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Original Contribution  |   September 2018
Empathy and Osteopathic Manipulative Medicine: Is It All in the Hands?
Author Notes
  • From the Departments of Clinical Integration (Dr Rizkalla) and Physiology and Osteopathic Manipulative Medicine (Dr Henderson) at the Midwestern University/Chicago College of Osteopathic Medicine (MWU/CCOM) in Downers Grove, Illinois. 
  • Financial Disclosures: None reported. 
  • Support: Funding for this study was provided by MWU/CCOM. 
  •  *Address correspondence to Kyle K. Henderson, PhD, Midwestern University Chicago College of Osteopathic Medicine, 555 31st St, Downers Grove, IL 60515-1235. Email: khende@midwestern.edu
     
Article Information
Medical Education / Neuromusculoskeletal Disorders / Professional Issues
Original Contribution   |   September 2018
Empathy and Osteopathic Manipulative Medicine: Is It All in the Hands?
The Journal of the American Osteopathic Association, September 2018, Vol. 118, 573-585. doi:10.7556/jaoa.2018.131
The Journal of the American Osteopathic Association, September 2018, Vol. 118, 573-585. doi:10.7556/jaoa.2018.131
Web of Science® Times Cited: 2
Abstract

Context: The osteopathic medical school curriculum is unique because of the inclusion of training in osteopathic manipulative medicine (OMM). Interest in and use of OMM promotes cognitive training in diagnosing conditions, emotional training in the alleviation of pain, and physical training in the application of OMM. Osteopathic manipulative medicine may mitigate a reduction in empathy levels of medical students and explain why osteopathic medical students do not follow the declining pattern of empathy previously reported in allopathic medical students.

Objective: To examine whether favorable opinions of OMM are positively correlated with overall student empathy as well as the cognitive, emotional, and behavioral subcomponents of empathy.

Methods: Institutional review board approval was obtained to measure empathy in medical students attending the Midwestern University/Chicago College of Osteopathic Medicine for this cross-sectional study. The 20-item Jefferson Scale of Empathy medical student version (JSE-S) was distributed via email to first-year students at the beginning of the 2016-2017 academic year and at the end of the academic year to all students. Items were divided into cognitive, emotional, and behavioral categories. Items related to demographics, interest and use of OMM and the osteopathic philosophy, frequency of touch, and personality were also included in the survey. Data were analyzed using SPSS software and presented as mean (SEM). Statistical significance was set at P<.05.

Results: Of the 801 students the survey was sent to at the end of the 2016-2017 academic year, 598 students completed the survey, for a response rate of 75%. When accounting for the effect of gender with a multivariate analysis of covariance, there were no differences in empathy scores across school years. When empathy scores from first- and second-year students were combined and compared with combined third- and fourth-year students’ scores to examine the difference between empathy in students during academic and clinical training, a difference in the mean (SEM) JSE-S empathy score was noted (114.6 [0.7] and 112.0 [0.7], respectively; P=.01); however, the effect size was small (partial η2=0.01). Interest in OMM and the osteopathic philosophy were significantly associated with higher empathy scores (P<.05; medium effect; partial η2=0.08).

Conclusion: Interest in and use of OMM are associated with higher empathy scores and empathy subcomponents. Training and use of OMM should be examined as a mechanism contributing to the durability of empathy in the osteopathic medical profession.

