a r l y to  wise  b l o c k when u s i n g a c r o s s o v e r d e s i g n as P o l o n i e c k i , Hews,  and Barker (1982) noted i n t h e i r review o f c r o s s o v e r s t u d i e s , \"Matching o f p a t i e n t s between t h e two groups makes good s c i e n t i f i c sense.  T h i s can be done on such v a r i a b l e s as age,  sex and s c o r e s on s u b j e c t i v e t e s t s \" i s f o l l o w e d because  (p. 71). T h i s procedure  i t i s d e s i r a b l e t o conclude t h a t  s i g n i f i c a n t experimental e f f e c t s a r e due t o t h e experimental i n t e r v e n t i o n r a t h e r than due t o i n t e r s u b j e c t  variability.  A d m i n i s t r a t i o n o f T r a i n i n g and P o s t - T e s t i n g The s e s s i o n s proceeded a c c o r d i n g t o t h e o u t l i n e o f training  (see Appendix  B).  During each s e s s i o n t h e r e was a  s h o r t break i n which s u b j e c t s enjoyed refreshments and s o c i a l i z e d among themselves.  I observed a l l t r a i n i n g s e s s i o n s  \u000C77  to  ensure t h a t the t r a i n i n g procedure was  standardized.  The  s u b j e c t s i n the f i r s t t r a i n i n g p e r i o d were asked not t o r e v e a l d e t a i l s about the nature of the empathy t r a i n i n g empathy formula) t o s u b j e c t s who  (e.g.,  were i n the d e l a y e d - t r a i n i n g  group. F o l l o w i n g the f i r s t t r a i n i n g , a l l s u b j e c t s were t e s t e d u s i n g a l l measures once again. subjects training.  Then the second group of  ( i . e . , w a i t - l i s t c o n t r o l group) r e c e i v e d the empathy F o l l o w i n g the second t r a i n i n g p e r i o d , measures were  taken once again on a l l s u b j e c t s . 13 s u b j e c t s was approximately  In t o t a l then,  d i r e c t l y i n v o l v e d i n the study  for  15 hours ( i . e . , 3 one-hour t e s t i n g  p l u s 12 hours of t r a i n i n g ) .  each o f the  occasions  I d i d not a c t as a t r a i n e r ,  a  r a t e r , o r a s i m u l a t e d p a t i e n t f o r any t e s t i n g or t r a i n i n g sessions.  However, I d i d observe a l l t r a i n i n g s e s s i o n s  co-ordinated  and administered  conducted w i t h o n l y one  and  a l l t e s t i n g s e s s i o n s which were  s u b j e c t and one  simulated p a t i e n t at a  time.  Statistical Crossover  Considerations  designs were f i r s t used i n a g r i c u l t u r a l  experiments i n the 1940's (Fellingham, because l a r g e experimental  Bryce,  &amp; Carter,  animals were expensive and  animals were r e q u i r e d f o r a study.  S i n c e then,  designs have been extremely popular  in clinical  pharmacological  research.  fewer  crossover  In f a c t , McNair r e p o r t e d t h a t  o f s t u d i e s t e s t i n g a n t i - a n x i e t y drugs used the  1981)  crossover  68%  \u000C78 design  ( c i t e d i n Brown, 1980).  The c r o s s o v e r d e s i g n has been  used a l s o i n c l i n i c a l p s y c h o l o g i c a l r e s e a r c h Kazdin,  1980)  t o compare two  Armitage and H i l l s  (Chassan,  1979;  or more d i f f e r e n t t h e r a p i e s .  (1982) noted t h a t the c r o s s o v e r d e s i g n  i s a simple and a t t r a c t i v e d e s i g n which i s used e x t e n s i v e l y , e s p e c i a l l y i n drug s t u d i e s . statistical  In d i s c u s s i n g the p r i n c i p a l  a s p e c t s of the c r o s s o v e r d e s i g n they s t a t e d ,  might have thought  that i t s s t a t i s t i c a l  f a m i l i a r and well-documented.  p r o p e r t i e s were  However, i t i s d i f f i c u l t t o  f i n d adeguate d i s c u s s i o n s of the d e s i g n i n textbooks, of  \"One  i t s p r o p e r t i e s are w i d e l y misunderstood\"  and many  (p. 119).  Because  the c r o s s o v e r d e s i g n i s not presented s p e c i f i c a l l y i n standard t e x t s such as Winer (1971) and K i r k (1968), i n v e s t i g a t i o n was statistical  a thorough  done t o determine the l o g i c a l type of  a n a l y s e s which would answer the q u e s t i o n s of  interest in this  study.  The c r o s s o v e r d e s i g n uses a L a t i n - s q u a r e arrangement (i.e.,  an x by x arrangement i n which x appears o n l y once i n  each row  and column) t o counterbalance  study, the s i m p l e s t form, the 2 x 2  the s u b j e c t s .  In t h i s  L a t i n square, was  used t o  produce the 2 p o s s i b l e arrangements i n the treatment that i s ,  A B  treatment.  and B A, where A = treatment  and B = absence of  Neter and Wasserman (1974) p o i n t e d out t h a t the  c r o s s o v e r d e s i g n has aspects of both a completely block design arrangement.  sequence  ( s u b j e c t s are b l o c k s ) and a L a t i n  randomized  square  A c r o s s o v e r d e s i g n uses t h r e e c l a s s i f i c a t i o n s :  groups, t e s t i n g o c c a s i o n s , and treatments.  Each  treatment  \u000C79 occurs o n l y once i n each column and o n l y once i n each  row  (Campbell &amp; S t a n l e y 1963). F i g u r e 4 i l l u s t r a t e s the mixed t w o - f a c t o r c o n t r o l experimental  crossover  f a c t o r i a l d e s i g n chosen f o r t h i s  study.  Bold double l i n e s i n d i c a t e the p o i n t a t which empathy t r a i n i n g was  introduced.  Factor A  groups, f i x e d f a c t o r . within-groups,  (order of t r a i n i n g ) i s a between-  F a c t o r B ( t e s t i n g occasion)  f i x e d , repeated-measures f a c t o r .  random f a c t o r , are nested w i t h i n groups.  is a  Subjects, a  Training i s fully  c r o s s e d w i t h groups.  Factor A Order of Intervention  Factor B - Testing I  L e v e l A^ (Training-Control)  Level A 5 (Control-Training)  F i g u r e 4.  An  Experimental  initial  Occasion  II  III  1  2  3  4  5  6  design.  glance a t F i g u r e 4 r e v e a l s a 2 x 3 mixed  model, and an a n a l y s i s f o r a standard s p l i t - p l o t d e s i g n K i r k , 1968)  was  initially  considered.  (e.g.,  However, even though  the c r o s s o v e r and the s p l i t - p l o t are both repeated measures designs, G i l l  (1978) p o i n t e d out a major d i f f e r e n c e .  s p l i t - p l o t d e s i g n , a d i f f e r e n t treatment  In the  i s a p p l i e d t o each  \u000C80  group of s u b j e c t s and what i s of i n t e r e s t are t r e n d s over time.  In the c r o s s o v e r d e s i g n , however, two or more  treatments are a p p l i e d t o a l l groups of s u b j e c t s , and time of treatment i s confounded comparisons  w i t h groups.  What i s of i n t e r e s t are  of the e f f e c t s of each of these treatments a t  v a r i o u s times.  A l s o , because  the groups are e q u i v a l e n t and  r e c e i v e i d e n t i c a l treatments, although not n e c e s s a r i l y a t the same p o i n t i n time, i t may  be of i n t e r e s t t o c o l l a p s e some  groups t o examine e f f e c t s ; whereas, i n the s p l i t - p l o t d e s i g n it  i s not. For i n s t a n c e , i n drug s t u d i e s , treatment e f f e c t s of  each of 2 drugs i s examined by l o o k i n g a t d i f f e r e n c e s i n s c o r e s p r e - p o s t drug A, and p r e - p o s t drug B, r e g a r d l e s s of the time i t was a d m i n i s t e r e d . In of  most c r o s s o v e r drug study d e s i g n s , a c a r r y - o v e r e f f e c t  one drug i n t o the next time p e r i o d i s u n d e s i r a b l e ; and  o f t e n a \"washout\" p e r i o d i s i n c l u d e d t o ensure t h a t the treatment does not contaminate the second. study, a c a r r y - o v e r e f f e c t i s d e s i r a b l e .  However, i n t h i s Because i t was  t h a t t h e r e would be a r e a c t i v e treatment i n the f i r s t i t was of  s c o r e s s i m i l a r t o the w a i t - l i s t c o n t r o l group.  hoped  group,  not expected t h a t the follow-up group would y i e l d  words, although s c o r e s f o r the two groups  first  level  In o t h e r  immediately p r e - and  post-treatment c o u l d be c o l l a p s e d , o p t i m a l r e s u l t s would i n c l u d e s t a b i l i t y of s c o r e s f o r the w a i t - l i s t and follow-up groups although they would be a t a d i f f e r e n t l e v e l .  Therefore  a s t a n d a r d ANOVA f o r a two-period c r o s s o v e r d e s i g n which c o l l a p s e s r e s u l t s over the two treatments, has o r d e r of  \u000C81 treatment  and s u b j e c t s as f a c t o r s , and has no i n t e r a c t i o n , was  inappropriate f o r t h i s  study.  A s i m i l a r d e s i g n i s used i n time s e r i e s s t u d i e s i n which a treatment another.  i s delayed f o r one group o f s u b j e c t s b u t not  I t i s known as t h e staggered b a s e l i n e o r time-lagged  c o n t r o l d e s i g n f i r s t suggested (1969).  by Gottman, M c F a l l , and B a r n e t t  However, t h e analyses f o r a time-lagged m u l t i p l e time  s e r i e s was c l e a r l y i n a p p r o p r i a t e f o r t h i s study.  The d e s i g n  used i n t h i s study had a time l a g , but not enough p o i n t s f o r time s e r i e s a n a l y s e s . Another s i m i l a r design, known as a two-period d e s i g n w i t h repeated measures w i t h i n a p e r i o d , was by O t t (1988).  crossover suggested  He d e s c r i b e d t h i s d e s i g n as an \" e x t e n s i o n \" t o  repeated measures designs i n which t h e concepts measures and c r o s s o v e r designs a r e combined.  o f repeated  However, O t t  made no s u g g e s t i o n f o r a n a l y s i s o f v a r i a n c e f o r t h i s d e s i g n . C o l l a p s i n g t h e two s e t s o f p r e - t e s t s f o r group two and the two s e t s o f p o s t - t e s t s f o r group one ( i . e . , c e l l s 2 w i t h 3 and 4 w i t h 5 i n F i g u r e 4) and computing a 2 x 2 between w i t h i n ANOVA was c o n s i d e r e d .  However an a n a l y s i s o f t h i s  sort  would not a l l o w t h e i n v e s t i g a t i o n o f w a i t - l i s t and follow-up effects. From t h e above d i s c u s s i o n i t i s e v i d e n t t h a t t h e c h o i c e of a n a l y s i s was not c l e a r .  A standard 2 x 3  a n a l y s i s of  v a r i a n c e w i t h post hoc comparisons would have been i n a p p r o p r i a t e because t r e n d s over time f o r b l o c k s o f s u b j e c t s r e c e i v i n g d i f f e r e n t treatments were not o f i n t e r e s t .  Also  \u000C82 t h e r e would be a problem w i t h i n t e r p r e t a t i o n o f the main and time e f f e c t s as w e l l as the i n t e r a c t i o n because  o f the  confounding by the treatment c r o s s o v e r ( i . e . , the treatment p o i n t f o r each group was  not the same t i m e ) .  t h i s study were comparisons  of how  r e s u l t of the t r a i n i n g which was times.  Of i n t e r e s t i n  the two groups changed as a  introduced at d i f f e r e n t  T h e r e f o r e , I d e c i d e d t h a t the b e s t way  to give clear  answers t o the q u e s t i o n s of i n t e r e s t i n t h i s study would be t o compute a s e r i e s of 2 x 2 repeated measures a n a l y s e s of v a r i a n c e w i t h one between-subjects one w i t h i n - s u b j e c t s f a c t o r  factor  ( i . e . , Group) and  ( i . e . , Testing Occasion).  N e i t h e r the type of a n a l y s e s nor any r e f e r e n c e s t o any e m p i r i c a l s t u d i e s which u t i l i z e d  the two-period time-lagged  c r o s s o v e r c o n t r o l d e s i g n f o r two groups were suggested E p s t e i n and T r i p o d i  (1977).  by  They d i d , however, suggest the  c o n t r a s t s of i n t e r e s t f o r t h i s d e s i g n which i n c l u d e : 1.  Before and a f t e r comparisons  w i t h i n and between the  two  groups f o l l o w i n g the f i r s t i n t e r v e n t i o n .  In o t h e r words,  the t y p i c a l comparisons  treatment  used t o determine  e f f e c t i v e n e s s i n any c l a s s i c a l experiment which i n c l u d e s a control 2.  group.  Comparisons t o determine whether the treatment e f f e c t s i n group one were maintained over time, t h a t i s , whether t h e r e were c a r r y - o v e r e f f e c t s .  3.  A n a l y s e s t o determine whether the experiment had been r e p l i c a t e d w i t h the second group and whether the treatment had been e q u a l l y e f f e c t i v e f o r both  groups.  \u000C83  A s e r i e s o f 2 x 2 ANOVAS and t - t e s t s proved e f f e c t i v e i n e x p l i c i t l y examining these comparisons and shedding l i g h t on q u e s t i o n s o f i n t e r e s t i n t h i s study.  The .05 l e v e l o f  s i g n i f i c a n c e was u t i l i z e d t o t e s t t h e F - r a t i o s f o r t h e primary contrasts. The  use o f MANOVA t o s i m u l t a n e o u s l y t e s t a l l t h e  v a r i a b l e s was c o n s i d e r e d over a s e r i e s o f ANOVAS. advantage o f u s i n g  a multivariate  One  a n a l y s i s over a s e r i e s o f  ANOVAS i s t h a t too many u n i v a r i a t e t e s t s can l e a d t o an increase  i n a Type I e r r o r  rate.  However, even though MANOVA would have been the use o f a m u l t i v a r i a t e reasons.  a n a l y s i s was r u l e d out f o r two  When u s i n g MANOVA, i t i s important t o have a g r e a t e r  number o f s u b j e c t s variables 1983).  preferable,  p e r c e l l than t h e number o f dependent  (Schutz &amp; G e s s a r o l i ,  1987;  Tabachnick &amp; F i d e l l ,  Because o f t h e small number o f s u b j e c t s  i n t h e present  study, t h e power o f the MANOVA would be lowered because o f reduced degrees o f freedom f o r e r r o r  (Tabachnick &amp; F i d e l l ,  1985). Also,  i f a l l the v a r i a b l e s were t o be t e s t e d  a n a l y s i s , small  d i f f e r e n c e s on t h e e x p l o r a t o r y  i n a single  v a r i a b l e s might  obscure a r e a l d i f f e r e n c e on some o f t h e o t h e r v a r i a b l e s which t h e r e was s t r o n g S i n c e MANOVA d e t e c t s  rationale  for  (e.g., measures o f empathy).  mainly e r r o r f o r the  set of v a r i a b l e s ,  t h e r e would be a r i s k t h a t i t would show no r e l i a b l e o v e r a l l difference  (Stevens, 1986).  \u000C84 Schutz and G e s s a r o l i (1987) p o i n t e d out t h a t employing a MANOVA w i t h s m a l l numbers may l a c k power t o d e t e c t even l a r g e effect sizes. Fidell, powerful  These and other s c h o l a r s (e.g., Tabachnick &amp;  1983) suggested  t h a t t h e ANOVA method may be more  than MANOVA f o r a n a l y z i n g repeated measures designs  w i t h s m a l l numbers. In a d d i t i o n t o t h e ANOVAS and t - t e s t s , e f f e c t s i z e s were calculated. Effect sizes  (Cohen, 1988) a r e measures  expressed  i n standard d e v i a t i o n u n i t s which y i e l d an i n d i c a t i o n o f t h e magnitude o f treatment (1989) suggested  gains.  K a z i s , Anderson, and Meenan  t h a t e f f e c t s i z e s can serve as benchmarks f o r  i n t e r p r e t i n g change, not only i n t h e b e h a v i o u r a l s c i e n c e s , but i n medicine as w e l l , where they appear t o be u n d e r - u t i l i z e d . E f f e c t s i z e s f o r t h i s study were c a l c u l a t e d u s i n g t h e methods d i s c u s s e d by Cohen (1988), G l a s s and Hopkins (1984) and K a z i s e t a l . (1989).  The s p e c i f i c c a l c u l a t i o n i n v o l v e d  t a k i n g t h e d i f f e r e n c e i n t h e means immediately  b e f o r e and  a f t e r t r a i n i n g and d i v i d i n g i t by t h e pooled  pre-treatment  standard d e v i a t i o n .  Designs Used t o T e s t t h e Hypotheses In t h i s s e c t i o n , each s u b s t a n t i v e h y p o t h e s i s first  i s stated  f o l l o w e d by an i n d i c a t i o n o f t h e c e l l s used i n t h e  a n a l y s e s t o t e s t each h y p o t h e s i s . t o each d e s i g n .  I have a l s o g i v e n a name  As w e l l , t h e s t a t i s t i c a l hypotheses, and  W h i l e t h e s u b s t a n t i v e hypotheses a r e s t a t e d d i r e c t i o n a l l y , the s t a t i s t i c a l hypotheses a r e s t a t e d i n t h e n u l l form, and 2 - t a i l e d t e s t s were used i n a l l s t a t i s t i c a l a n a l y s e s . 2  \u000C85  c o n t r a s t s o f primary i n t e r e s t t o t e s t t h e hypotheses, a r e emphasized. Hypothesis 1A:  S u b j e c t s who  r e c e i v e empathy  skill  t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y h i g h e r s c o r e s on measures o f empathy than w i l l s u b j e c t s who (delayed-treatment) c o n t r o l Hypothesis IB:  are i n a w a i t - l i s t  group.  