Empathy is one of the most critical virtues of medical practice. It is among the most frequently mentioned humanistic dimensions of patient care and is linked to improved patient-physician communication; symptom reporting; diagnostic accuracy; and patient compliance, satisfaction, and quality of life.1 Empathy is difficult to define because of its complex psychosocial action. Despite the conceptual ambiguity, physicians and their patients intuitively know what empathy is and can recognize its absence in the health care setting. 
For the osteopathic physician, accurately understanding the patient's perspective is the central basis for assessing his or her body, mind, and spirit. The vehicle for achieving this level of insight is empathy, which is the active attempt to enter the private, perceptual world of another person. Osteopathic philosophy focuses on patient-centered care, hands-on manual diagnosis and management, and pragmatic patient education to address personal, familial, and societal concerns.2 Therefore, the osteopathic medical profession has cultivated a culture that favors empathy, owing to the unique communication style and information flow that creates a rhythmic, mutually kinetic exchange between patient and physician.3,4 
The hierarchical approach to empathy has been championed by Mohammadreza Hojat, PhD, who fractioned empathy into the subcomponents of cognition and emotion.5 Cognitive empathy is a higher-order thought process in which understanding is attained by acquiring facts and reasoning through them. Emotional empathy, by contrast, is more primitive in nature and rooted in subcortical arousal.6 This type of empathy is spontaneous and involves the contagious experience of another person's affective state.5 Evidence in psychopathology7,8 and neurology9 suggests a dissociation between cognitive and emotional empathy, as some individuals can show impairment in one system and intact ability in the other. 
This hierarchical view provides context for further delineating new subcomponents of empathy. To empathize with something is to render it meaningful, be it the convergence of understanding (cognitive empathy) or the parallelism in feelings (emotional empathy). Once understanding is achieved, it becomes possible to outwardly communicate this understanding through behavior. We propose that behavioral empathy is a goal-oriented motivational state that encourages one to increase the welfare of others. Unlike cognition and emotion, which are self-centered, the hallmark of behavior is intentionality that is tangible, other-focused, and readily observable. In other words, behavioral empathy is the advanced product of cognitive and emotional empathy. 
Empathy in allopathic medical students appears to degrade over time, with the most significant decline occurring in the clinical years10 and a continuing decline in residency training.11,12 Whether this erosion is observed in osteopathic medical students is debated13 and increasingly difficult to ascertain, as differences in training between osteopathic and allopathic institutions are becoming diluted with the move toward a single accreditation system for graduate medical education.14,15 Despite growing similarities, some concrete and potentially protective distinctions remain between the 2 medical streams. In osteopathic medical schools, students learn and practice osteopathic manipulative medicine (OMM). Within the first month of osteopathic medical school, most students are taught how to assess somatic dysfunction. Specifically, they learn how to use their hands to identify tenderness, asymmetry, restriction, and differences in tissue texture by practicing on other students. Early “patient” contact and success in alleviating somatic dysfunction may contribute to, sustain, and reinforce empathy levels of osteopathic medical students throughout medical school. 
The Importance of Fractionating Empathy
Very little is known about the subcomponents of empathy and how their various combinations comprise the empathetic response. It seems likely that each component in the empathy network is associated with distinct functions that have relevance to medical training and clinical competence. For example, although cognition and emotion can both motivate social behavior, these constructs reflect different human qualities that affect physicians’ professional behavior differently. That is, because cognition is determined by objectivity and mindfulness, it is more likely to prompt altruistic behavior that is strategically intended to alleviate suffering, which may indicate that cognitive empathy is beneficial to patient-physician relationships and is an enabling factor to patient care.10 In contrast, emotional empathy, because of its affective valence, is more likely to induce nonstrategic egoistic behavior intended to reduce personal distress.16 Such anxiety can cloud clinical neutrality and has been associated with fatigue, exhaustion, and vicarious traumatization.17 On the other hand, behavioral empathy is related to a body of work18-20 that suggests that helping behavior is associated with health and longevity.18 For example, it buffers the effect of stressful life events19 and is associated with the neuropeptide oxytocin, which diminishes anxiety though inhibition of the hypothalamo-pituitary-adrenal axis, blood pressure, and cortisol.20 Collectively, these findings are a reminder that the term empathy refers to a complex multidomain construct that must be measured from different angles and approaches. 
This cross-sectional study was designed to measure the effect of student interest and use of OMM on their overall level of empathy and its cognitive, emotional, and behavioral subcomponents. Our central hypothesis is that the OMM curriculum in osteopathic medical schools accounts for the differences in empathy between osteopathic and allopathic medical students.21 Specifically, we hypothesized that favorable impressions of OMM would be positively correlated to student empathy. 
Methods
The Midwestern University Institutional Review Board granted approval for this cross-sectional study. An annual license to use the medical student version of the Jefferson Scale of Empathy medical student version (JSE-S) was obtained. The JSE-S is a validated, 20-item survey, copyrighted by Thomas Jefferson University, with responses measured on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree) (50% of the items reverse scored). These 20 items were divided by the investigators into cognitive (9 items), emotional (7 items), and behavioral (4 items) categories. The total potential score of the cognitive items was 9 to 63; the emotional items, 7 to 49; and the behavioral items, 4 to 28. Scores were converted to percentages of the highest total score for each range.22 An additional 40 items, created by the investigators, regarding demographics, specialty choice, interest in the value of OMM and osteopathic philosophy, frequency of touch, and personality traits (eg, medical authoritarianism, elitism, coercion, self-serving motive, egalitarianism) were included in the survey. Response options included a yes or no format for items regarding the students’ opinion of OMM and osteopathic philosophy, timeframe options (>1 time/d, 1 time/d, 4-6 times/wk, 2-3 times/wk, 1 time/wk, and <1 time/wk) to measure frequency of nonspecific or OMM-specific touch, and a 7-point Likert scale in which students ranked their level of agreement with statements regarding their personality traits from 1 (strongly disagree) to 7 (strongly agree). Items regarding the students’ opinion of OMM and osteopathic philosophy were reviewed and revised with the help of OMM faculty. Students were asked to create a unique code by entering the last letter of their middle name followed by the last letter of their last name and the last 4 digits of their phone number at the beginning of the survey. 
The survey was sent at the end of the 2015-2016 academic year, at the beginning of the 2016-2017 academic year, and at the end of the 2016-2017 academic year. At the end of the 2015-2016 academic year, the survey was distributed by class representatives via email to all Midwestern University/Chicago College of Osteopathic Medicine (MWU/CCOM) students. Students had from the end of April 2016 to mid-June 2016 to complete the survey and were sent reminders during that time. Because of the low response rate of the initial survey and lack of useable data, the investigators worked with the dean of MWU/CCOM to identify class times to give to students to complete the survey during the 2016-2017 academic year. For the 2016-2017 academic year, the survey link was sent indicating that they would be given class time to complete the survey. At the beginning of the 2016-2017 academic year, the survey link was sent to first-year students via email during orientation in August 2016 to obtain a baseline empathy score. At the end of the 2016-2017 academic year, the survey link was sent to first- through fourth-year students. First-year students were given time during the last OMM workshop before finals (April 2017), second-year students were given time after finals and before boards during clerkship orientation (May 2017), third-year students were given time during integrated clinical activities (June 2017), and fourth-year students were given time during financial service planning before graduation (April 2017). An incentive lottery program (3 t-shirts per class) was created and email reminders were sent to encourage participation for the 2016-2017 academic year. A Research Electronic Data Capture system was used to provide the online, anonymous, and secure web-based survey23 that took students approximately 10 to 15 minutes to complete. 
After each survey deployment, data were progressively extracted from the Research Electronic Data Capture system and collated using SPSS software (IBM). The data were analyzed using a multivariate analysis of covariance, with gender as a covariate, empathy score as the dependent variable, and year of medical school as the independent variable. Effect sizes (partial η2) were reported alongside significance tests to further index outcomes. All data were tabulated using SPSS software and presented as mean (SEM). Statistical significance was defined as P<.05. Because of the social and genetic influences of gender on empathy scores,24 data were separated by men and women. Two outliers were identified and removed. Empathy data were not normally distributed (Kurtosis 3.57); therefore, nonparametric tests were used. 
Results
Of the 791 first- through fourth-year students who were sent the survey at the end of the 2015-2016 academic year, 83 responses were included in the analysis. Of the 209 first-year students who were sent the survey at the beginning of the 2016-2017 academic year, 191 responses were included in the analysis. Of the 801 first- through fourth-year students who were sent the survey at the end of the 2016-2017 academic year, 598 responses were included in the analysis (Table 1). 
Table 1.
Empathy and Osteopathic Manipulative Medicine: Results on the JSE-S by Year in Osteopathic Medical School
Aug 2016 Spring 2017, by Class Spring 2017, Grouped
Characteristic OMS I OMS I OMS II OMS III OMS IV OMS I-IV OMS I-II OMS III-IV
Class Size 209 209 200 197 195 801 409 392
Male-Female Ratio 1.55 1.55 1.22 1.26 2.10 1.49 1.38 1.61
Respondents, No. (%) 191 (91) 187 (89) 139 (70) 159 (81) 113 (58) 598 (75) 326 (80) 272 (69)
 Male, No. 114 110 74 82 76 342 184 158
 Female, No. 77 77 65 77 37 256 142 114
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
JSE-S Score,b Mean (SEM) 117.9 (0.6) 114.2 (0.9) 115.1 (1.0) 112.5 (1.0) 111.2 (1.2) 113.4 (0.5) 114.6 (0.7) 112.0 (0.7)
 Male 116.4 (0.8) 111.3 (1.3) 114 (1.4) 108.9 (1.5) 109.6 (1.6) 110.0 (0.7) 112.5 (0.9) 109.3 (1.1)
 Female 120.0 (0.8) 118.2 (1.1) 116.1 (1.5) 116.4 (0.9) 114.4 (1.6) 116.6 (0.6) 117.2 (0.9) 115.8 (0.8)
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
 Subcomponent, %c
  Cognitive 76.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Emotional 85.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Behavioral 85.1 (0.7) 77.3 (1.1) 80.9 (1.1) 77.9 (1.1) 77.3 (1.3) 78.3 (0.6) 78.9 (0.8) 77.7 (0.8)