S u b j e c t s who  r e c e i v e empathy  skill  t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y lower s c o r e s on a measure o f p e r c e i v e d s t r e s s wait-list  than w i l l s u b j e c t s who  (delayed treatment) c o n t r o l  are i n a  group.  The d e s i g n used t o t e s t hypotheses 1A and IB i s a c l a s s i c p r e - p o s t treatment d e s i g n w i t h a c o n t r o l S t a n l e y , 1963).  group  The purpose o f t h i s a n a l y s i s  (Campbell &amp; i s t o determine  whether t h e r e i s a treatment e f f e c t and whether t h i s e f f e c t i s g r e a t e r f o r the treatment group than f o r the c o n t r o l which has had t e s t i n g o n l y .  group  C e l l s used i n ANOVAS t o t e s t  hypotheses 1A and IB are i n d i c a t e d  with a slash  i n Figure 5.  The s t a t i s t i c a l h y p o t h e s i s expressed i n n u l l form i s as follows:  H  o  :  (^2  \"  ~  ^5  ~ ^4)  =  \u00B0-  The c o n t r a s t o f primary i n t e r e s t t o t e s t t h i s h y p o t h e s i s was the  Group-by-Time i n t e r a c t i o n  term.  That i s , i f the t r a i n i n g  were t o be s u f f i c i e n t l y potent, an i n t e r a c t i o n  would  result.  \u000C86  Time II  I  III  Group 1  Group 2  F i g u r e 5.  C e l l s used i n ANOVAS t o t e s t hypotheses 1A and IB.  Hypothesis 2 A i :  S u b j e c t s who  are i n the p o s t t r a i n i n g  f o l l o w - u p group w i l l demonstrate s i g n i f i c a n t l y h i g h e r s c o r e s on measures o f empathy than w i l l s u b j e c t s i n t h e w a i t - l i s t control  group.  Hypothesis 2 B i ;  S u b j e c t s who  are i n t h e p o s t t r a i n i n g  f o l l o w - u p group w i l l demonstrate s i g n i f i c a n t l y lower s c o r e s on a measure o f p e r c e i v e d s t r e s s list  control  than w i l l s u b j e c t s i n the w a i t -  group.  The c e l l s used i n the a n a l y s e s t o t e s t the second t e s t of hypotheses are i n d i c a t e d  with a slash  terminology o f Cook and Campbell removed-treatment, two o c c a s i o n s .  U s i n g the  (1979), i t c o u l d be named a  no-treatment comparison w i t h measures on  The purpose o f t h i s a n a l y s i s  whether the e f f e c t s the  i n F i g u r e 6.  o f the i n t e r v e n t i o n  was t o determine  were m a i n t a i n e d f o r  t r e a t e d group a f t e r the t r a i n i n g was t e r m i n a t e d and  whether o r not t h i s e f f e c t o f t r a i n i n g was g r e a t e r f o r the post-treatment group than f o r the c o n t r o l  group which had  \u000C87  testing  only.  The s t a t i s t i c a l  h y p o t h e s i s expressed i n n u l l  form i s as f o l l o w s :  /i  3  +  /i  2  H :H-2-*&gt; 0  M  5  +  /  i  4  \" (-^T- ) 4  =  0  The main c o n t r a s t o f i n t e r e s t t o t e s t h y p o t h e s i s 2 A i and 3 B i was i n t h e group main e f f e c t .  The second s e t o f ANOVAS  compared two p o s t - t r a i n i n g s c o r e s f o r group one w i t h two p r e training  s c o r e s f o r group two.  That i s , d e s i r a b l e  results  i n c l u d e d a s t r o n g main e f f e c t due t o t h e potency o f t h e intervention.  Time I  I I I  I I  Group 1 1  /  2  /  3  Group 2 /  F i g u r e 6. 2Biii.  5  6  C e l l s used i n ANOVAS t o t e s t hypotheses 2 A i through  Hypothesis 2 A i i :  S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  group w i l l m a i n t a i n s c o r e s on measures o f empathy d u r i n g t h e follow-up time p e r i o d .  \u000C88  Hypothesis group w i l l  2Bii:  S u b j e c t s who  are i n the  post-training  m a i n t a i n s c o r e s on a m e a s u r e o f p e r c e i v e d s t r e s s  during the follow-up time p e r i o d . The in null  Ho:  h y p o t h e s i s t o t e s t h y p o t h e s i s 2 A i i and  2Bii  expressed  form i s  M3  ^2  -  0  =  Hypothesis  2Aiii:  (delayed treatment)  S u b j e c t s who  are i n the  c o n t r o l group w i l l  not  wait-list  increase i n scores  on m e a s u r e s o f empathy d u r i n g t h e w a i t - l i s t c o n t r o l  time  period. Hypothesis  2Biii:  (delayed treatment)  S u b j e c t s who  are i n the  c o n t r o l group w i l l  wait-list  not decrease  i n scores  on a m e a s u r e o f p e r c e i v e d s t r e s s d u r i n g t h e w a i t - l i s t  control  time p e r i o d . The null  hypothesis to test hypothesis 2 A i i i  and  2Biii  expressed  form i s  H: Q  M  5  - A*  4  =  0  P a i r e d group t - t e s t s were computed t o d e t e r m i n e  the  separate  e f f e c t s o f t i m e , t h a t i s whether t h e r e were c a r r y - o v e r r e t e n t i o n e f f e c t s f o r g r o u p one  and w h e t h e r t h e r e was  or any  d i f f e r e n c e b e t w e e n t h e p r e - t e s t and p o s t - t e s t f o r t h e w a i t list  control  group.  in  \u000C89 Hypothesis training  3A:  S u b j e c t s who  at different  r e c e i v e empathy  p o i n t s i n time w i l l  skills  increase i n scores  on m e a s u r e s o f e m p a t h y . Hypothesis training of  3B:  S u b j e c t s who  at different  r e c e i v e empathy  p o i n t s i n time w i l l  a measure i n p e r c e i v e d  decrease  with a slash  i n scores  stress.  C e l l s used i n analyses t o t e s t hypotheses indicated  skills  i n F i g u r e 7.  c l a s s i c one-group p r e - p o s t d e s i g n  3A and  3B  are  I t i s an e x t e n s i o n o f  (Campbell  &amp; Stanley,  t h a t i s , one-group p r e - p o s t d e s i g n w i t h r e p l i c a t i o n .  1963). The  purpose of t h i s design i s t o determine  whether t r a i n i n g has  effect,  i s similar  and w h e t h e r o r n o t t h i s e f f e c t  groups. as  The  s t a t i s t i c a l hypothesis expressed  the  an  f o r both  in null  form i s  follows:  I  Time II  III  Group 1  Group 2  F i g u r e 7.  C e l l s u s e d i n ANOVAS t o t e s t h y p o t h e s e s  3A and  3B.  \u000C90 The c o n t r a s t o f primary i n t e r e s t t o t e s t t h i s h y p o t h e s i s was i n the time main e f f e c t .  I f the groups were g e n u i n e l y  e q u i v a l e n t , and the treatment s u f f i c i e n t l y p o t e n t , t h e r e should have been a d e f i n i t e time e f f e c t .  Additional Exploratory A series the  Questions  o f 2 x 2 ANOVAS s i m i l a r t o those used t o t e s t  hypotheses were used a l s o t o e x p l o r e the q u e s t i o n s o f  whether h a r d i n e s s and number o f problem-focused and emotionfocused c o p i n g s t r a t e g i e s changed as a r e s u l t o f empathy training.  An examination o f frequency counts i d e n t i f i e d t h e  ways o f c o p i n g most commonly used by t h i s sample o f second year medical students.  Data Analyses  Procedures  The a n a l y s e s o f v a r i a n c e were computed u s i n g the BMDP 4V computer package. researchers 1985)  BMDP i s the program  recommended by many  (e.g., Schutz &amp; G e s s a r o l i , 1 9 8 7 ; Hertzog &amp; Rovine,  t o a n a l y z e repeated measures data, due t o i t s  versatility.  Another major reason t h a t t h i s program was  chosen t o a n a l y z e the data f o r t h i s study was t h a t i t does not r e q u i r e an equal number o f s u b j e c t s p e r group. unweighted means s o l u t i o n  I t uses t h e  t o a d j u s t f o r unequal sample s i z e s .  The SPSS program was used t o compute  reliabilities  (Cronbach's a l p h a , Pearson product-moment c o r r e l a t i o n s ) and t-tests.  The T e l l - A - G r a f G r a p h i c s Program was used t o  generate the graphs.  \u000C91 CHAPTER I V Results  Introduction T h i s c h a p t e r p r e s e n t s t h e r e s u l t s o f t h e study w i t h emphasis on t h e s t a t i s t i c a l treatment description  I t opens w i t h a  o f t h e sample and a r e p o r t on t h e r e s e a r c h  procedures.  The r e s u l t s o f t h e analyses t o t e s t t h e hypotheses  are then presented, additional  o f t h e data.  f o l l o w e d by r e s u l t s o f a n a l y s e s f o r some  exploratory questions.  The chapter concludes w i t h a  summary o f r e s u l t s .  Subject C h a r a c t e r i s t i c s Of t h e 13 v o l u n t e e r s u b j e c t s who completed male and 7 were female.  t h e study, 6 were  The f i r s t group c o n s i s t e d o f 4 women and  3 men, and t h e second group c o n s i s t e d o f 3 women and 3 men. The s u b j e c t s ranged 2 5.5  years.  i n age from 24 t o 28 years w i t h an average  Group one had an average  two had an average  age o f  age o f 25.7 y e a r s ; group  age o f 25.3 y e a r s .  A l l s u b j e c t s had an  academic background i n t h e s c i e n c e s except f o r one person who had an e d u c a t i o n  degree.  I m p l e m e n t a t i o n Check o f t h e S i m u l a t e d P a t i e n t s The tapes o f t h e i n t e r v i e w s were checked  by myself and by  one o f t h e r a t e r s t o ensure t h a t a t l e a s t 3 o f t h e 4 t r i g g e r sentences were used by a l l t h e a c t o r s .  Although t h e v e r b a l  messages seemed t o be v e r y s i m i l a r a c r o s s a l l a c t o r s , t h e ways i n  \u000C92  which t h e emotions were presented v a r i e d .  For instance, g r i e f  statements were accompanied by t e a r s f o r some a c t o r s and by low mood and l e t h a r g y by o t h e r s .  Although  the actors d i f f e r e d to  some extent i n t h e i r p r e s e n t a t i o n s o f t h e emotion, both r a t e r s and  I agreed  t h a t t h e i n t e n s i t y o f t h e emotion d i s p l a y e d by t h e  s i m u l a t e d p a t i e n t s was s u f f i c i e n t l y h i g h f o r a l l a c t o r s .  In  a d d i t i o n , a t - t e s t r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e b e f o r e and a f t e r t r a i n i n g i n t h e degree o f emotional  d i s t r e s s d i s p l a y e d by  the s i m u l a t e d p a t i e n t s as p e r c e i v e d by t h e s u b j e c t s based on s c o r e s on t h e t h i r d q u e s t i o n o f t h e P e r c e i v e d S t r e s s Questionnaire 5.53;  (Mean b e f o r e t r a i n i n g = 5.47; Mean a f t e r t r a i n i n g =  t = -0.19, p = .85).  Inter-rater  Reliability  In t h e study, t h e r e were 1160 medical of  which were r a t e d by both r a t e r s .  student u t t e r a n c e s a l l  The average percentage o f  responses which were a t l e v e l 3 o r above f o r t h e two r a t e r s were used i n t h e data a n a l y s e s .  The i n t e r - r a t e r r e l i a b i l i t y  c a l c u l a t e d u s i n g a Pearson product  was  - moment c o r r e l a t i o n .  Agreement between t h e r a t e r s ' s c o r e s f o r a l l u t t e r a n c e s was r = .88 (p &lt; .001).  Analyses o f Training  Effects  In t h i s s e c t i o n , the means and standard d e v i a t i o n s f o r a l l measures over a l l times a r e presented of  first  (Table 2 ) .  t e s t s o f t h e hypotheses a r e then d e s c r i b e d .  Results  The s e c t i o n  \u000CTable 2.  Means and Standard Measures (N=13)  Carkhuff Empathy R a t i n g S c a l e Responses)  D e v i a t i o n s f o r Dependent  (Percentage  of Level 3  Time 1  Time 2  Time 3  Group 1  M SD  3 .20 2.76  40.56 17.55  49.29 19.81  Group 2  M SD  5.77 2.61  3.01 1.96  55.86 17 .33  BLRI  (Simulated P a t i e n t R a t i n g o f Empathy  Scale)  Time 1  Time 2  Time 3  Group 1  M SD  1.43 24.38  23.14 15. 09  29.86 10.42  Group 2  M SD  0.33 21.71  2.33 13.29  23 . 83 13 . 64  BLRI (Medical Student R a t i n g o f Empathy  Scale)  Time 1  Time 2  Time 3  Group 1  M SD  14.57 8.20  25.57 7.64  24.43 8.38  Group 2  M SD  8.67 7.58  8.67 7.53  17.17 8.98  Perceived Stress Scale Time 1  Time 2  Time 3  Group 1  M SD  17.71 3.35  10.29 1.80  11.86 2.67  Group 2  M SD  18.67 3.72  18.33 2.50  14.33 3.45  \u000CTable 2  Hardiness  (cont'd)  Scale Time 1  Time 2  Time 3  Group 1  M SD  75.29 10.86  76.21 10.14  75.36 12.82  Group 2  M SD  66.58 14.09  64.58 12.04  66.58 13.37  Emotion-Focused S c a l e  (Number o f S t r a t e g i e s Used)  Time 1  Time 2  Time 3  Group 1  M SD  25. 00 3.37  27.14 5.61  26.14 4.88  Group 2  M SD  27.67 6.77  26.33 6.89  28 . 50 8.41  Problem-Focused Coping S c a l e (Number o f S t r a t e g i e s Used) Time 1  Time 2  Time 3  Group 1  M SD  22.86 3.85  25.29 4.15  26.57 4.10  Group 2  M SD  24.00 5.44  26. 67 5.35  27.00 6.07  \u000C95 concludes w i t h t h e r e s u l t s o f a n a l y s e s o f t h e e x p l o r a t o r y questions.  H y p o t h e s e s 1A a n d I B Hypothesis  1A:  S u b j e c t s who r e c e i v e empathy s k i l l  training  w i l l demonstrate s i g n i f i c a n t l y h i g h e r s c o r e s on measures o f empathy than w i l l s u b j e c t s who a r e i n a w a i t - l i s t treatment)  (delayed-  c o n t r o l group.  Hypothesis  IB:  S u b j e c t s who r e c e i v e empathy s k i l l  training  w i l l demonstrate s i g n i f i c a n t l y lower s c o r e s on a measure o f p e r c e i v e d s t r e s s than w i l l s u b j e c t s who a r e i n a w a i t - l i s t (delayed-treatment)  c o n t r o l group.  C a r k h u f f Empathy R a t i n g S c a l e (Percentage o f L e v e l 3 Responses) percentage  The r e s u l t s o f t h e 2 x 2 o f l e v e l 3 responses  shown i n T a b l e 3 ( a ) .  a n a l y s i s o f v a r i a n c e f o r the  f o r each t e s t i n g o c c a s i o n a r e  The comparison o f primary i n t e r e s t , t h e  group-by-time i n t e r a c t i o n i s s t a t i s t i c a l l y  significant  (p &lt; .05).  That i s , t h e t r e a t e d group i n c r e a s e d i t s s c o r e s s i g n i f i c a n t l y more t h a t t h e w a i t - l i s t group. An examination  o f t h e means i n Table 2 r e v e a l s t h a t a f t e r  t r a i n i n g t h e s c o r e on t h e p o s t - t e s t f o r group 1 i s much h i g h e r than any o f t h e remaining means f o r t h i s comparison.  In  a d d i t i o n , as may be seen i n the graph o f means f o r t h i s measure ( F i g u r e 8 ) , when t e s t i n g o c c a s i o n s 1 and 2 a r e compared, t h e 3 means f o r c e l l 1, 4 and 5 c l u s t e r whereas t h e mean f o r c e l l 2 i s much more e l e v a t e d . at  That i s t o say, t h e percentage  o f responses  l e v e l 3 was much h i g h e r f o l l o w i n g t h e empathy t r a i n i n g than i n  \u000C96  T a b l e 3.  3(a)  Summary o f Analyses o f V a r i a n c e f o r Dependent Measures (Hypotheses 1A &amp; IB: Comparison o f C e l l s 1 &amp; 2 w i t h 4 &amp; 5, N=13)  Percentage o f L e v e l 3 Responses  Source of Variance  SS  df  MS  F  p  Group (G)  1976.48  1  1976.48  19.08  .001  Error: between groups  1139.25  11  103.57  Time (T)  1933.13  1  1933.13.  26.32  .000  GXT  2601.01  1  2601.01  35.42  .000  807.85  11  73.44  F  p  Between Groups:  Within Groups:  Error: within group  3(b)  BLRI Empathy S c a l e  Source of Variance  (Simulated P a t i e n t Rating) SS  df  MS  Between Groups: Group (G)  775.09  1  775.09  2779.52  11  252.68  Time (T)  908.44  1  GXT  627.82 6041.71  Error: between groups  3.07  .108  908.44  1.65  .225  1  627.82  1.14  .308  11  549.25  Within Groups:  Error: within group  \u000C97  Table 3 cont'd  3(c)  BLRI Empathy S c a l e  (Medical Student  Rating)  SS  df  MS  Group (G)  840.00  1  840.44  Error: between groups  942.10  11  85.65  Time (T)  195.46  1  GXT  195.46  Error: within group  382.00  Source of Variance  Between Groups: 9.81  .010  195.46  5.63  .037  1  195.46  5.63  .037  11  34.72  SS  df  MS  130.85  1  130.85  17.55  .002  82.00  11  7.45  Time (T)  97.32  1  97.32  10.15  .009  GXT  81.32  1  81.32  8.48  .014  105.52  11  9.59  Within Groups:  3(d)  Perceived Stress Scale  Source of Variance  Between Groups: ' Group (G) Error: between groups  Within Groups:  Error: within group  \u000C98  60-i  Legend 50-  O  Group One  A  Group Two  40  30  \u00A3  2  0  10  0  Testing Occasion  F i g u r e 8.  Means f o r percentage o f l e v e l 3 responses r a t e d on the Carkhuff Empathy S c a l e .  \u000C99  Testing Occasion F i g u r e 9.  Means f o r simulated p a t i e n t r a t i n g s on the Empathy S c a l e of the BLRI.  \u000C100  26  n  1  1  1 2  1  . 3  Testing Occasion F i g u r e 10.  Means f o r medical student r a t i n g s on the Empathy S c a l e of the BLRI.  \u000Croi  19-|  1  1  1 2  1  .  Testing Occasion Figure 11.  Means f o r medical student r a t i n g s on the Perceived Stress Scale.  3  \u000C102 the w a i t - l i s t c o n t r o l c o n d i t i o n .  S i n c e a l e v e l o f a t l e a s t 3 on  the Carkhuff S c a l e i s i n t e r p r e t e d as an i n t e r c h a n g e a b l e of  f e e l i n g and content o f the s i m u l a t e d p a t i e n t ' s response by the  medical to  response  student, t h e t r a i n i n g , i t appears, enabled  the s u b j e c t s  i n t e r a c t i n a more empathic f a s h i o n . BLRI Empathy S c a l e  (Simulated P a t i e n t Ratincr) - The summary  ANOVA t a b l e f o r the f i r s t s e t o f comparisons f o r the s i m u l a t e d p a t i e n t r a t i n g s f o r the Empathy S c a l e o f the BLRI may be found i n Table 3 ( b ) . The e f f e c t s o f treatment  were i n the hypothesized  d i r e c t i o n ; however, the group x time i n t e r a c t i o n was not statistically significant.  T h i s may have been due t o t h e wide  range i n i n d i v i d u a l s c o r e s by the a c t o r s as w e l l as t h e s m a l l numbers o f s u b j e c t s r e s u l t i n g i n a r e l a t i v e l y l a r g e standard error. BLRI Empathy S c a l e  (Medical Student Rating)  - Table 3(c)  c o n t a i n s the a n a l y s i s o f v a r i a n c e t a b l e f o r t h e s u b j e c t r a t e d s c o r e s f o r t h e Empathy S c a l e o f the BLRI f o r the f i r s t a n a l y s i s . The c o n t r a s t o f primary  i n t e r e s t , the i n t e r a c t i o n between group  and time achieved the p r o b a b i l i t y v a l u e o f l e s s than  .05.  I t can be seen i n Table 2 and F i g u r e 10 t h a t the p o s t - t e s t s c o r e f o r group 1 i s h i g h e r than the p r e - t r a i n i n g s c o r e s f o r groups 1 and 2. medical  That i s , a f t e r p a r t i c i p a t i n g i n t h e t r a i n i n g the  students p e r c e i v e d themselves as b e i n g more empathic.  P e r c e i v e d S t r e s s S c a l e - Table 3(d) p r e s e n t s t h e ANOVA t a b l e for the Perceived Stress Scale.  The group x time i n t e r a c t i o n was  s t a t i s t i c a l l y s i g n i f i c a n t a t p &lt; .05.  The mean s c o r e f o r group 1  (Table 2) was lower than f o r e i t h e r the p r e - t r a i n i n g s c o r e or f o r  \u000C103 both mean s c o r e s f o r group 2.  The graph f o r t h e p e r c e i v e d s t r e s s  measure ( F i g u r e 11) i l l u s t r a t e s t h e f a c t t h a t t h e p e r c e i v e d s t r e s s s c o r e s f o r group 1 were reduced a f t e r t r a i n i n g , w h i l e t h e s c o r e s f o r group 2 d i d not i n c r e a s e o r decrease over time.  Thus  empathy t r a i n i n g i s a s s o c i a t e d w i t h a s i g n i f i c a n t decrease i n perceived  stress.  Hypotheses 2 A i through Hypothesis 2 A i :  2Biii S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  f o l l o w - u p group w i l l demonstrate  s i g n i f i c a n t l y h i g h e r s c o r e s on  measures o f empathy than w i l l s u b j e c t s i n t h e w a i t - l i s t  control  group. Hypothesis 2 B i :  S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  f o l l o w - u p group w i l l demonstrate  s i g n i f i c a n t l y lower s c o r e s on a  measure o f p e r c e i v e d s t r e s s than w i l l s u b j e c t s i n t h e w a i t - l i s t control  group.  The r e s u l t s o f t h e 2 x 2 ANOVAS f o r a l l f o u r dependent measures t o t e s t t h e second hypotheses may be found i n T a b l e s 4a t o 4d.  A l l f o u r dependent measures r e s u l t e d i n a s t a t i s t i c a l l y  s i g n i f i c a n t group main e f f e c t  (p &lt; .05), which g i v e s an  i n d i c a t i o n o f t h e potency o f t h e i n t e r v e n t i o n .  The i n c r e a s e d  l e v e l s o f empathy and decreased l e v e l s o f p e r c e i v e d s t r e s s which r e s u l t e d from t h e t r a i n i n g were maintained f o r s u b j e c t s d u r i n g the f o l l o w - u p time p e r i o d and were s i g n i f i c a n t l y d i f f e r e n t  from  the s c o r e s on these measures than those o f s u b j e c t s i n t h e w a i t l i s t control  condition.  \u000C104 T a b l e 4.  4(a)  Summary o f Analyses of V a r i a n c e f o r Dependent Measures (Hypotheses 2Ai &amp; 2 B i : comparisons o f c e l l s 2 &amp; 3 w i t h 4 &amp; 5, N=13)  Percentage  o f L e v e l 3 Responses SS  df  MS  Group (G)  10614.7  1  10614.7  Error: between groups  2586.31  11  235.12  57.31  1  213.25 1670.80  Source of Variance  Between Groups: 45.15  .000  57.31  .38  .552  1  213.25  1.40  .261  11  151.89  Within Groups: Time (T) GXT Error: within group  4(b)  BLRI Empathy S c a l e (Simulated P a t i e n t Rating)  Source of Variance  SS  df  MS  F  p  Group (G)  4092.49  1  4092.49  17.01  .001  Error: between groups  2646.67  11  240.61  122.67  1  122.67  .41  .533  35.90  1  35.90  .12  .734  3257.71  11  296.16  Between Groups:  Within Groups: Time (T) GXT Error: within group  \u000C105 Table 4 cont'd 4(c)  BLRI Empathy S c a l e  Source of Variance  (Medical Student SS  df  Rating) MS  F  p  87.89  .000  Between Groups: Group (G)  1723.79  1  1723.79  916.67  11  83.33  Time (T)  2.11  1  2.11  .05  .820  GXT  2.11  1  2.11  .05  .820  425.43  11  38.68  SS  df  MS  356.57  1  356.57  55.69  .000  70.43  11  6.40  Time (T)  2.48  1  2.47  .29  .598  GXT  5.86  1  5.86  .70  .422  92.52  11  8.41  Error: between groups  Within Groups:  Error: within group  4(d)  Perceived Stress Scale  Source of Variance  Between Groups: Group (G) Error: between groups  Within Groups:  Error: within group  \u000C106 An examination  o f Table 2 r e v e a l s t h a t t h e r e was v e r y  little  change i n t h e means f o r t h e pre-and p o s t - s c o r e s d u r i n g t h e no intervention period. for  T h i s e f f e c t can a l s o be found i n t h e graphs  t h e empathy and p e r c e i v e d s t r e s s  measures ( F i g u r e s 8-11)  when t e s t i n g o c c a s i o n s 2 and 3 f o r group one a r e compared w i t h t e s t i n g o c c a s i o n s 1 and 2 f o r group two. Hypothesis  2Aii:  S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  group w i l l m a i n t a i n s c o r e s on measures o f empathy d u r i n g t h e f o l l o w - u p time p e r i o d . Hypothesis  2Aiii:  (delayed-treatment)  S u b j e c t s who a r e i n t h e w a i t - l i s t  c o n t r o l group w i l l not i n c r e a s e i n s c o r e s on  measures o f empathy d u r i n g t h e w a i t - l i s t c o n t r o l time p e r i o d . Hypothesis  2Bii:  S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g  group w i l l m a i n t a i n s c o r e s on a measure o f p e r c e i v e d s t r e s s d u r i n g t h e f o l l o w - u p time p e r i o d . Hypothesis  2Biii:  (delayed-treatment)  S u b j e c t s who a r e i n t h e w a i t - l i s t  c o n t r o l group w i l l not decrease  i n s c o r e s on  a measure o f p e r c e i v e d s t r e s s d u r i n g t h e w a i t - l i s t c o n t r o l  time  period. Hypotheses 2 A i i , 2 A i i i , 2 B i i , and 2 B i i i were t e s t e d u s i n g paired  (dependent) group t - t e s t s w i t h a r e l a x e d alpha o f .25 i n  order t o be c e r t a i n t h a t t h e r e was no change ( i . e . , empathy and decrease  increase i n  i n perceived stress) i n scores i n the  absence o f any treatment.  The t - t e s t s used t o t e s t  hypotheses  2 A i i and 2 B i i serve a l s o as comparisons o f simple main e f f e c t s (i.e.,  simple e f f e c t s t e s t s comparing l e v e l s o f one f a c t o r a t a  p a r t i c u l a r l e v e l o f t h e second  f a c t o r ) when a s i g n i f i c a n t  \u000C107 i n t e r a c t i o n i s o f i n t e r e s t f o rhypotheses  1A a n d I B .  f o u n d i n T a b l e 5, showed t h a t none o f t h e p a i r s  The r e s u l t s  o f means was  s i g n i f i c a n t l y d i f f e r e n t w i t h t h e e x c e p t i o n o f one ( C a r k h u f f p e r c e n t a g e l e v e l 3 r e s p o n s e s , p = .11 f o r h y p o t h e s e s  2Aiii).  f a c t , h o w e v e r , t h e mean s c o r e s f o r t h i s m e a s u r e  actually  decreased across time f o rthe w a i t - l i s t control  group  absence  of treatment  In  i n the  (M, p r e = 5.77, M, p o s t = 3 . 0 1 ) .  Thus, t h e  w a i t i n g p e r i o d d i d n o t r e s u l t i n an i n c r e a s e i n p e r c e n t a g e o f level  3 responses.  approximated  O n l y one o u t o f t h e e i g h t  significance  t-tests  a t a = .25, a n d i t was i n t h e o p p o s i t e  direction. T a b l e 5.  R e s u l t s o f the T-Tests f o r C a r r y - o v e r and Effects  Wait-List  Measure Carkhuff % Level 3  BLRI S-P R a t e d  C a r r y o v e r e f f e c t s ( n = 7) ( i . e . , comparisons o f c e l l 2 v s c e l l  BLRI M-S R a t e d  3 i n group  Perceived Stress  1, F i g u r e 4)  Mean C e l l 2  40.56  23.14  25.57  10.29  Mean C e l l 3  49.29  29.86  24.43  11.86  t  -0.99  -1.15  .58  -1.14  p  .36  .29  .58  .30  W a i t l i s t c o n t r o l (n = 6 ) ( i . e . , comparisons o f c e l l  4 vs c e l l  5 i n group  2, F i g u r e 4)  Mean C e l l 4  5.77  .33  8.67  18.67  Mean C e l l 5  3.01  2.33  8.67  18.33  t  1.92  ^0.15  .0  .18  p  .11  .88  1.0  .87  \u000C108  Therefore t h e r e s u l t s  indicate  t h a t empathy m e a s u r e s d i d n o t  increase s i g n i f i c a n t l y during the waiting period f o r t h e delayedt r a i n i n g g r o u p , w h i l e t h e e f f e c t s o f empathy t r a i n i n g were maintained  f o r the post-treatment  perceived stress  d i d not decrease  f o l l o w - u p group.  Similarly,  i nthepost-test of the  d e l a y e d - t r a i n i n g group, and c a r r y - o v e r e f f e c t s o f p e r c e i v e d stress  f o r t h e empathy t r a i n e d  g r o u p s were  maintained.  H y p o t h e s e s 3A a n d 3B Hypothesis  3A;  S u b j e c t s who r e c e i v e empathy s k i l l s  at d i f f e r e n t p o i n t s i n time w i l l of  training  i n c r e a s e i n s c o r e s on measures  empathy. Hypothesis  3B:  S u b j e c t s who r e c e i v e e m p a t h y s k i l l s  at d i f f e r e n t p o i n t s i n time w i l l in perceived  decrease  training  i n s c o r e s o f a measure  stress.  The r e s u l t s o f t h e 2 x 2 ANOVAS f o r a l l f o u r d e p e n d e n t measures t o t e s t t h e t h i r d hypotheses to  6d.  may b e f o u n d  The c o n t r a s t o f p r i m a r y i n t e r e s t , t h e t i m e m a i n e f f e c t ,  achieved t h e p r o b a b i l i t y value o f l e s s than Overall  i n T a b l e s 6a  .05 f o r a l l m e a s u r e s .  t h e p o s t - s c o r e s were d i f f e r e n t from t h e p r e s c o r e s i n t h e  d i r e c t i o n p r e d i c t e d by t h e s u b s t a n t i v e An e x a m i n a t i o n shown i n T a b l e  hypotheses.  o f t h e means i n T a b l e 2 a n d t h e ANOVA  6 a-d r e v e a l t h a t ,  a f t e r t r a i n i n g the scores f o r  t h e t h r e e empathy measures f o r b o t h g r o u p s were higher than t h e p r e - t r a i n i n g  results  means.  significantly  A s F i g u r e s 8-10 show, when  t e s t i n g o c c a s i o n s 1 and 2 f o r g r o u p one and t e s t i n g o c c a s i o n s 2  \u000CT a b l e 6.  6(a)  Summary o f Analyses o f V a r i a n c e f o r Dependent Measures (Hypotheses 3A &amp; 3B: Comparison o f C e l l s 1 &amp; 2 w i t h 5 &amp; 6, N=13)  Percentage o f L e v e l 3 Responses  Source of Variance  SS  df  MS  F  p  368.61  1  368.61  2.24  .163  1809.48  11  164.50  13146.2  1  13146.2  90.10  .000  387.68  1  387.68  2.66  .131  1604.93  11  145.90  Between Groups: Group (G) Error: between groups Within Groups: Time (T) GXT Error: within group  6(b)  BLRI Empathy S c a l e  Source of Variance  (Simulated P a t i e n t Rating) SS  df  MS  F  p  .02  .900  Between Groups: Group (G) Error: between groups  4.11  1  4.11  2735.27  11  248.66  3016.69  1  3016.69  7.58  .019  .75  1  .74  0.00  .989  4375.46  11  397.77  Within Groups: Time (T) GXT Error: within group  \u000CTable 6 cont'd  6(c)  BLRI Empathy S c a l e  (Medical Student  Rating)  SS  df  MS  F  p  Group (G)  330.77  1  330.77  4.17  .066  Error: between groups  872.85  11  79.35  614.25  1  614.25  11.92  .005  10.10  1  10.10  .20  .667  566.75  11  51.52  df  MS  7.21  .021  Source of Variance  Between Groups:  Within Groups: Time (T) GXT Error: within group  6(d)  Perceived Stress Scale  Source of Variance  SS  Between Groups: Group (G)  35.18  1  35.18  Error: between groups  53.67  11  4.88  210.99  1  210.99  18.74  .001  18.99  1  18.99  1.69  .221  123.86  11  11.26  Within Groups: Time (T) GXT Error: within group  \u000CIll and 3 f o r group two are compared, the p o s t - t r a i n i n g means are s i g n i f i c a n t l y h i g h e r than the p r e - t r a i n i n g means r e s u l t i n g i n parallel lines  ( t h e r e f o r e no i n t e r a c t i o n ) .  That i s , s c o r e s f o r  both s u b j e c t i v e and o b j e c t i v e measures of empathy were s i g n i f i c a n t l y h i g h e r f o l l o w i n g the empathy t r a i n i n g f o r both groups. F o l l o w i n g t r a i n i n g , the means f o r the p e r c e i v e d s t r e s s measure f o r both groups were lower than the pre-treatment means (Table 2 ) .  As F i g u r e 11 shows, when t e s t i n g o c c a s i o n 1 and 2 f o r  group one and t e s t i n g o c c a s i o n s 2 and 3 f o r group two  are  compared, the p o s t - t r a i n i n g means are lower than the p r e - t r a i n i n g means, thus p a r a l l e l l i n e s r e s u l t .  Scores on the p e r c e i v e d  s t r e s s measure were s i g n i f i c a n t l y lower f o r s u b j e c t s f o l l o w i n g the empathy t r a i n i n g .  Summary From the r e s u l t s presented above, i t i s c l e a r t h a t i n g e n e r a l the data confirmed the hypotheses.  The treatment  s u f f i c i e n t l y p o t e n t t o enable the d i f f e r e n c e s t o be significant.  The one e f f e c t which was  was  statistically  non-significant  was  p r o b a b l y due t o a combination of a s m a l l c e l l number and a l a r g e standard d e v i a t i o n .  Thus, these r e s u l t s support the main  h y p o t h e s i s t h a t empathic  communication s k i l l s t r a i n i n g i n c r e a s e s  l e v e l s of empathy and decreases p e r c e i v e d s t r e s s of second year medical s t u d e n t s .  \u000C112 Results of Exploratory Hardiness  Analyses  Scale  The r e s u l t s o f t h e s e t o f 2 x 2 ANOVA's f o r t h e Hardiness S c a l e can be found i n T a b l e 7 and d i s p l a y e d g r a p h i c a l l y i n F i g u r e 12.  There was no s i g n i f i c a n t d i f f e r e n c e on any o f t h e  comparisons o f primary i n t e r e s t .  The s e r i e s o f ANOVAS were a l s o  computed f o r each o f t h e h a r d i n e s s s u b s c a l e s o f commitment, c o n t r o l and c h a l l e n g e .  Again t h e r e s u l t s were i n s i g n i f i c a n t f o r  a l l contrasts. A l i t e r a t u r e review r e v e a l e d o n l y one study which r e p o r t e d s c o r e s f o r t h e v a r i o u s s u b s c a l e s f o r t h e s h o r t form o f t h e h a r d i n e s s measure ( H u l l , VanTreuren &amp; V i r n e l l i ,  1987).  In order  t o compare r e s u l t s , I c o n t a c t e d H u l l t o v e r i f y h i s s c o r i n g procedure,  and then t h e h a r d i n e s s measure f o r t h e p r e s e n t sample  was r e s c o r e d u s i n g h i s method.  I t i s o f i n t e r e s t t o note t h a t  the s c o r e s f o r t h e medical students i n t h e p r e s e n t study were not s i g n i f i c a n t l y d i f f e r e n t from t h e s c o r e s o f a group r e p o r t e d by H u l l e t a l . (1987) o f 447 psychology undergraduates. were as f o l l o w s :  Commitment  The r e s u l t s  r e s u l t e d i n a mean o f 16.15 and  standard d e v i a t i o n o f 3.45 i n H u l l ' s sample, and w i t h a mean o f 16.82 and standard d e v i a t i o n o f 4.71 i n t h e c u r r e n t study. C o n t r o l r e s u l t e d i n a mean o f 34.67 and standard d e v i a t i o n o f 8.58 i n H u l l ' s sample, and w i t h a mean o f 32.40 and standard d e v i a t i o n o f 10.65 i n t h e present study.  Challenge r e s u l t e d i n a  mean o f 20.54 and standard d e v i a t i o n o f 3.12 i n H u l l ' s sample, w h i l e i n t h i s study t h e r e was a mean o f 21.36 and a standard d e v i a t i o n o f 2.71.  \u000C113 T a b l e 7.  (a)  Summary o f Analyses o f V a r i a n c e f o r Hardiness S c a l e (N=13)  Comparison o f C e l l s 1 &amp; 2 w i t h 4 &amp; 5  Source of Variance  Between Groups: Group (G) Error: between groups Within Groups: Time (T) GXT Error: within group  (b)  SS  df  MS  F  667.82 2927.17  1 11  667.82 266.11  2.51  .1414  1.85 13.85 116.61  1 1 11  1.85 13.85 10.60  .17 1.31  .6838 .2772  Comparison o f C e l l s 2 &amp; 3 w i t h 4 &amp; 5  Source of Variance  Between Groups: Group (G) Error: between groups  SS  df  MS  672.57 3180.27  1 11  672.57 289.12  2.33  .555  13.19 2.11 142.43  1 1 11  13.19 2.11 12.95  1.02 .16  .335 .694  Within Groups: Time (T) GXT Error: within group  (c)  Comparison o f C e l l s 1 &amp; 2 w i t h 5 &amp; 6  Source of Variance  Between Groups: Group (G) Error: between groups Within Groups: Time (T) GXT Error: within group  SS  df  MS  667.87 2863.17  1 11  667.87 260.29  2.57  .138  13.85 1.85 80.61  1 1 11  13.85 1.85 7.33  1.89 .25  .197 .625  \u000C114  \u000C115 Thus the sample o f medical students who  participated in this  study s c o r e d n e i t h e r h i g h e r nor lower i n h a r d i n e s s than d i d a l a r g e sample o f students e n r o l l e d a t an American  academic  institution.  B e h a v i o u r a l Coping Measures As can be seen i n T a b l e 2, the mean number o f both  emotion-  focused and problem-focused s t r a t e g i e s used by the s u b j e c t s t o cope w i t h the s t r e s s e s o f medical t r a i n i n g i n c r e a s e d a f t e r the empathy t r a i n i n g .  The r e s u l t s o f the s e t s o f 2 x 2 ANOVAS f o r  number f o r both emotion-focused and problem-focused c o p i n g s t r a t e g i e s can be found i n T a b l e s 8 and 9.  There was  s i g n i f i c a n t d i f f e r e n c e f o r any o f the comparisons interest.  The same s e r i e s o f 2x2 ANOVAS was  o f primary  computed on the  degree t o which the c o p i n g s t r a t e g i e s were used on the 0-3).  no  (i.e.,  computed  Again the r e s u l t s were n o n - s i g n i f i c a n t f o r  c o n t r a s t s o f primary i n t e r e s t  (see F i g u r e s 13 and 14).  Frequency counts were computed t o i d e n t i f y the c o p i n g s t r a t e g i e s which were used by a l l the s u b j e c t s p r e - and p o s t training  (Table 10).  T - t e s t s were computed f o r s u b j e c t s  immediately pre-and p o s t - t r a i n i n g t o determine i f t h e r e was  any  d i f f e r e n c e i n the r a t i o o f the number o f emotion-focused compared w i t h the number o f problem-focused c o p i n g s t r a t e g i e s . t r a i n i n g t h i s d i f f e r e n c e was  non-significant  (p = .33).  Before However,  a f t e r the empathy t r a i n i n g , the number o f emotion-focused c o p i n g s t r a t e g i e s compared w i t h the number o f problem-focused c o p i n g s t r a t e g i e s used approached  significance  (p =  .053).  \u000C116  T a b l e 8.  (a)  Summary o f Analyses o f V a r i a n c e f o r Emotion-Focused Coping S c a l e (Number o f S t r a t e g i e s Used) N=13  Comparison o f C e l l s 1 &amp; 2 w i t h 4 &amp; 5  Source of Variance  Between Groups: Group (G) Error: between groups Within Groups: Time (T) GXT Error: within group  (b)  df  MS  5.57 647.43  1 11  5.57 58.86  .09  .764  1.06 19.52 76.10  1 1 11  1.06 19.52 6.92  .15 2.82  .703 .121  Comparison o f C e l l s 2 &amp; 3 w i t h 4 &amp; 5  Source of Variance  Between Groups: Group (G) Error: between groups Within Groups: Time (T) GXT Error: within group  (c)  SS  SS  df  MS  .82 785.71  1 11  .82 71.43  .01  .916  8.80 .18 12.67  1 1 11  8.80 .18 1.15  7.64 .16  .018 .700  Comparison o f C e l l s 1 &amp; 2 w i t h 5 &amp; 6  Source of Variance  Between Groups: Group (G) Error: between groups Within Groups: Time (T) GXT Error: within group  SS  df  MS  11.69 757.85  1 11  11.69 68.90  .17  .688  30.00 .92 89.85  1 1 11  30.00 .92 8.17  3.67 0.00  .08 .99  \u000C117 T a b l e 9.  (a)  Summary o f Analyses o f V a r i a n c e f o r Problem-Focused Coping S c a l e (Number o f S t r a t e g i e s Used) N=13  Comparison o f C e l l s 1 &amp; 2 w i t h 4 &amp; 5  Source of Variance  Between Groups: Group (G) Error: between groups Within Groups: Time (T) GXT Error: within group  (b)  SS  df  MS  F  i  10.29 400.10  1 11  10.29 36.37  .28  .605  41.94 .92 83.52  1 1 11  41.94 .92 7.59  5.52 .01  .039 .915  F  p  Comparison o f C e l l s 2 &amp; 3 w i t h 4 &amp; 5  Source of Variance  SS  df  MS  Between Groups: Group (G) Error: between groups  2.29 525.10  1 11  2.29 47.74  .05  .830  25.23 3.08 19.38  1 1 11  25.23 3.08 1.76  14.32 1.75  .003 .213  Within Groups: Time (T) GXT Error: within group  (c)  Comparison o f C e l l s 1 &amp; 2 w i t h 5 &amp; 6  Source of Variance  SS  df  MS  Between Groups: Group (G) Error: between groups  49.29 425.10  1 11  49.29 38.65  1.28  .283  Within Groups: Time (T) GXT Error: within group .  12.32 7.09 94.52  1 1 11  12.32 7.09 8.59  1.43 .83  .256 .383  \u000CLd  25  Legend O  Group One  A  Group Two  Testing Occasion F i g u r e 13.  Means f o r Emotion-Focused Coping S c a l e .  \u000C27  26 H  CD i_ O  o CO CO 25-  0^'  c *o_  Oo x&gt;  CU  CD CO  24 \u00B1  o LZ 1  1  E CD _Q O  Q_  23-  C  c  o CD  Legend  2  22  O  Group One  A  Group Two  21  Testing Occasion  F i g u r e 14.  Means f o r P r o b l e m - F o c u s e d  Coping  Scale,  \u000C120 T a b l e 10. B e h a v i o u r a l Coping S t r a t e g i e s Used by a l l S u b j e c t s Pre- and P o s t - t r a i n i n g (N=13) P r e - T r a i n i n g Coping S t r a t e g i e s Emotion-Focused: 7* 60 68  I b e l i e v e d i n myself. I had l e a r n e d t o accept c e r t a i n t h i n g s . I t a l k e d with others.  Problem-Focused: 4 19 39 46 55 57 69  I l o g i c a l l y thought t h i n g s out. I d i d what I needed t o do. I hung i n t h e r e and kept p l u g g i n g away. I d i d the best I could. I was o r g a n i z e d and e f f i c i e n t . I assumed a p r o f e s s i o n a l r o l e / a c t e d l i k e an adult. I responded t o p o s i t i v e feedback.  P o s t - T r a i n i n g Coping S t r a t e g i e s Emotion-Focused: 7 9 62 68 74  I b e l i e v e d i n myself. I used/kept my sense o f humor. What I c o u l d not do then, I d i d l a t e r . I t a l k e d with others. I enjoyed i t and wanted t o be t h e r e .  Problem-Focused: 2 4 12 27 29 40 44 46 55 57 *Item number  I stepped back and t r i e d t o e v a l u a t e how I was doing. I hung i n t h e r e and kept p l u g g i n g away. I ordered t h i n g s by p r i o r i t y . I had s e t my own e x p e c t a t i o n s . I accommodated/made compromises. I t r i e d t o understand what people were saying. I had e s t a b l i s h e d c l e a r p r i o r i t i e s . I d i d t h e best I c o u l d . I was o r g a n i z e d and e f f i c i e n t . I assumed a p r o f e s s i o n a l r o l e / a c t e d l i k e an adult.  \u000C121  Effect Sizes  The table of e f f e c t sizes f o r measures i n t h i s study can be found i n Table 11.  The magnitude of the e f f e c t sizes f o r the  three empathy measures and the perceived stress measure was very large.  For instance on the empathy measures, subjects gained an  average of 18.32 standard units on the Carkhuff Scale, 1.25 standard units on the BLRI (M-S Rating), 1.08 on the BLRI (S-P Rating), while perceived stress was lowered by 1.95 standard units as indicated by the negative e f f e c t s i z e .  T a b l e 11.  E f f e c t S i z e s f o r Measures (N = 13, 2 Groups Pooled)  Unweighted Mean (Pre)  Measure C a r k h u f f Empathy Scale (percentage o f responses &gt; l e v e l  Unweighted Mean (Post)  Pooled Standard D e v i a t i o n (Pre)  Effect Size  3.11  47.62  2.43  18.32  BLRI ( m e d i c a l student r a t i n g s )  11.85  21.69  7.90  1.25  BLRI ( s i m u l a t e d patient ratings)  1.85  23.46  20.11  1.08  Perceived Stress Scale  18.00  12.16  2.99  -1.95  Hardiness  70.35  71.77  11.41  .13  Emotion-Focused Coping S c a l e (number o f ways)  25.61  27.77  5.27  .41  Problem-Focused Coping S c a l e (number o f ways)  24.62  26.08  4.59  .32  Scale  3)  \u000C122  The p r e - t r a i n i n g standard d e v i a t i o n f o r the Carkhuff was  Scale  v e r y s m a l l due t o a s m a l l v a r i a n c e and f l o o r e f f e c t s .  The  t r a i n i n g had the e f f e c t of r a i s i n g and s p r e a d i n g out the s c o r e s , as t h e r e was s i z e was  a l a r g e range o f s c o r e s on p o s t - t e s t i n g .  The  effect  c a l c u l a t e d u s i n g the p r e - t r a i n i n g standard d e v i a t i o n  based on the recommendation of G l a s s and Hopkins (1984) t h a t when \"the treatment  can a f f e c t the h e t e r o g e n e i t y as w e l l as the mean  of the treatment  group, s  denominator\" (p. 236). large.  c o n  ^.  r o  ^  should be used i n the  Hence, the r e s u l t i n g e f f e c t s i z e was  very  However, i f the pooled p o s t - t r a i n i n g standard d e v i a t i o n  were t o be used i n the c a l c u l a t i o n , the e f f e c t s i z e o f t h i s measure would be much s m a l l e r than 18.32.  I t i s of i n t e r e s t t o  note t h a t u s i n g the p o s t - t r a i n i n g standard d e v i a t i o n would r e s u l t a l s o i n a l a r g e r e f f e c t s i z e f o r BLRI s i m u l a t e d p a t i e n t r a t i n g . The  standard d e v i a t i o n s of the o t h e r measures, however, were much  l e s s v a r i a b l e p r e - and p o s t - t r a i n i n g e f f e c t s i z e s would be approximately  (see T a b l e 2) and so the the same.  These e f f e c t s i z e s v e r i f y the r e s u l t s of the hypotheses t h a t empathy t r a i n i n g l e a d s t o an i n c r e a s e of s c o r e s on measures of empathy and a decrease stress.  of s c o r e s on a measure o f p e r c e i v e d  Even though t h i s study had a s m a l l number of s u b j e c t s ,  the h i g h power due t o the repeated measures d e s i g n means t h a t t h e r e was  a h i g h p r o b a b i l i t y t h a t i t would l e a d t o the  rejection  of the f a l s e n u l l hypotheses i f the i n t e r v e n t i o n were t o be s u f f i c i e n t l y potent. i n t e r v e n t i o n was  Large e f f e c t s i z e s mean t h a t the  e f f e c t i v e because e f f e c t s i z e s are the degree t o  \u000C123  w h i c h t h e r e s u l t i n g change i n s c o r e s and  n o t t o c h a n c e (Cohen, 1988).  of the exploratory analyses  e x i s t due  to the  treatment  E f f e c t s i z e s f o r the  (hardiness,  and  number o f  measures coping  s t r a t e g i e s ) w e r e much s m a l l e r t h a n f o r t h e m e a s u r e s o f t h e hypotheses.  T h i s may  be  due,  main  i n p a r t , t o l a c k o f power, w i t h  a  s m a l l number, t o d e t e c t c h a n g e s i n t h e s e p a r t i c u l a r m e a s u r e s .  S e s s i o n and Comments b y t h e were p l a c e d  Training Evaluation  s u b j e c t s on t h e  individual training  i n t o c a t e g o r i e s b a s e d on t h e s t a n d a r d  steps  s k i l l s - t r a i n i n g p r o g r a m i d e n t i f i e d by E g a n ( 1 9 8 6 ) . cognitive clarity, reflection.  behavioural  clarity,  sessions in a  They  include  practice, evaluation,  A l l s e g m e n t s o f t h e w r i t t e n f e e d b a c k c o u l d be  categorized  i n t o these mutually  exclusive groupings  and  easily  (Tables  12  &amp;  13) . Forty-nine subjects  percent  of the answers concerning  learned pertained to cognitive c l a r i t y  of empathy).  The  what (e.g.,  aspect of the course which the  t h e m o s t was  p r a c t i s i n g ( b o t h p a t i e n t and  i n d i c a t e d by  49 p e r c e n t  of the responses.  e.g.,  \" I was  ( 3 0 % o f r e s p o n s e s ) and  t i r e d and  had  importance  subjects  enjoyed  p h y s i c i a n r o l e s ) as The  aspects  c o u r s e w h i c h t h e c l i e n t s l i k e d t h e l e a s t were i n d i c a t e d reflection,  the  difficulty  \"Nothing I didn't l i k e \"  of  was  the  as  concentrating\"  (26%  of  responses). S u g g e s t i o n s f o r improvement o f t h e c o u r s e a r e p r e s e n t e d T a b l e 14.  J u s t a s p r a c t i c e o f s k i l l s was  course which the  the aspect of  the  s u b j e c t s a p p e a r e d t o l i k e t h e m o s t , more  in  \u000C124  T a b l e 12. (A)  F r e q u e n c y o f Responses from  s i on Feedback  WHAT I LEARNED TODAY WAS . . .  Theme No.  of Examples  Session 1  Responses  Cognitive Clarity  15  Purpose and rationale of the course e . g . , importance of paraphrasing  Practice  9  Active listening  Reflection on Training  4  To trust my intuition on how I perceive another is feeling  Cognitive Clarity  6  Empathy formula  Practice  4  How to \"concentrate\" on reflecting  Behavioural Clarity  2  Integrating the specific s k i l l s with my style  Evaluation  1  Became more aware of non verbal cues from videotaping  Behavioural Clarity  7  How anger can be handled using empathy  Cognitive Clarity  4  Nature of the emotion of anger  Reflection  3  Awareness of self, i . e . , my empathizing with anger  Session 2  Session 3  involves avoidance Practice  1  Practice of skills  Evaluation  1  I need to build my vocabulary of phrases to use for the empathic responses  Cognitive Clarity  11  Grief is a complex emotion  Behavioural Clarity  5  Mechanics of empathic responding  Evaluation  1  From feedback - insight into personal attributes  Session 4  and idiosyncrasies  \u000C125  Table 12 Continued  (B)  WHAT I LIKED MOST ABOUT TODAY WAS  Theme Session 1  No. of Responses  Examples  Practice  12  Small group practice of s k i l l s  Behavioral Clarity  5  Model 1ing  Reflection on Training  3  Being challenged and having informal  Cognitive Clarity  1  Simple principles taught  Evaluation  5  Usefulness of videotaped feedback  Practi ce  4  Role playing  Refl ection  3  Feeling that I've accomplished something  Cognitive Clarity  1  Usefulness of empathic formula  structure  Session 2  Session 3 Practice  Role playing (including role of patient being played by instructor)  Evaluation  Videotaping and following discussions  Cognitive Clarity  Awareness that you can apply empathy to various emotions  Behavioral Clarity  SIMED tape on anger  Session 4 Practice  Chance of doing 2 interviews  Evaluation  Feedback from videotaping  Behavioral Clarity  Having leader role-play  Cognitive Clarity  Critical thinking can be suspended in interview to benefit both the patient and doctor  \u000C126  Table 12 Continued  (C)  WHAT I LIKED LEAST ABOUT TODAY WAS . . .  Theme No. of Examples  Session 1  Responses  Reflection  6  Cognitive Clarity  4  Listening to difference between empathy and sympathy  Practice  4  Having to \"act\" doesn't come easy to me  Nothing I didn't like  4  Goal-oriented attitude in myself and others; The feeling that being empathic doesn't achieve anything concrete  Session 2 Reflection  4  My own hesitancy in giving feedback  Evaluation  4  Being on videotape with myself as the patient  Nothing I didn't 1 ike  2  Session 3 Nothing I didn't like  6  Practice  5  Acting the emotion  Reflection  1  Feeling not in control during my interview  Session 4 Nothing I didn't 1 ike  5  Reflection  4  I was tired and had difficulty concentrating  Evaluation  3  Role playing - I can't \"act\"!  Cognitive Clarity  2  Wanted more discussion on grieving and how a grieving patient may present  \u000C127 T a b l e 1 3 . Number o f R e s p o n s e s t o E v a l u a t i o n s Sessions  for a l l  Session 3  4  \"What I l e a r n e d ...\" Cognitive c l a r i t y 15 Practice 9 Reflection 4 Behavioural c l a r i t y Evaluation  \"What I l i k e d  36 14 7 14 3 74  2 1  1 5 12 3 0  1 0 4 3 5  1 1 6 0 4  1 1 9 0 7  4 7 31 6 16 64  4 0 4 6 0 4  0 0 0 4 4 2  0 0 5 1 0 6  2 0 0 4 3 5  6 0 9 15 7 17 54  5 1  most\"  Cognitive c l a r i t y Behavioural c l a r i t y Practice Reflection Evaluation  \"What I l i k e d  11  1 3 7 1  least\"  Cognitive c l a r i t y Behavioural c l a r i t y Practice Reflection Evaluation Nothing  \u000C128 p r a c t i c e was a l s o t h e most f r e q u e n t l y mentioned s u g g e s t i o n f o r improvement.  T a b l e 14.  S u g g e s t i o n s f o r Improvements t o t h e C o u r s e  Suggestion 1.  No. o f Times Mentioned  More time f o r r o l e p l a y i n g i n f r o n t o f the v i d e o camera ( i . e . , more p r a c t i c e ) and l e s s time watching.  5  2.  More i n t e g r a t i o n w i t h t h e medical interview  2  3.  Have people o t h e r than classmates ( i d e a l l y r e a l p a t i e n t s ) do t h e r o l e p l a y i n g t o h e l p i n terms o f r e a l i s m .  2  4.  F i x feedback n o i s e on v i d e o machine.  2  5.  Suggest t o students t h a t they implement t h e i r s k i l l s w i t h p a t i e n t s once a week and r e l a t e i t back t o t h e group.  1  6.  Have more d i s c u s s i o n on how t o r e c o g n i z e p a r t i c u l a r emotions i n a p a t i e n t .  