a Two surveys were sent in the 2016-2017 academic year: the first in August 2016 to first-year osteopathic medical students (OMS I) and the second in April, May, or June 2017, depending on the class, to all osteopathic medical students (OMS I-IV).

b The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140. Higher scores indicate greater empathy. Scores on the JSE-S were significantly higher among female than male participants in each class year (P<.05). No significant differences were found in JSE-S scores between classes. In the grouped classes, compared with clinical classes (OMS III-IV), academic classes (OMS I-II) had a significantly higher JSE-S score and cognitive and emotional subcomponents (P≤.02), but effect sizes were small (partial η2=0.01).

c The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

Table 1.
Empathy and Osteopathic Manipulative Medicine: Results on the JSE-S by Year in Osteopathic Medical School
Aug 2016 Spring 2017, by Class Spring 2017, Grouped
Characteristic OMS I OMS I OMS II OMS III OMS IV OMS I-IV OMS I-II OMS III-IV
Class Size 209 209 200 197 195 801 409 392
Male-Female Ratio 1.55 1.55 1.22 1.26 2.10 1.49 1.38 1.61
Respondents, No. (%) 191 (91) 187 (89) 139 (70) 159 (81) 113 (58) 598 (75) 326 (80) 272 (69)
 Male, No. 114 110 74 82 76 342 184 158
 Female, No. 77 77 65 77 37 256 142 114
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
JSE-S Score,b Mean (SEM) 117.9 (0.6) 114.2 (0.9) 115.1 (1.0) 112.5 (1.0) 111.2 (1.2) 113.4 (0.5) 114.6 (0.7) 112.0 (0.7)
 Male 116.4 (0.8) 111.3 (1.3) 114 (1.4) 108.9 (1.5) 109.6 (1.6) 110.0 (0.7) 112.5 (0.9) 109.3 (1.1)
 Female 120.0 (0.8) 118.2 (1.1) 116.1 (1.5) 116.4 (0.9) 114.4 (1.6) 116.6 (0.6) 117.2 (0.9) 115.8 (0.8)
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
 Subcomponent, %c
  Cognitive 76.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Emotional 85.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Behavioral 85.1 (0.7) 77.3 (1.1) 80.9 (1.1) 77.9 (1.1) 77.3 (1.3) 78.3 (0.6) 78.9 (0.8) 77.7 (0.8)

a Two surveys were sent in the 2016-2017 academic year: the first in August 2016 to first-year osteopathic medical students (OMS I) and the second in April, May, or June 2017, depending on the class, to all osteopathic medical students (OMS I-IV).