1  7.  Have group s i t i n a c i r c l e .  1  8.  S t a r t course e a r l i e r i n t h e year.  1  9.  Shorten t h e s e s s i o n s t o 2 hours and have them more f r e q u e n t l y .  1  The o v e r a l l comments from a l l t h e s u b j e c t s were v e r y favourable.  S u b j e c t s expressed  a p p r e c i a t i o n f o r t h e course and  the o v e r a l l feedback was predominantly  enthusiastic.  Excerpts  from t h e g e n e r a l s e t o f comments from t h r e e s u b j e c t s w i l l now be presented.  \u000C129 \"I  t h i n k t h e c o u r s e was g r e a t !  v e r y u s e f u l and h e l p f u l  I'm s u r e i t w i l l  i n practice.  be  Watching t h e  v i d e o t a p e s o f t h e T.V. c o u r s e , a s w e l l a s e x p e r i e n c e i n my own l i f e ,  r e a l l y brought  t o my a t t e n t i o n how  important empathic t r a i n i n g i s . to  The s k i l l s  t h e p a t i e n t and t o t h e d o c t o r as w e l l .  interviewing s k i l l s  (and empathic t r a i n i n g )  are helpful I'm amazed aren't  taught t o a l l health care students i n 1 s t year. skills  The  a r e r e l a t i v e l y e a s y t o l e a r n a n d make a w o r l d o f  d i f f e r e n c e i n h e l p i n g t h e p a t i e n t work t h r o u g h problem  their  and i n h e l p i n g t h e d o c t o r t o understand t h e  p a t i e n t b u t remain next  patient\".  \"The  course  o b j e c t i v e and capable o f s e e i n g t h e  i s extremely u s e f u l ,  already, i n \"raising  t h e c o n s c i o u s n e s s \" o r awareness t o t h e p a t i e n t ' s f e e l i n g s a n d a g e n d a ( i n t h e 2nd y e a r m e d i c a l s t u d e n t ) . There a r e almost  a handful of occasions i n the l a s t 6  weeks on t h e wards where I n o t i c e d t h a t t h e p a t i e n t ' s concerns  were n o t addressed  dystress  (sic).  and \"I  and were c a u s i n g him/her  A good e x p e r i e n c e .  I enjoyed  myself  l e a r n e d a g o o d d e a l a t t h e same t i m e . \" felt  t h i s t r a i n i n g was e x c e l l e n t a n d t h a t I h a v e  r e a l l y b e n e f i t e d from  it.  I f e e l l i k e I c o u l d go i n t o  a l m o s t a n y s i t u a t i o n a n d come o u t o f i t h e l p i n g t h e patient feel better.  I think this training  (ora  m o d i f i c a t i o n o f i t ) would be v e r y w o r t h w h i l e f o r  \u000C130 anybody i n t h e f i e l d o f medicine,  and would h e l p  both  the p h y s i c i a n and p a t i e n t \" .  Summary o f F i n d i n g s A summary o f t h e f i n d i n g s from t h e t e s t s o f t h e main hypotheses can be found  i n Table 15.  Table 15. Summary o f S i g n i f i c a n t R e s u l t s from Analyses o f V a r i a n c e f o r t h e Main Hypotheses  Carkhuff BLRI % L e v e l 3 Sim.-Pt.  BLRI Med. Stud.  Perceived Stress  Hypothesis 1A &amp; IB (Treatment v s C o n t r o l ) .00* Group x Time I n t e r a c t i o n  ns  .04  .01  Hypotheses 2 A i &amp; 2 B i (Follow-Up v s C o n t r o l ) Group Main E f f e c t  .00  .00  .00  .00  Hypotheses 3A &amp; 3B (Pre- v s Post-Treatment).00 Time Main E f f e c t  .02  .01  .00  *p  values  In a d d i t i o n , t - t e s t s r e v e a l e d t h a t t h e empathy s c o r e s d i d not i n c r e a s e and t h e p e r c e i v e d s t r e s s s c o r e s d i d not decrease f o r the s u b j e c t s i n t h e delayed treatment  c o n t r o l group.  Results of  t - t e s t s a l s o showed t h a t empathy and p e r c e i v e d s t r e s s s c o r e s were maintained  a f t e r a follow-up time p e r i o d .  \u000CA n a l y s e s o f v a r i a n c e r e v e a l e d t h a t t h e s c o r e s on h a r d i n e s s , a n d number o f e m o t i o n - f o c u s e d a n d p r o b l e m - f o c u s e d strategies  coping  d i d n o t change s i g n i f i c a n t l y o v e r any t i m e p e r i o d .  E f f e c t s i z e s as a r e s u l t o f t r e a t m e n t were l a r g e f o r a l l dependent measures used t o t e s t t h e main  hypotheses.  \u000C132  CHAPTER V Discussion  Introduction T h i s chapter  opens with a summary of r e s u l t s f o l l o w e d  by  d i s c u s s i o n of the f i n d i n g s f o r each of the measures. Implications for  f o r empathy s k i l l  t r a i n i n g i n medical s c h o o l s  and  p h y s i c i a n - p a t i e n t communication are suggested.  Recommendations f o r f u r t h e r r e s e a r c h c l o s e the  chapter.  Summary The  r e s u l t s from t h i s study showed t h a t second year  medical students simulated  l e a r n e d t o i n t e r a c t with e m o t i o n a l l y  p a t i e n t s i n a more empathic manner as a r e s u l t of a  s h o r t t r a i n i n g course i n empathic communication. the treatment, t h e i r p e r c e i v e d emotionally  s t r e s s concerning  i n t e n s e encounters was  reduced.  Also, a f t e r these  These r e s u l t s  were not demonstrated with a c o n t r o l group of students been e n r o l l e d i n r e g u l a r medical c l a s s e s .  treatment) c o n t r o l group a l s o demonstrated a i n c r e a s e i n empathy scores and  who  stress.  Results  r e c e i v e d the i n i t i a l  were maintained.  who  had  After participating  i n the empathy t r a i n i n g however, the students  perceived  intense  i n the  (delayed-  significant  a s i g n i f i c a n t decrease i n  from a s h o r t follow-up  f o r subjects  t r a i n i n g showed t h a t these e f f e c t s  \u000C133 D i s c u s s i o n o f R e s u l t s o f Dependent Measures Percentage o f L e v e l 3 Responses No o t h e r study was found which used percentage o f t o t a l responses c o n s i d e r e d t o be m i n i m a l l y f a c i l i t a t i v e as an outcome measure.  F o r i n s t a n c e , i n t h e Poole and Sanson-Fisher  (1979) study, t h r e e , 2-minute randomly s e l e c t e d segments f o r each s u b j e c t were r a t e d .  The o v e r a l l l e v e l was t h e mean o f  the t h r e e separate r a t i n g s .  A f u r t h e r d i f f e r e n c e i n t h e two  s t u d i e s was t h a t s u b j e c t s i n t h e p r e s e n t study were unaware t h a t t h e i r responses were going t o be r a t e d u s i n g t h e Carkhuff scale.  In c o n t r a s t , s u b j e c t s i n t h e Poole and Sanson-Fisher  (1979) study were t o l d s p e c i f i c a l l y t o empathize as b e s t as they c o u l d w i t h t h e p a t i e n t s and t h a t t h e i r responses would be r a t e d u s i n g t h e A c c u r a t e Empathy S c a l e .  F u r t h e r , t o motivate  the s u b j e c t s , t h e Poole and Sanson-Fisher s u b j e c t s were t o l d i f they achieved a r a t i n g . a t a c e r t a i n l e v e l , then they would be exempt from t a k i n g an a d d i t i o n a l communication course. During t h e t r a i n i n g s e s s i o n s o f t h e p r e s e n t study, i n answer t o t h e q u e s t i o n , \"How l o n g do we c o n t i n u e t o g i v e empathic responses?\" medical students were t o l d t o use t h e i r judgement t o determine when t h e emotional i n t e n s i t y o f t h e i n t e r v i e w had d e - e s c a l a t e d t o a p o i n t where they c o u l d go on t o more medical aspects o f i n t e r v i e w i n g .  S u b j e c t s were not  t o l d t o g i v e as many empathic responses d u r i n g t h e t e s t i n g o c c a s i o n s as they c o u l d ; they were i n s t r u c t e d on t h e w r i t t e n i n f o r m a t i o n sheet t o \"explore t h e nature o f t h e problem\" (See Appendix C).  The average mean o f t h e percentage o f l e v e l 3  \u000C134 responses f o r the t h r e e p o s t - t r a i n i n g c e l l s was average, then, approximately h a l f of the  T h i s would not,  f o r r e a l interviews agenda as w e l l .  On  interviews  i n i n t e r a c t i n g i n an empathic manner w i t h the patients.  49%.  were spent  simulated  however, n e c e s s a r i l y r e f l e c t a  i n which p h y s i c i a n s  Further research  a n a l y s i s i s needed t o explore,  goal  must f o l l o w a medical  such as i n t e r a c t i o n a l  f o r example, p o s s i b l e markers  which i n d i c a t e a t what p o i n t s medical s t u d e n t s c o u l d move on t o more medical a s p e c t s of the  interview.  BLRI ( P a t i e n t Ratings o f Empathy Scale) The  r e s u l t s f o r t h i s measure showed t h a t when the  groups* s c o r e s were c o l l a p s e d and  and  p o s t - t r a i n i n g , the s u b j e c t s  compared immediately  were r a t e d by the  two pre-  simulated  p a t i e n t s as b e i n g s i g n i f i c a n t l y more empathic. Even though the means were much h i g h e r f o r s u b j e c t s the  f i r s t t r a i n i n g group compared t o those i n the  in  control  group f o r the p a t i e n t r a t e d empathy s u b s c a l e , the wide range i n d i s t r i b u t i o n of scores l e d to a n o n - s i g n i f i c a n t The  l a r g e standard d e v i a t i o n  and  unique i n t e r a c t i o n s .  i n d i c a t e s t h a t t h e r e were v a r i e d  As Schweitzer has  . . . the a r t of l e t t i n g our own the  i n d i v i d u a l i t y of the p a t i e n t \"  p. 33).  Also,  discussing  s a i d \"medicine i s  i n d i v i d u a l i t y i n t e r a c t with (cited in Siegel,  1986,  as I have mentioned i n chapter 3 when  i n t e r n a l threats to v a l i d i t y ,  s t u d e n t s performed as b e s t as they c o u l d occasions.  difference.  I t h i n k the  medical  in a l l testing  Most people w i l l respond t o a p h y s i c i a n who  is  \u000C135 t r y i n g hard t o communicate w i t h them ( F l e t c h e r &amp; S a r i n , The s i m u l a t e d p a t i e n t s may  1988).  have g i v e n h i g h r a t i n g s t o the  s u b j e c t s whom they p e r c e i v e d t o be making g r e a t attempts t o understand them through f o r example non v e r b a l means.  As  one  s i m u l a t e d p a t i e n t wrote on the BLRI a f t e r i n t e r a c t i n g w i t h a pre-trained subject: (I f e l t he was  \"[name of s u b j e c t ] has the understanding  s e n s i t i v e ) , but not the words.  He wants t o  understand, but f e e l s awkward, I t h i n k , without the words.\" Perhaps  some of the s i m u l a t e d p a t i e n t s , gave r a t i n g s t o  the s u b j e c t s p a r t l y based on a \" n i c e guy\" q u a l i t y , or r a t e d s u b j e c t s on t h e i r i n n e r s e n s i t i v i t y . (1981) noted t h a t empathic  Indeed B a r r e t t - L e n n a r d  understanding i s not a concept i n  the awareness of a person answering the BLRI s i n c e i t does not r e q u i r e them t o r a t e the s u b j e c t ' s l e v e l of empathy d i r e c t l y . The instrument i s an i n d i c a t i o n of \" r e l a t i o n a l response, which are then put t o g e t h e r and i n t e r p r e t e d as p r o v i d i n g an index of empathic  understanding\" ( B a r r e t t - L e n n a r d , 1981,  p. 95).  BLRI (Medical Student R a t i n g o f Empathy Scale) One  of the purposes of t h i s study was  t o show how  s k i l l t r a i n i n g would h e l p medical s t u d e n t s . One may  empathy  of the ways i t  have h e l p e d i s t h a t a f t e r t r a i n i n g the medical students  p e r c e i v e d themselves t o be more empathic r e c e i v e d the t r a i n i n g .  than b e f o r e they  T h i s means, a c c o r d i n g t o some  q u e s t i o n s on t h i s s c a l e , t h a t the medical students  saw  themselves as more understanding toward the p a t i e n t s and b e t t e r a b l e t o a p p r e c i a t e p a t i e n t s ' e x p e r i e n c e s without  \u000C136 l e t t i n g t h e i r own f e e l i n g s i n t e r f e r e .  They were a b l e t o  respond c o n c r e t e l y t o t h e f e e l i n g s and meanings a s s o c i a t e d with p a t i e n t s ' experiences,  and p o s s i b l y f o u n d empathy t o be a  h e l p f u l and c r e d i b l e t a s k as i m p o r t a n t medical  t o p a t i e n t s as a  a c t i v i t y g i v e n t h a t p a t i e n t s were  considerable emotional The  experiencing  distress.  l a s t three sections provided  a discussion of the  phases i n v o l v e d i n t h e c y c l e of empathic i n t e r a c t i o n . complete process  The  was e x a m i n e d t o a v o i d m e a s u r i n g v e r b a l  empathy o r a f f e c t i v e s e n s i t i v i t y o n l y .  This  i s important  b e c a u s e a p e r s o n c o u l d communicate v e r b a l empathy y e t l a c k sensitivity,  or conversely,  a p e r s o n c o u l d have  internal  empathic s e n s i t i v i t i e s but l a c k t h e a b i l i t y t o v e r b a l i z e a f f e c t i v e awareness  (Hackney, 1978).  A l l three stages  of the  c y c l e o f empathic communication were measured i n an a t t e m p t t o gain a greater understanding skills  o f c h a n g e s a s a r e s u l t o f empathy  training.  Perceived  Stress  Questionnaire  A f t e r t h e empathy t r a i n i n g ,  subjects i n general  viewed  i n t e r a c t i o n s w i t h simulated p a t i e n t s as being  less  and  They a l s o  l e s s demanding t h a n b e f o r e  the training.  stressful felt  more c o n f i d e n t i n t h e i r r e s p o n s e s a n d more h e l p f u l t o simulated  p a t i e n t s a f t e r the course.  Thus, by a t t e n d i n g t o  t h e s i m u l a t e d p a t i e n t s * i n t e n s e emotions and by h a v i n g t h e s k i l l s t o r e s p o n d i n a way t h a t t h e y v i e w e d a s h e l p f u l , viewing  themselves as empathic, t h e m e d i c a l  students'  and by  stress  \u000C137 l e v e l s were a p p a r e n t l y decreased. concrete s k i l l s ,  In o t h e r words, by  they were a b l e t o cope w i t h the  stressful  s i t u a t i o n more a p p r o p r i a t e l y , and thus a p p r a i s e d the as b e i n g l e s s Batson  having  situation  stressful.  e t a l . (1987) presented a two-part  model  s u g g e s t i n g t h a t d i s t r e s s l e a d s t o m o t i v a t i o n t o reduce one's own  l e v e l of a r o u s a l w h i l e empathy l e a d s t o m o t i v a t i o n t o  reduce the o t h e r ' s need.  T h i s suggests t h a t the two  mutually e x c l u s i v e , t h a t i s , an \" e i t h e r - o r \" R e s u l t s from t h i s study may t r a i n i n g empathic responding d i s t r e s s being  situation.  suggest t h a t a f t e r empathy also resulted i n subjects'  own  reduced.  Folkman and Lazarus  (1988) suggested  emotion p o s s i b l y by a c t i n g as a mediator. s u b j e c t s may  are  t h a t coping After  affects  training,  have f e l t more c o n f i d e n t w i t h t h e i r a b i l i t i e s t o  d e a l w i t h the e m o t i o n a l l y i n t e n s e s i t u a t i o n s due t o having some u s e f u l coping s k i l l s . decreased.  Empathic responding may  emotion-focused the emotional medical  Thus, t h e i r s t r e s s l e v e l s would be be viewed as a form of  coping, t h a t i s , an a c t i o n t o t r y t o a l l e v i a t e d i s t r e s s of the s i t u a t i o n .  s t u d e n t s ' focus may  After training  have been more on the  simulated  p a t i e n t s ' f e e l i n g s and experiences i n s t e a d of on t h e i r sense of h e l p l e s s n e s s and  the  own  f r u s t r a t i o n as i n p r e - t r a i n i n g .  s u b j e c t s f e l t c o n f i d e n t t h a t they c o u l d manage because they had  some a p p r o p r i a t e s k i l l s .  responding, used reduced  then, may  The a c t i v i t y of empathic  have a mediating  f u n c t i o n which when  the s t r e s s f u l n e s s of the e m o t i o n a l l y i n t e n s e  The  \u000C138  encounter.  M e d i c a l students may have f e l t e f f e c t i v e because  they were doing something  which was h e l p f u l t o t h e p a t i e n t .  A  model i l l u s t r a t i n g t h e d i f f e r e n c e between empathy and d i s t r e s s , and s u g g e s t i n g how empathic  responding a c t s as a  mediator o f emotion i s presented i n F i g u r e 15. Distress (Pre-Training) Presentation of intense emotional issue by patient \u00A3 A*  Awareness by medical student ^ of patient's ^ 1) intense emotion, and of emotional reaction in self. Desire to \"do something.\"  Distress experienced by medical ^ \u2014 student e.g., frustration  Ineffective coping (i.e., Uncertainty as to how best ^ to deal with the situation)  Empathy experienced by medical ^ student e.g., confidence in ability to respond to patient's feelings.  