b The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140. Higher scores indicate greater empathy. Scores on the JSE-S were significantly higher among female than male participants in each class year (P<.05). No significant differences were found in JSE-S scores between classes. In the grouped classes, compared with clinical classes (OMS III-IV), academic classes (OMS I-II) had a significantly higher JSE-S score and cognitive and emotional subcomponents (P≤.02), but effect sizes were small (partial η2=0.01).

c The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

×
Empathy Scores, Gender, and Class Year
Jefferson Scale of Empathy medical school version scores range from a potential 20 to 140 points. Regarding the students who were surveyed and responded at the end of the 2016-2017 academic year, the mean (SEM) JSE-S empathy scores were significantly higher for women than for men (116.6 [0.6] and 111.0 [0.7], respectively; P<.001). Women's mean scores were also higher regarding all subcomponents of empathy (P<.001). When accounting for gender, no statistically significant differences in empathy scores were found between class years. To further investigate potential differences between academic and clinical training, first- and second-year student data were combined (n=326; academic training), and third- and fourth-year student data were combined (n=272; clinical training) and compared. With this grouped comparison, mean (SEM) JSE-S empathy scores were higher in students undergoing academic training than clinical training (114.6 [0.7] and 112.0 [0.7], respectively; P=.01). Although the difference was statistically significant, the effect size was small (partial η2=.01) (Table 1). 
Empathy and Specialty Choice
Clinical specialty choices of fourth-year students surveyed at the end of the 2016-2017 academic year (n=113) were divided into hands-on and hands-off occupations.21,25-27 Regardless of the categorization of emergency medicine, there were no significant differences in mean (SEM) empathy scores between hands-on and hands-off specialties (hands-on+emergency medicine vs hands-off: 110.7 [1.4] vs 112.7 [2.8]; P=.28; hands-on vs hands-off+emergency medicine: 111.3 [1.5] vs 110.1 [2.3]; P=.23). 
Experience or Interest in OMM
Regarding all students who were surveyed at the end of the 2016-2017 academic year, receiving OMT or manual therapy before medical school was associated with significantly greater behavioral empathy scores (P=.02). Students who practiced OMM on their classmates outside of the OMM workshop and reported success after treating others with OMT had higher empathy scores, including all subcomponents of empathy, than those who did not (P≤.01). Students seeking an OMM residency or program that encouraged the use of or training in OMT had higher JSE-S empathy scores (P<.01; medium effect; r2=0.05). Also, students who believed that OMM is a helpful skill to build connection and rapport with patients had higher JSE-S empathy scores (P<.01; r2=0.07). If students’ decision to attend an osteopathic medical school was influenced by the philosophy of treating the whole person or if they thought OMM was a valuable method for resolving problems other than musculoskeletal problems, their JSE-S empathy scores were significantly higher than those of their counterparts (P<.01; r2=0.05; Table 2). 
Table 2.
Comparison of Osteopathic Medical Students’ Empathy Scores by Experience and Interest in OMM
JSE-S Subcomponent, %b
Question n JSE-S Score, Mean (SEM)a Behavioral Cognitive Emotional
Do you have a DO in your family?
 Yes 57 113.3 77.6 75.2 80.9
 No 540 113.5 78.5 75.6 80.5
Do you have an MD in your family?
 Yes 224 113.0 78.8 74.9 80.1
 No 373 113.7 78.1 76.0 80.7
Were you ever treated with OMT or manual therapy before medical school?
 Yes 109 114.8 81.1c 76.1 81.5
 No 488 113.2 77.8 75.5 80.3
Did the osteopathic philosophy of treating the whole person influence your decision to attend osteopathic medical school?
 Yes 449 115.0c,d 79.1c 76.9c 82.1c,d
 No 148 108.8 76.0 71.8 75.7
Do you intend to use OMM in your future practice?
 Yes 389 115.8c,d 80.1c 77.5c 82.7c,d
 No 199 108.7 74.9 71.8 76.1
Do you practice OMM on your classmates outside of the OMM workshop?
 Yes 393 114.9c 79.4c 76.7c 81.9c
 No 204 110.7 76.4 73.5 77.8
Are you afraid to perform OMT?
 Yes 146 112.5 77.8 74.5 80.2
 No 451 113.7 78.6 76.0 80.6
Have you been successful treating others with OMT?
 Yes 486 114.4c 79.4c 76.3c 81.4c
 No 111 109.1 74.0 72.6 76.7
Do you plan on entering an OMM residency or program that encourages use/training in OMT?
 Yes 210 116.5c 81.0c 77.9c 83.4c,d
 No 387 111.8 77.0 74.4 79.0
Do you feel that OMM is a valuable method for resolving musculoskeletal problems?
 Yes 565 114.0c 78.7c 76.0c 81.1c
 No 32 104.2 72.1 68.5 71.1
Do you feel that OMM is a valuable method for resolving problems other than musculoskeletal problems?
 Yes 349 115.7c,d 79.6c 77.4c 82.8c,d
 No 248 110.3 76.6 73.1c 77.3
Do you believe that OMM is a helpful skill to build connection and rapport with patients?
 Yes 499 115.0c,d 79.5c 76.8c 82.0c,d
 No 98 105.6 72.6 69.5 73.1