Effective coping (i.e., Empathic responding which \u00A3 also helped the patient)  Increase in stress level of -^medical student  Empathy ( P o s t - T r a i n i n g ) Presentation of intense emotional issue by patient ^~  Awareness by medical student -^of patient's ^ intense emotion, and of emotional reaction in self. Desire to \"do something.\"  Decrease in stress level of medical student  F i g u r e 15. O u t l i n e o f d i f f e r e n c e s i n medical s t u d e n t s ' emotions and coping behaviours b e f o r e and a f t e r empathy t r a i n i n g .  Hardiness There was no change i n t h e h a r d i n e s s s c o r e s as a r e s u l t of t h e treatment.  Hardiness may be c o n s i d e r e d t o be a s t a b l e  t r a i t measure which may not be amenable t o change over a s h o r t p e r i o d o f time.  I t appears t h a t s u b j e c t s i n t h i s study were a  \u000C139 f a i r l y homogeneous group w i t h r e s p e c t t o h a r d i n e s s . t h a t t h e i r s c o r e s were no d i f f e r e n t than a group of psychology undergraduates  ( H u l l e t a l . , 1987)  may  The  fact  447  l e n d support  t o the c o n c l u s i o n t h a t persons need not be s u p e r i o r w i t h r e s p e c t t o \" s t r e s s - r e s i s t a n c e \" i n order t o l e a r n empathic responding and be a b l e t o cope e f f e c t i v e l y w i t h e m o t i o n a l l y intense s i t u a t i o n s .  Behavioural Coping  Strategies  O v e r a l l , the number of coping s t r a t e g i e s used t o cope w i t h the s t r e s s of medical t r a i n i n g d i d not i n c r e a s e as a r e s u l t o f the empathy t r a i n i n g . noting.  First,  However, two  t r e n d s are worth  a f t e r the empathy t r a i n i n g , the number of  emotion-focused  coping s t r a t e g i e s compared w i t h the number of  problem-focused  coping s t r a t e g i e s approached s i g n i f i c a n c e  (p=.053).  Perhaps the empathy t r a i n i n g , i n which s u b j e c t s  acknowledged o t h e r ' s emotions, encouraged them a l s o t o a t t e n d t o t h e i r own the emotional  emotions and seek a c t i o n s or thoughts t o r e l i e v e impact  of s t r e s s .  F u r t h e r r e s e a r c h i s needed t o  i n v e s t i g a t e whether empathy t r a i n i n g has an impact on the number of c o p i n g s t r a t e g i e s used t o d e a l w i t h the s t r e s s of medical  training.  Second, a f t e r the empathy t r a i n i n g , the number of emotion-focused  coping s t r a t e g i e s used by s u b j e c t s i n both  groups compared w i t h the number used b e f o r e t r a i n i n g approached s i g n i f i c a n c e a t (p=.08).  Empathic responding  be viewed as a form of emotion-focused  coping  may  ( i . e . , action to  \u000C140 r e d u c e t h e e m o t i o n a l i m p a c t o f s t r e s s ) , a n d s o t h e number o f o t h e r e m o t i o n - f o c u s e d ways o f c o p i n g may h a v e i n c r e a s e d F u r t h e r r e s e a r c h i s needed t o i n v e s t i g a t e whether  also.  empathy  t r a i n i n g r e s u l t s i n a s i g n i f i c a n t i n c r e a s e i n t h e number o f emotion-focused s t r a t e g i e s used t o cope w i t h t h e s t r e s s o f medical t r a i n i n g . a long period  Ways o f c o p i n g may b e h a b i t s ,  o f t i m e , a n d s o may b e r e s i s t a n t t o c h a n g e a s a  r e s u l t o f a s h o r t term  Effect  learned over  intervention.  Sizes  One m i g h t e x p e c t b i g g e r e f f e c t s i z e s f o r t h e e m p a t h y a n d p e r c e i v e d s t r e s s measures because r e l a t e d t o and i n f l u e n c e d  t h e y may b e more d i r e c t l y  by t h e t r a i n i n g .  h a r d i n e s s may b e a more s t a b l e p e r s o n a l i t y  A s was d i s c u s s e d , trait  a n d ways o f  c o p i n g may b e l o n g t e r m h a b i t s ; b o t h may n o t b e e a s i l y influenced  by such a s h o r t term  intervention.  I m p l i c a t i o n s f o r Empathy S k i l l  Training  i n Medical Education One o f t h e i m p l i c a t i o n s o f t h e r e s u l t s o f t h i s s t u d y i s t h a t medical students can l e a r n t o respond t o s i m u l a t e d patients  i n a more e m p a t h i c manner a f t e r p a r t i c i p a t i n g i n a n  empathy s k i l l s  t r a i n i n g course.  Although studies  have been  conducted which evaluated t h e e f f e c t s o f a general . interviewing  skills  course f o r second y e a r m e d i c a l s t u d e n t s  ( e . g . , Monahan, G r o v e r , K a v e y , G r e e n w a l d , Weinberger,  Jacobsen, &amp;  1 9 8 8 ) , no s t u d y was f o u n d i n w h i c h  empathy  \u000C141 t r a i n i n g s p e c i f i c a l l y was o f f e r e d t o second y e a r s t u d e n t s .  It  may be important f o r medical students t o r e c e i v e empathy training i n addition to a basic interviewing s k i l l s  course.  They have i n d i c a t e d a need t o a c q u i r e s p e c i f i c s k i l l s t o use when d e a l i n g w i t h p a t i e n t s ' emotions (Batenburg 1983).  &amp; Gerritsma,  Intense emotions can be v e r y c h a l l e n g i n g and r e q u i r e  special s k i l l s .  One s u b j e c t , a f t e r a p o s t - t r a i n i n g i n t e r v i e w  i n response t o t h e q u e s t i o n \"What made t h i s  situation  demanding f o r you?\": wrote \" I t i s more d i f f i c u l t  (demanding)  to h e l p a p a t i e n t d e a l w i t h an i n t e n s e emotion than t o take a medical h i s t o r y \" . (1971).  T h i s echoes t h e o f t e n quoted words o f Kafka  \"To w r i t e p r e s c r i p t i o n s i s easy, but t o come t o an  understanding w i t h people i s hard\"  (p. 223).  The second year o f medical t r a i n i n g may be an a p p r o p r i a t e time t o i n t r o d u c e a s h o r t course i n empathy s k i l l s i n t o t h e medical s c h o o l c u r r i c u l u m .  training  Medical students could  then b e g i n e a r l y i n t h e i r t r a i n i n g , when they f i r s t b e g i n t o see p a t i e n t s , t o i d e n t i f y s i t u a t i o n s i n which responding may be a p p r o p r i a t e .  empathic  For i n s t a n c e , d u r i n g t h i s  t r a i n i n g , one s u b j e c t s a i d she n o t i c e d t h a t when one h o s p i t a l p a t i e n t ' s emotional i s s u e was not acknowledged by h e r p h y s i c i a n , t h e p a t i e n t kept b r i n g i n g up t h e i s s u e . By a c q u i r i n g empathy s k i l l s e a r l y i n t h e i r  training,  medical students c o u l d p r a c t i c e and g a i n more e x p e r i e n c e i n managing e m o t i o n a l l y i n t e n s e encounters. to  When s t u d e n t s begin  i n t e r v i e w p a t i e n t s , they may have a n x i e t i e s about  their  communication s k i l l s , t h e i r medical knowledge, and t h e i r  role  \u000C142 as p h y s i c i a n s .  In s i t u a t i o n s i n which t h e r e a r e no easy  medical s o l u t i o n s o r when p a t i e n t s somatize d i s t r e s s , s t u d e n t s may f i n d empathic of  medical  responding t o be u s e f u l as a method  d e a l i n g w i t h p a t i e n t s ' emotional i s s u e s .  During t h e  t r a i n i n g one s u b j e c t r e p o r t e d an experience i n which she found empathic  responding t o be e f f e c t i v e .  She was t a l k i n g t o some  members o f a f a m i l y who expressed a l o t o f t h e i r  frustrations  a s s o c i a t e d w i t h p l a c i n g an aging parent i n t o a n u r s i n g home. While she r e c o g n i z e d t h a t t h e r e was n o t h i n g medical which c o u l d be done, she r e p o r t e d t h a t by l i s t e n i n g and empathizing and a l l o w i n g t h e people t o express t h e i r f e e l i n g s , she f e l t she was a b l e t o do something members a t t h e time.  which was h e l p f u l t o t h e f a m i l y  As a r e s u l t o f empathy t r a i n i n g , t h e  high s t r e s s l e v e l s associated with emotionally intense i n t e r a c t i o n s may be reduced because medical s t u d e n t s have e f f e c t i v e coping s k i l l s .  Students need more than t o mean  w e l l ; they want t o do something. s u b j e c t s appeared  Before t h e t r a i n i n g , t h e  eager t o h e l p t h e s i m u l a t e d p a t i e n t s ;  however many f e l t d i s t r e s s e d i n not knowing t h e b e s t way t o proceed.  Although empathic  responding may not seem as  c o n c r e t e as a medical procedure, through r o l e p l a y i n g students r e a l i z e t h a t i t i s an a d d i t i o n a l s k i l l which i s t h e r a p e u t i c for  patients.  Researchers have concluded t h a t w h i l e p a t i e n t s  do not expect p h y s i c i a n s t o s o l v e a l l o f t h e i r problems,  they  do expect t h e i r d o c t o r s t o l i s t e n t o them (Putnam e t a l . , 1988).  E i s e n b e r g (1988) a l s o  noted:  \u000C143 Doctors are t r a i n e d t o 'do something'. They b e l i e v e t h a t p a t i e n t s expect a c o n s u l t a t i o n t o have a t a n g i b l e outcome: a p i l l or a shot. I t r e q u i r e s the d i s r u p t i o n of o v e r l e a r n e d h a b i t s t o change from doing t o l i s t e n i n g (and t o come t o r e c o g n i z e t h a t l i s t e n i n g i s an important way of d o i n g ) . I t demands a s h i f t i n paradigms from d i s e a s e t o i l l n e s s i n o r d e r t o change from p r e s c r i b i n g t o a t t e n d i n g t o meanings and t o h e l p i n g p a t i e n t s t o examine o p t i o n s , (p. 208)  Through p r a c t i c e and r e i n f o r c e m e n t i n a course e a r l y i n medical t r a i n i n g , students can i n c o r p o r a t e empathic i n t o t h e i r n a t u r a l communication s t y l e .  responding  However, i t i s  necessary a l s o t o review empathy s k i l l s i n subsequent  years,  g i v e n E n g l e r e t a l . ' s (1981) r e s u l t s t h a t w h i l e medical technical s k i l l  i n c r e a s e s w i t h medical t r a i n i n g , the  and  ability  t o communicate w e l l w i t h p a t i e n t s i s not maintained i f the s t u d e n t s do not r e c e i v e a p p r o p r i a t e s k i l l t r a i n i n g .  Wolraich  e t a l . (1981) a l s o found t h a t w h i l e f i r s t year medical s t u d e n t s d i d i n q u i r e about p a t i e n t s ' p s y c h o s o c i a l concerns, s e n i o r s t u d e n t s n e g l e c t e d t o gather p s y c h o s o c i a l data w h i l e b e i n g e f f i c i e n t i n h i s t o r y t a k i n g around p h y s i c a l Having more medical knowledge appeared  concerns.  to i n t e r f e r e with  communication i n the p h y s i c i a n - p a t i e n t r e l a t i o n s h i p .  Putnam  e t a l . (1988) r e p o r t e d a study i n which medical r e s i d e n t s f e l t inadequate as c o u n s e l l o r s , but, because they wanted t o something\",  they searched even harder f o r b i o l o g i c a l  f o r p a t i e n t s * p s y c h o s o c i a l problems, t h i s was  quite f u t i l e .  \"do  causes  even though they knew  Thus empathy s k i l l s should be  c o n t i n u a l l y r e i n f o r c e d w i t h t r a i n i n g so they are not f o r g o t t e n w i t h medical and t e c h n i c a l knowledge.  In a d d i t i o n , i n o r d e r  \u000C144 to  r e i n f o r c e s t u d e n t s ' l e a r n i n g i t would be most h e l p f u l t o  have i n s t r u c t o r s and peers use empathy s k i l l s . As a r e s u l t of empathy t r a i n i n g , medical students have an o p p o r t u n i t y t o b u i l d t h e i r c o n f i d e n c e about managing e m o t i o n a l l y i n t e n s e s i t u a t i o n s , so t h a t when they w i t h \" r e a l \" p a t i e n t s , i t i s not a completely e x p e r i e n c e f o r them.  interact  foreign  A number of s u b j e c t s remarked, a f t e r  demanding i n t e r v i e w s w i t h s i m u l a t e d p a t i e n t s , t h a t they were c e r t a i n they would encounter s i m i l a r e m o t i o n a l l y i n t e n s e situations in their practice.  Logan (1987) suggested  communication s k i l l s w i l l remain r e l e v a n t throughout medical c a r e e r s , w h i l e medical knowledge may  not.  that students'  And Numann  (1988) concluded t h a t i f medical students do not r e c e i v e courses d u r i n g t h e i r medical t r a i n i n g , then t h e r e i s no assurance t h a t students w i l l be a b l e t o communicate e f f e c t i v e l y with patients. Another advantage of i n t r o d u c i n g empathy s k i l l s e a r l y i n medical t r a i n i n g i s t h a t students who medicine may  tendency,  into  and may  r e q u i r e more  s k i l l t r a i n i n g t o enhance t h i s d e s i r a b l e q u a l i t y .  D i s e k e r and  Michielutte  be low i n empathic  are admitted  (1981) measured empathy i n a c l a s s o f medical  students i n 1979  u s i n g Hogan's empathy s c a l e , and they  t h a t the s c o r e s were u n r e l a t e d e i t h e r t o academic or t o performance  found  performance  on P a r t s I or I I of the exams of the  N a t i o n a l Board of M e d i c a l Examiners.  Empathy s c o r e s a l s o  c o r r e l a t e d n e g a t i v e l y w i t h M e d i c a l C o l l e g e Admission  Test  Scores, and these authors concluded t h a t \" i t i s p o s s i b l e t h a t  \u000C145 the medical  student  s e l e c t i o n process  nonempathic s t u d e n t s \"  i s b i a s e d i n f a v o r of  (p. 1009).  Other measures have been used t o assess q u a l i t i e s of a p p l i c a n t s t o medical  schools.  empathic For  instance,  s c h o l a r s a t Michigan S t a t e U n i v e r s i t y , a f t e r f i n d i n g e x i s t i n g empathy t e s t nor i n t e r v i e w s t o be d e v i s e d a new empathy.  no  satisfactory,  measure t o assess a v a r i e t y of s k i l l s r e l a t e d t o  T h i s t e s t , which takes one hour t o complete,  c o n s i s t s of t h r e e w r i t t e n s u b t e s t s and two v i s u a l  subtests  (Krupka, E p s t e i n , M o l i d o r ,  King, Parsons &amp; Son,  1977  cited in  R e z l e r &amp; F l a h e r t y , 1985).  E n t r y s c o r e s on the Empathy S k i l l s  R a t i n g S c a l e were r e l a t e d t o f a c u l t y r a t i n g s of empathy but were u n r e l a t e d t o s c o r e s on t e s t s measuring knowledge (Rezler &amp; F l a h e r t y , 1985). DiMatteo to  e t a l . (1986) p o i n t e d out t h a t two  i n c r e a s e humanism i n medical  training.  practitioners:  However, these s c h o l a r s concluded  routes  exist  s e l e c t i o n and  t h a t t o date no  a c c e p t a b l e measures of i n t e r p e r s o n a l s k i l l s are a v a i l a b l e t o s c r e e n a p p l i c a n t s f o r medical T r a i n i n g , they suggested may  s c h o o l or r e s i d e n c y programs. be a much b e t t e r approach t o  enhance the l e v e l of humanism i n medical One study  practitioners.  o f the reasons t h a t the t r a i n i n g g i v e n i n the c u r r e n t  i n c r e a s e d l e v e l s of empathy may  e x p e r i e n t i a l nature  of the e x e r c i s e s .  have been due Role-playing  the s u b j e c t s the o p p o r t u n i t y t o imagine and feelings.  t o the allowed  identify patients'  They were a l s o encouraged t o be aware of what they  \u000C146 themselves were e x p e r i e n c i n g . empathy t r a i n i n g , they may e i t h e r i n themselves  I f medical students r e c e i v e  not a v o i d o r deny i n t e n s e emotions  or t h e i r p a t i e n t s .  Through d e b r i e f i n g  t h e i r p r a c t i s e e x e r c i s e s , students have an o p p o r t u n i t y t o express and d i s c u s s t h e i r f e e l i n g s , e s p e c i a l l y t h e i r about  i n t e r a c t i n g w i t h emotional p a t i e n t s .  t h e i r own  emotions,  students may  work g i v e n t h a t l e s s energy emotions dampened down.  s t a t e d by C r a i g  By b e i n g aware of  have more energy  for their  i s r e q u i r e d t o keep t h e i r  Awareness of t h e i r own  necessary a l s o f o r empathic  fears,  own  emotions i s  responding t o p a t i e n t s .  As  (1987), \"Our c a p a c i t y t o empathize and  o t h e r s ' e x p e r i e n c e of d i s t r e s s  was share  . . . provides a basis f o r  caring f o r others i n physical d i s t r e s s  (p. 311).  And  Elizur  and Rosenheim (1982) noted t h a t an understanding of one's  own  emotions a l l o w s one t o i d e n t i f y o t h e r ' s f e e l i n g s .  Rogers  s t r e s s e d the importance  stance i n  of m a i n t a i n i n g the \"as i f \"  order t o remain o b j e c t i v e , because empathy i s f e e l i n g w i t h o t h e r s and not f e e l i n g as do o t h e r s . remain  i n touch w i t h h i s or her own  Yet the c l i n i c i a n must f e e l i n g s as a f o u n d a t i o n  on which t o r e l a t e e m o t i o n a l l y t o a p a t i e n t 1981).  During the empathic  (Meador &amp; Rogers,  process Rogers b e l i e v e d t h a t :  The t h e r a p i s t . . . t r i e s t o immerse h i m s e l f i n the f e e l i n g world of h i s c l i e n t and t o e x p e r i e n c e t h a t world w i t h i n h i m s e l f . H i s understanding comes out of h i s own i n n e r e x p e r i e n c i n g of h i s c l i e n t s ' f e e l i n g s , u s i n g h i s own i n n e r p r o c e s s e s of awareness f o r a r e f e r e n t . He a c t i v e l y e x p e r i e n c e s not o n l y h i s c l i e n t ' s f e e l i n g s , but a l s o h i s own i n n e r responses t o those f e e l i n g s . (p. 132)  \u000C147 A f u r t h e r advantage of b e i n g s e l f - a w a r e , i s t h a t medical students may patients.  not p r o j e c t t h e i r own  emotions onto  their  T h i s i s important i n l i g h t of the r e s u l t s r e p o r t e d  by Hornblow e t a l . (1988) which showed t h a t f o u r t h y e a r medical s t u d e n t s who  were themselves more anxious o r depressed  c o n s i s t e n t l y o v e r r a t e d a n x i e t y and d e p r e s s i o n i n p a t i e n t s . Hornblow e t a l . concluded:  These data suggest a need i n medical e d u c a t i o n f o r s y s t e m a t i c t e a c h i n g of empathic s k i l l s and f o r r e c o g n i t i o n of p o t e n t i a l b i a s i n c l i n i c a l d e c i s i o n making a r i s i n g from the c l i n i c i a n ' s own emotional s t a t e , (p. 16) In  the p r e s e n t study, a f t e r the t r a i n i n g , s u b j e c t s  r e p o r t e d e x p e r i e n c i n g much l e s s d i s t r e s s when they engaged i n emotionally intense s i t u a t i o n s .  Empathy t r a i n i n g  p o t e n t i a l l y h e l p t o combat d e p r e s s i o n , f a t i g u e ,  may  and  d i s s a t i s f a c t i o n which s c h o l a r s (e.g. G i r a r d e t a l . , Smith e t a l . , education. to  1986)  1986;  have found i n c r e a s e s d u r i n g medical  In a d d i t i o n , medical students may  cope w i t h o t h e r p a t i e n t s and may  have more energy  not c a r r y t h e i r  d i s t r e s s and f r u s t r a t i o n s i n t o t h e i r next medical U l t i m a t e l y empathy t r a i n i n g may  own  encounter.  be a f a c t o r i n h e l p i n g t o  decrease s t r e s s - r e l a t e d c o n d i t i o n s such as n e g a t i v e a t t i t u d e s towards p a t i e n t s , emotional burnout,  and substance  abuse.  F u r t h e r s t u d i e s are needed t o i n v e s t i g a t e whether r e s u l t s  from  the p r e s e n t study g e n e r a l i z e t o students i n o t h e r medical c l a s s y e a r s as w e l l as t o p r a c t i c i s i n g p h y s i c i a n s and  actual  \u000C148 patients.  A l s o , a long term f o l l o w up may  prove e f f e c t i v e i n  determining the l a s t i n g b e n e f i t s of empathy t r a i n i n g . R e c e n t l y , s c h o l a r s have suggested  t h a t the h i g h l e v e l s of  s t r e s s experienced by medical students may  l e a d t o the  development of n e g a t i v e coping p a t t e r n s and may  i n t e r f e r e with  the n a t u r a l development of humanistic and i n t e r p e r s o n a l s k i l l s which, i n t u r n , a d v e r s e l y a f f e c t s the p h y s i c i a n - p a t i e n t relationship McCue, 1982). t r a i n i n g may  (Matthews, C l a s s e n , Willms,  &amp; Cotton,  1989;  I t i s my hope t h a t the advantages o f empathy fulfill,  i n p a r t , a need expressed by a Harvard  medical student when d i s c u s s i n g h i s t r a i n i n g : There i s no time t o express our f e e l i n g s of sadness f o r the p a t i e n t , t o a r t i c u l a t e our f e a r t h a t he o r she or our r e l a t i v e s or o u r s e l v e s w i l l d i e , t o d i s c u s s the impact of our d e c i s i o n t o e n t e r a p r o f e s s i o n where s u f f e r i n g i s a c o n s t a n t companion. Instead, we f l o u n d e r , s t r i v i n g t o ask i n s i g h t f u l q u e s t i o n s both t o impress our i n s t r u c t o r s and t o combat our sense of sadness and inadequacy. We are taught from the b e g i n n i n g not t o express our emotions, as i f they might i n some way i n t e r f e r e w i t h our a b i l i t y t o be competent d o c t o r s . . . I o f t e n q u e s t i o n . . . whether I w i l l be a b l e t o keep up w i t h r e c e n t advances, . . . or t o understand and empathize w i t h my p a t i e n t s . . . . My medical t r a i n i n g , by i g n o r i n g these q u e s t i o n s , i s not making me more c o n f i d e n t about these i s s u e s , r a t h e r i t i s t e a c h i n g me not t o c o n s i d e r them, denying me the chance t o r e c o g n i z e my f e a r s . ( H i l f i k e r , 1985, p. 205) /  \u000C149 I m p l i c a t i o n s f o r Communication i n  the  Physician-Patient Relationship The  purpose  of t h i s section i s to present  i m p l i c a t i o n s and t o s u g g e s t how  the r e s u l t s of the  s t u d y s u p p o r t t h e a d o p t i o n o f t h e more  how  e m p a t h y may  h e l p a c h i e v e two p u r p o s e s  interview i s presented.  The  first  present  inclusive  b i o p s y c h o s o c i a l model o f m e d i c a l i n t e r v i e w i n g . of  clinical  A  discussion  of the medical  o f t h e s e g o a l s as  outlined  by E n g l e r e t a l . (1981) i s t o g a t h e r i n f o r m a t i o n c o n c e r n i n g the nature of patients', i l l n e s s e s i n order to i d e n t i f y diagnoses  and t r e a t m e n t p l a n s .  A second  goal of the  correct  medical  interview i s to establish interpersonal relationships  between  p h y s i c i a n s and p a t i e n t s s o t h a t e f f e c t i v e c o m m u n i c a t i o n  can  occur. A c e n t r a l theme o f t h e b i o p s y c h o s o c i a l m o d e l o f  medicine  i s t h a t p h y s i c i a n s must g a t h e r i n f o r m a t i o n c o n c e r n i n g patients' understand  \"lifeworlds.\" the cause  e x p e r i e n c e s o f them. to  These f a c t o r s w i l l  help physicians  o f t h e i l l n e s s e s and p a t i e n t s ' Such i n f o r m a t i o n w i l l  their  subjective  enable p h y s i c i a n s  make more a c c u r a t e d i a g n o s e s and e f f e c t i v e t r e a t m e n t p l a n s .  Empathy c o u l d be a v a l u a b l e s k i l l p a t i e n t s ' p e r s p e c t i v e s because, ability  t o understand  t o use  i n understanding  by d e f i n i t i o n ,  other persons'  i t i s the  f e e l i n g s and m e a n i n g s o f  t h e i r experiences. Engel  ( 1 9 8 8 ) , t h e p h y s i c i a n who  b i o p s y c h o s o c i a l model, suggested to  be t r u l y s c i e n t i f i c ,  f i r s t described the  that i n order f o r physicians  t h e y must t a k e i n t o a c c o u n t  patients'  \u000C150 \"inner experiences\"  (p. 121), because such i n f o r m a t i o n  p h y s i c i a n s t o gather complete and a c c u r a t e  data.  allows  He supported  the use o f empathy i n t h i s p r o c e s s as i n d i c a t e d i n h i s writing: The p h y s i c i a n has no a l t e r n a t i v e but t o behave i n a humane and empathic manner, t h a t i s , t o understand and be understanding, i f t h e p a t i e n t i s t o be enabled t o r e p o r t c l e a r l y and f u l l y . Only then can the p h y s i c i a n proceed s c i e n t i f i c a l l y ; t o be humane and empathic i s not merely a p r e s c r i p t i o n f o r compassion . . . i t i s a requirement f o r s c i e n t i f i c work i n t h e c l i n i c a l realm. (p. 122) P h y s i c i a n s must have s k i l l s t o e l i c i t information due  from p a t i e n t s - which may be a c h a l l e n g i n g  t o t h e complexity o f human b e i n g s .  pointed  out, p a t i e n t s present  wholeness.\"  relevant task  As Stephens (1988)  themselves i n \" e x a s p e r a t i n g  In s i t u a t i o n s i n which a problem i s h i g h l y  a f f e c t i v e l y charged o r has p s y c h o s o c i a l  r o o t s , p a t i e n t s may be  emotional and may not be aware o f what i n f o r m a t i o n  i s relevant  or what i s i r r e l e v a n t .  physicians  I t i s thus imperative  have s k i l l s t o i d e n t i f y and a t t e n d t o r e l e v a n t  that  information  (Schwartz &amp; Wiggins, 1988). Empathy can be e f f e c t i v e i n e l i c i t i n g regarding  p a t i e n t s ' emotional concerns.  information  I f patients  feel  understood by p h y s i c i a n s who demonstrate empathic understanding, they may c o n t i n u e t o v o l u n t e e r information  - i n f o r m a t i o n which can c l a r i f y t h e source and  cause o f f a c t o r s r e l a t e d t o i l l n e s s . by being  useful  In a d d i t i o n ,  l e s s s t r e s s e d , may a l s o be l e s s d e f e n s i v e  d e a l i n g w i t h p a t i e n t s ' emotions such as anger.  physicians, when  Research  \u000C151 conducted by Gibb  (1961) r e v e a l e d t h a t d e c r e a s e d  l e a d s t o more e f f i c i e n t c o m m u n i c a t i o n . defensive, medical the  for  By b e i n g  less  p r a c t i t i o n e r s may b e a b l e t o b e t t e r  information they gather The  defensiveness  process  from p a t i e n t s .  c o m m u n i c a t i o n o f empathy may b e p a r t i c u l a r l y h e l p f u l  p h y s i c i a n s t o u s e when t h e f e e l i n g s t a t e i s t h e p r i m a r y  problem o r , i n t h e term o f Eisenberg \"somatize d i s t r e s s \"  (1988) , when p a t i e n t s  (p. 2 0 5 ) . I f p h y s i c i a n s  acknowledge  emotions d i r e c t l y , p a t i e n t s t h e n have an o p p o r t u n i t y t o express  t h e i r emotions and, through t h i s v e n t i l a t i o n , t h e  emotional  i n t e n s i t y may b e d i f f u s e d .  P h y s i c i a n s may t h e n b e  a b l e t o a s s e s s what p a r t emotions have i n t h e p r e s e n t i n g problems.  The d i a g n o s i s may b e \"no f o r m a l d i s e a s e  t h a t i s , t h e f e e l i n g s t a t e may b e t h e p r o b l e m . be has  able t o better recognize,  P h y s i c i a n s may  f o r e x a m p l e , t h a t a p a t i e n t who  s u f f e r e d a r e c e n t l o s s a n d i s c r y i n g , may b e  i n t e n s e sadness and n o t n e c e s s a r i l y c l i n i c a l may n o t r e q u i r e m e d i c a t i o n .  The t r e a t m e n t  experiencing  d e p r e s s i o n and  p l a n may  a n o t h e r v i s i t w i t h t h e p h y s i c i a n o r an a p p r o p r i a t e I n some c i r c u m s t a n c e s  present\";  t h e emotional  include referral.  r e l e a s e a f f o r d e d by  e m p a t h i c c o m m u n i c a t i o n may i n i t s e l f b e s u f f i c i e n t treatment  f o r t h e p a t i e n t (C.P. H e r b e r t ,  communication,  personal  1989).  Empathy may b e a v a l u a b l e s k i l l  f o r p h y s i c i a n s t o use i n  other s i t u a t i o n s i n which a h i g h l y charged emotional or psychosocial was d i s c u s s e d  component  f a c t o r accompanies a p h y s i c a l complaint.  i n t h e l i t e r a t u r e review,  psychosocial  As  factors  \u000C152 are  a p a r t of p a t i e n t s  1  concerns i n a majority  the primary care p h y s i c i a n .  I f the emotion i s  a c k n o w l e d g e d , t h e p a t i e n t may the p h y s i c i a n cannot obtain p h y s i c a l c o m p l a i n t and  be  further information  t h i s may  r e s u l t i n the  the  (Korsch  regarding  data c o l l e c t i o n regarding easier task  be  and  t o examine the u s e f u l n e s s  further be  an  Empathy i s , p e r h a p s , deal with the  component o f p a t i e n t s ' c o m p l a i n t s .  Further  in  emotion,  t h e p h y s i c a l c o m p l a i n t may  means t o a c k n o w l e d g e , e x p l o r e ,  the  &amp; Negrete,  r e d u c e d so t h a t  (Engler e t a l . , 1981).  the  result also  I f , however, the p h y s i c i a n acknowledges t h e  i n t e n s i t y o f t h e a f f e c t may  i t that  i n a b i l i t y of  o f f e r e d and  b o t h persons becoming h i g h l y s t r e s s e d  with  not  so p r e o c c u p i e d w i t h  p a t i e n t t o f o c u s on m e d i c a l a d v i c e  1972).  of v i s i t s  emotional  s t u d i e s are  o f empathy i n a c t u a l  a  needed  medical  interviews. In the terminology (Levenstein and  of the p a t i e n t - c e n t r e d  e t a l . , 1 9 8 6 ) , by  model  acknowledging emotions  directly  t h e r e b y c o n s i d e r i n g p a t i e n t s ' agendas, p h y s i c i a n s  that i t f a c i l i t a t e s includes gathering  attending  t o t h e i r own  information,  g i v i n g useful medical advice. 'lifeworlds'  exploring  i n addition to attending  aspects of the  complaint,  physicians  find  agendas which  making accurate By  may  to the  diagnoses,  and  patients biomedical  make p o s s i b l e  an  i n t e g r a t i o n of b o t h agendas. Empathy i s an e f f e c t i v e s k i l l counsellors  for both physicians  e v e n t h o u g h t h e p r o c e s s and  o f h e l p i n g p r o f e s s i o n a l s may  be  a i m s o f t h e two  different.  The  focus of  and types the  \u000C153 medical  i n t e r v i e w i s on d i a g n o s i s and treatment i n the  of g e n e r a l l y b r i e f and  context  i n f r e q u e n t c o n t a c t , whereas, the  focus  of c o u n s e l l i n g i n t e r v i e w s i s on promoting d e s i r e d changes i n i n d i v i d u a l s which occur as a r e s u l t of a s e r i e s of visits.  longer  However, both d i s c i p l i n e s r e q u i r e s k i l l s t o e s t a b l i s h  r a p p o r t and t h e r a p e u t i c r e l a t i o n s h i p s w i t h c l i e n t s , and  both  r e q u i r e s k i l l s t o s u c c e s s f u l l y i d e n t i f y and e x p l o r e the  nature  of complaints.  Empathy i s a common s k i l l which can  both types o f p r o f e s s i o n a l s i n the h e l p i n g  assist  process.  A popular b e l i e f i s t h a t demonstrating empathy takes much time - time which busy p h y s i c i a n s do not have et  a l . , 1983).  it  i s p o s s i b l e both f o r medical  (Dickinson  However, as the r e s u l t s from t h i s study show, p r a c t i t i o n e r s to  explore  s i m u l a t e d p a t i e n t s ' f e e l i n g s and t o respond e m p a t h i c a l l y , for  too  and  s i m u l a t e d p a t i e n t s t o f e e l understood, i n the time frame  of the s h o r t o f f i c e i n t e r v i e w . view, empathic responding  From p h y s i c i a n s ' p o i n t s of  and a t t e n d i n g t o p a t i e n t s ' cues  a s s i s t them i n g a i n i n g an a c c u r a t e understanding experience  of t h e i r i l l n e s s - an understanding  u l t i m a t e l y save time and h e a l t h c o s t s .  may  of p a t i e n t s '  which  may  As a r e s u l t of e a r l y  r e c o g n i t i o n of a a p s y c h o s o c i a l f a c t o r , a more a c c u r a t e d i a g n o s i s may visits,  repeated  c o s t l y and perhaps r i s k y d i a g n o s t i c t e s t s and  procedures, (Branch,  be r e v e a l e d a v o i d i n g the need f o r  and use of unnecessary drugs and  1987;  Eisenberg,  communication, 1989).  1988;  C.P.  Herbert,  E m p i r i c a l evidence  referrals personal  i s needed t o examine  \u000C154 whether i n f o r m a t i o n  gained from a c t u a l p a t i e n t s as a r e s u l t o f  e m p a t h i c r e s p o n d i n g l e a d s t o a more a c c u r a t e Empathy may h e l p  diagnosis.  t o achieve a second goal  of the medical  interview which i s t o e s t a b l i s h a t r u s t i n g i n t e r p e r s o n a l r e l a t i o n s h i p so t h a t good c o m m u n i c a t i o n c a n o c c u r .  Improving  empathy s k i l l s  their  o f m e d i c a l p r a c t i t i o n e r s may i m p r o v e  relationships with patients, particularly intense  interactions.  i n emotionally  P a t i e n t s , by h a v i n g t h e i r  emotions  acknowledged and l e g i t i m i z e d , might f i n d t h a t t h e i r p o t e n t i a l t o manage t h e i r own i s s u e s  i s released.  Improving  r e l a t i o n s h i p s w i t h p a t i e n t s i s important because, as s t a t e d i n e a r l i e r chapters,  m i s c o m m u n i c a t i o n c a n be a m a j o r f a c t o r i n  p a t i e n t d i s s a t i s f a c t i o n , non-compliance, poor h e a l i n g , rapport,  malpractice  litigation,  errors i n diagnosis,  poor and can  r e s u l t a l s o i n a s t r e s s f u l r e l a t i o n s h i p f o r b o t h p h y s i c i a n and patient.  Providing  i n t e r v i e w i n g and communication  courses t o physicians  was i d e n t i f i e d a s a means t o  t h e s e problems as n o t e d by White  skills ameliorate  (1988):  Of a l l t h e e f f o r t s t h e m e d i c a l e s t a b l i s h m e n t m i g h t make, t h i s one i s t h e m o s t l i k e l y t o r e d u c e m a l p r a c t i c e l i t i g a t i o n , improve p a t i e n t compliance, s a v e money a n d e n h a n c e t h e m e d i c a l p r o f e s s i o n ' s p u b l i c image. ( p . 71) A s p e c t s o f t h e i n t e r a c t i o n between p h y s i c i a n s and p a t i e n t s h a v e b e e n shown t o b e i m p o r t a n t f a c t o r s i n v o l v e d i n p a t i e n t s a t i s f a c t i o n and c o m p l i a n c e  (Ben-Sira,  1980; D i M a t t e o ,  T a r a n t a , Friedman, &amp; P r i n c e , 1980; K o r s h &amp; N e g r e t e , P h y s i c i a n s ' b e h a v i o r w h i c h was more p a t i e n t - c e n t e r e d  1972). has been  \u000C155 a s s o c i a t e d w i t h b e t t e r outcome. (1986) found t h a t p a t i e n t s who  The  Headache Study Group  perceived  that t h e i r  physicians  engaged i n a thorough d i s c u s s i o n about t h e i r headaches an i n i t i a l one  i n t e r v i e w r e p o r t e d b e t t e r recovery  year l a t e r .  Stewart  physicians'  from headaches  (1984) found t h a t p a t i e n t s  expressed t h e i r f e e l i n g s (e.g., t e n s i o n s )  during  who  as a r e s u l t of  f a c i l i t a t i n g behaviours tended t o be more  s a t i s f i e d and  r e p o r t e d g r e a t e r compliance.  r e l e v a n t outcome r e s e a r c h  After  reviewing  Stewart, Brown, and Weston (1989)  concluded, \" t h a t important p a t i e n t outcomes are improved communication between d o c t o r s  and p a t i e n t s t h a t i s  c h a r a c t e r i z e d by f u l l e x p r e s s i o n  of the p a t i e n t s ' problems,  l e a d i n g t o a mutual understanding\"  (p.  160).  E f f e c t i v e r e l a t i o n s h i p s between p h y s i c i a n s p a t i e n t s i s not a new Balint  and  their  area of a t t e n t i o n or i n v e s t i g a t i o n .  (1957) maintained t h a t a t r u s t i n g r e l a t i o n s h i p between  a p h y s i c i a n and p a t i e n t can be h e a l i n g i n i t s e l f . have always a p p r e c i a t e d  p h y s i c i a n s who  Patients  were s e n s i t i v e t o  emotional needs (DiMatteo, e t a l . , 1986).  In f a c t , one  v i r t u e s of the g e n e r a l  the r i s e i n  p r a c t i t i o n e r before  t h e r a p e u t i c advances i n medical technology was i n t e r p e r s o n a l manner.  For i n s t a n c e ,  grandmother p r a i s e the d o c t o r who,  old  so s p e c i a l about him,  he was  j u s t an o r d i n a r y man,  were s u f f e r i n g . \"  Her  r e p l y t o my  of  the  my  i n r u r a l Nova S c o t i a at  10 b a b i e s .  grandmother what was  their  his caring  I o f t e n heard  farmhouse, d e l i v e r e d her  \"Oh,  by  When I asked my  91  year  she r e p l i e d ,  and he j u s t knew how  her  you  i n q u i r y about the medical  \u000C156 equipment he c a r r i e d was, babies, knew how  \"Not  t h a t ' s about a l l \" and you were s u f f e r i n g . \"  much - t o o l s f o r d e l i v e r i n g she r e i t e r a t e d t h a t \"he I was  just  impressed t h a t i t was  t h a t t h i s d o c t o r took away p a t i e n t s ' s u f f e r i n g , but t h a t understood and  acknowledged i t which made him  This physician's  fondly  been dead f o r over 25  R e a l i s t i c a l l y , however, the o l d g e n e r a l  and  the f a m i l y  i s not as l i k e l y t o know the f a m i l y network. much more p r e s s u r e  had  1988). physician  Also, there i s  on p h y s i c i a n s t o be aware of the many  advances i n medicine. yesteryear  years.  practitioner is  not a r o l e model f o r p h y s i c i a n s today (Eisenberg, S o c i e t y i s much more t r a n s i e n t now,  he  so s p e c i a l .  i n t e r p e r s o n a l c a r i n g manner was  remembered - even a f t e r he had  not  Whereas the g e n e r a l  an abundance of c a r i n g and  p r a c t i t i o n e r of compassion, and  few  e f f e c t i v e medical treatments t o o f f e r , p h y s i c i a n s today have t e c h n o l o g i c a l advantages and many impressive options.  These t e c h n o l o g i c a l developments can make medical  treatment seem v e r y p a i n and  treatment  impersonal, and  s u f f e r i n g ( C a s s e l , 1982;  p a t i e n t s may c a r i n g and  can r e s u l t i n p a t i e n t s '  Maquire, 1981).  depend even more on t h e i r p h y s i c i a n s  compassion  (Messenger, 1989).  Therefore, f o r human  I t i s important  t h e r e f o r e t o s u s t a i n a balance between n a t u r a l s c i e n c e humanism.  McWhinney (1988) s t a t e d :  P a r a d o x i c a l l y , i t i s the successes of medical technology t h a t have exposed so v i v i d l y the l i m i t a t i o n s of the t r a d i t i o n a l method. C o n c e n t r a t i o n on the t e c h n i c a l a s p e c t s o f care has d i v e r t e d us from the p a t i e n t ' s i n n e r world, an aspect of i l l n e s s the method does not r o u t i n e l y f o r c e on our a t t e n t i o n . The c o m p l e x i t i e s and  and  \u000C157 d i s c o m f o r t s of modern t h e r a p e u t i c s have made i t even more important f o r us t o understand the p a t i e n t ' s experience. (p. 221)  Research from t h i s p r e s e n t study supports the r e c e n t l i t e r a t u r e which i n d i c a t e s t h a t empathy i s an important communication s k i l l  f o r medical p r a c t i t i o n e r s .  s t r e s s r e d u c t i o n , empathy may  a l s o p r o v i d e a b a l a n c e between  o v e r i d e n t i f i c a t i o n and dehumanization responses t o p a t i e n t s .  Carek  In a d d i t i o n t o  i n regard to physicians'  (1987) suggested t h a t empathy  can b r i d g e the gap between psyche and soma, between the mindbody d u a l i s m .  In 1927  Peabody concluded t h a t \"the s e c r e t of  the c a r e of the p a t i e n t i s i n c a r i n g f o r the p a t i e n t \" (p. 882).  Buchsbaum (1986) s t a t e d t h a t \"empathy  conveys  c a r i n g , the sine qua non of the d o c t o r - p a t i e n t r e l a t i o n s h i p \" (p. 425). Carkhuff  I f empathic  communication i s , as suggested by  (1969) \"the key i n g r e d i e n t of h e l p i n g , \" then i t i s  important t h a t a l l medical p r a c t i t i o n e r s possess such an ability.  Suggestions f o r Further  Research  Suggestions f o r f u r t h e r r e s e a r c h i n c l u d e : (a)  M e d i c a l s t u d e n t - s i m u l a t e d p a t i e n t encounters c o u l d be analyzed u s i n g i n t e r a c t i o n a l a n a l y s i s such as B a l e s I n t e r a c t i o n Process A n a l y s i s  (1951) or Kagan's (1975)  I n t e r p e r s o n a l Process R e c a l l technique i n o r d e r t o begin t o generate a f u n c t i o n a l model of how may  empathic  responding  be i n c o r p o r a t e d w i t h the more medical a s p e c t s of  \u000C158 interviewing.  The model c o u l d have separate s e c t i o n s f o r  the d i f f e r e n t emotions of f e a r , anger, and g r i e f .  Also,  the tapes from t h i s study c o u l d be analyzed u s i n g the c r i t e r i a i d e n t i f i e d by the P a t i e n t - C e n t r e d Method (Stewart,  Clinical  Brown, L e v e n s t e i n , McCracken, &amp;  McWhinney, 1986) . (b)  T h i s study c o u l d be r e p l i c a t e d u s i n g p r a c t i s i n g p h y s i c i a n s as w e l l as students  i n other medical  years t o see i f the r e s u l t s would be (c)  S u b j e c t s c o u l d be followed-up maintained  (d)  class  replicated.  t o see i f the r e s u l t s  are  over a long time p e r i o d .  I t would be of i n t e r e s t t o r e p l i c a t e t h i s study  using  outcome measures from a c t u a l p a t i e n t s ; however, c o n t r o l c o n c e r n i n g the i n t e n s i t y and nature of the emotions presented would not be p o s s i b l e .  An advantage of  s t u d y i n g a c t u a l p a t i e n t s i s t h a t i t would be p o s s i b l e t o examine whether an a s s o c i a t i o n e x i s t s between empathy measures and p a t i e n t s ' h e a l t h outcome measures Empathy s c a l e of the BLRI may  The  be an a p p r o p r i a t e measure  because h i g h s c o r e s on the c l i e n t form of the BLRI have been a s s o c i a t e d with treatment (Barrett-Lennard, (e)  gains i n c o u n s e l l i n g  1962).  Future s t u d i e s u s i n g a l a r g e number of s u b j e c t s c o u l d d i v i d e s u b j e c t s i n t o high-hardy Analyses  and  low-hardy c a t e g o r i e s .  c o u l d examine whether h i g h l e v e l s of  hardiness  would be a s s o c i a t e d w i t h h i g h l e v e l s of empathy, i n order t o determine whether h a r d i n e s s i s a h e l p e r  \u000C159 characteristic.  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In M. Deutsch, &amp; H. A. H o r n s t e i n (Eds.), A p p l y i n g s o c i a l psychology: Implications f o r r e s e a r c h , p r a c t i c e , and t r a i n i n g . New York: John Wiley. Zinn, W. M. (1988). Doctors have f e e l i n g s t o o . J o u r n a l o f the American M e d i c a l A s s o c i a t i o n . 259 (22), 3296-3298.  \u000CAppendix A Perceived Stress  Questionnaire  \u000C179 Post Interview Questionnaire  (1)  How s t r e s s f u l was t h i s i n t e r a c t i o n 1 2 not a t a l l  3  f o r you?  4 somewhat  5  6  7 extremely  5  6  7 extremely  5  6  7 extremely  5  6  7 extremely  What made i t s t r e s s f u l f o r you?  (2)  How demanding was t h i s s i t u a t i o n 1 2 not a t a l l  3  f o r you?  4 somewhat  What made i t demanding f o r you?  (3)  How e m o t i o n a l l y d i s t r e s s e d 1 2 not a t a l l  3  How d i d the p a t i e n t  (4)  4 somewhat  indicate  this  How c o n f i d e n t were you i n your 1 2 not a t a l l  3  What would you have l i k e d  (5)  was the p a t i e n t ?  How h e l p f u l  distress?  responses? 4 somewhat  to have done or s a i d  d i d you f e e l when i n t e r a c t i n g  1 . 2 not a t a l l What f e e l i n g s f e e l i n g now?  .  3  4 somewhat  differently?  with this 5  d i d you have d u r i n g t h i s i n t e r v i e w ?  person? 6  7 extremely  What are you  \u000C\u2022\u20221-8.0--  Appendix B O u t l i n e o f Empathy T r a i n i n g  Sessions  \u000CO u t l i n e o f Empathy T r a i n i n g S e s s i o n s Session I Introductions Overview and o u t l i n e o f t r a i n i n g Relationship Discussion  building:  of  Identifying fears  and e x p e c t a t i o n s  simulations  Lecturette: Empathy - What i t i s - Why i t i s i m p o r t a n t i n relationships M o d e l l i n g Empathy a n d A c t i v e  physician-patient  Listening  Practice of M i c r o s k i l l s ( i n Pairs) - a t t e n d i n g ( i m p o r t a n c e o f SOLER) -active listening - p a r a p h r a s i n g c o n t e n t and f e e l i n g u s i n g leads Process of a c t i v i t y  communication  i n whole group  Closing Session II Opening Comments a n d r e a c t i o n s Empathy f o r m u l a : Guidelines Practice dyads)  re paraphrasing  \"you f e e l .  forfacilitative  . . . because.  ...\"  feedback  o f empathic responses u s i n g communication leads (  O v e r v i e w on t o p i c o f e m o t i o n o f \" f e a r \" D e m o n s t r a t i o n ( m o d e l l i n g ) o f d e m o n s t r a t i n g empathy i n situations involving fear \"Round R o b i n \" r o l e - p l a y  exercise  Empathy p r a c t i c e u s i n g \" n a t u r a l \"  communication  Videotape of practice  i n v o l v i n g emotion o f fear  interviews  leads  \u000C.182  P r o c e s s i n g o f taped i n t e r v i e w Closing Session I I I Introduction Overview o f t o p i c o f emotion of Anger Tape on Anger and d i s c u s s i o n Demonstration of u s i n g empathy i n anger s i m u l a t i o n s P r a c t i c e and videotape emotion o f anger  of p r a c t i c e i n t e r v i e w s i n v o l v i n g  P r e s e n t a t i o n and d i s c u s s i o n of the \" P a t i e n t - C e n t r e d \" Lecturette:  Non-verbal cues t o emotion  Model  (e.g., v o i c e tone)  P r a c t i c e and d i s c u s s i o n of non-verbal cues t o v a r i o u s emotions Closing S e s s i o n IV Introduction Overview of t o p i c of emotion of G r i e f Tape on G r i e f and d i s c u s s i o n Demonstration of the use of empathy i n g r i e f P r a c t i c e and videotape emotion o f g r i e f  of p r a c t i c e i n t e r v i e w s i n v o l v i n g  F u r t h e r p r a c t i c e on responding t o e m o t i o n a l l y situations Feedback on empathy program Termination  situation  e x e r c i s e and c l o s i n g  intense  \u000C183  Appendix C Case D e s c r i p t i o n s P r e s e n t e d t o t h e M e d i c a l  Students,  and T r i g g e r S e n t e n c e s Used by S i m u l a t e d  Patients  in F e a r , Anger and G r i e f T e s t i n g  Occasions  \u000C184  Case Presented to Physician-ln-Traininq  Patient i s a 30 year old male/female who has noted lumps in his/her neck.  The surgeon to whom your partner referred  him/her has recommended biopsy. he/she has cancer.  The patient thinks t h i s means  He/she i s seeing you today f o r the f i r s t  time because your partner i s away.  You have 15 minutes during which time you are to explore the nature of the problem, recognizing the l i m i t a t i o n s of your length of t r a i n i n g to date.  There i s no \"one r i g h t way.\"  Trigger Sentences f o r Simulated Patient \"I want to have the biopsy immediately\u2014I can't stand not knowing.\"  \"My mother had cancer and she died i n great pain.\"  \"What w i l l happen to my two children i f anything happens to me?\"  \"How can I possibly break t h i s news to my husband/wife?\"  \u000C-1.85  Case Presented to Physician-In Training  P a t i e n t i s a 35 year o l d t e a c h e r who enjoys s p o r t s as a hobby and who had a knee i n j u r y about 2 y e a r s ago.  She/he  c o n t i n u e s t o have knee p a i n and was sent by your p a r t n e r , her f a m i l y p h y s i c i a n , who i s away t e m p o r a r i l y , t o an o r t h o p a e d i c surgeon, Dr. S t i l l w e l l ,  whom you both c o n s u l t f r e q u e n t l y .  The  p a t i e n t a r r i v e s i n your o f f i c e , a f t e r having seen t h e specialist.  You have 15 minutes d u r i n g which time you a r e t o e x p l o r e the  nature o f the problem,  r e c o g n i z i n g t h e l i m i t a t i o n s o f your  l e n g t h o f t r a i n i n g t o date.  There i s no \"one r i g h t way.\"  Trigger Sentences for Simulated Patient  \"That s p e c i a l i s t you sent me t o , Dr. S t i l l w e l l , a l l those X-rays over a g a i n !  he took  I thought X-rays were bad f o r  you! \" \"He h a r d l y even t a l k e d t o me, j u s t j e r k e d my knee around and gave me some p i l l s !  I t o l d him what was wrong w i t h my  knee and he d i d n ' t even answer me! \"That man j u s t wants t o operate so he can make a l o t o f money!  I thought d o c t o r s were supposed t o h e l p a person.\"  \"It's  been 2 y e a r s Doctor!  I haven't been a b l e t o p l a y  s p o r t s o r keep up w i t h my f a m i l y . \"  \u000C18 6 Case Presented  to Physician-ln-Traininq  P a t i e n t i s a 35 year o l d married man/woman. comes t o you complaining  Patient  of tightness i n h i s chest,  sporadic  d i f f i c u l t y b r e a t h i n g and insomnia.  You  have 15 minutes d u r i n g which time you a r e t o e x p l o r e  the nature o f t h e problem, r e c o g n i z i n g t h e l i m i t a t i o n s l e n g t h o f t r a i n i n g t o date.  There i s no \"one r i g h t  T r i g g e r Sentences f o r Simulated  o f your  way.\"  Patient*  \"I wake up a t 4:30 A . M . and I can't  breathe.\"  \" I t ' s l i k e I'm i n a f o g . \" \"I know my husband/wife blames me.\" \"I should have watched him/her more c a r e f u l l y . \"  * I t was e x p l a i n e d t o t h e simulated p a t i e n t d u r i n g  role  t r a i n i n g t h a t t h e g r i e f r e a c t i o n was due t o t h e f a c t t h a t h i s / h e r 5 year o l d c h i l d was s t r u c k by a c a r and d i e d two months e a r l i e r .  T h i s was t o be r e v e a l e d by t h e s i m u l a t e d  patient during the interview.  "@en
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