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c P<.05.

d Medium effect size (r2≥0.05).

Abbreviations: OMM, osteopathic manipulative medicine; OMT, osteopathic manipulative treatment.

Table 2.
Comparison of Osteopathic Medical Students’ Empathy Scores by Experience and Interest in OMM
JSE-S Subcomponent, %b
Question n JSE-S Score, Mean (SEM)a Behavioral Cognitive Emotional
Do you have a DO in your family?
 Yes 57 113.3 77.6 75.2 80.9
 No 540 113.5 78.5 75.6 80.5
Do you have an MD in your family?
 Yes 224 113.0 78.8 74.9 80.1
 No 373 113.7 78.1 76.0 80.7
Were you ever treated with OMT or manual therapy before medical school?
 Yes 109 114.8 81.1c 76.1 81.5
 No 488 113.2 77.8 75.5 80.3
Did the osteopathic philosophy of treating the whole person influence your decision to attend osteopathic medical school?
 Yes 449 115.0c,d 79.1c 76.9c 82.1c,d
 No 148 108.8 76.0 71.8 75.7
Do you intend to use OMM in your future practice?
 Yes 389 115.8c,d 80.1c 77.5c 82.7c,d
 No 199 108.7 74.9 71.8 76.1
Do you practice OMM on your classmates outside of the OMM workshop?
 Yes 393 114.9c 79.4c 76.7c 81.9c
 No 204 110.7 76.4 73.5 77.8
Are you afraid to perform OMT?
 Yes 146 112.5 77.8 74.5 80.2
 No 451 113.7 78.6 76.0 80.6
Have you been successful treating others with OMT?
 Yes 486 114.4c 79.4c 76.3c 81.4c
 No 111 109.1 74.0 72.6 76.7
Do you plan on entering an OMM residency or program that encourages use/training in OMT?
 Yes 210 116.5c 81.0c 77.9c 83.4c,d
 No 387 111.8 77.0 74.4 79.0
Do you feel that OMM is a valuable method for resolving musculoskeletal problems?
 Yes 565 114.0c 78.7c 76.0c 81.1c
 No 32 104.2 72.1 68.5 71.1
Do you feel that OMM is a valuable method for resolving problems other than musculoskeletal problems?
 Yes 349 115.7c,d 79.6c 77.4c 82.8c,d
 No 248 110.3 76.6 73.1c 77.3
Do you believe that OMM is a helpful skill to build connection and rapport with patients?
 Yes 499 115.0c,d 79.5c 76.8c 82.0c,d
 No 98 105.6 72.6 69.5 73.1

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c P<.05.

d Medium effect size (r2≥0.05).

Abbreviations: OMM, osteopathic manipulative medicine; OMT, osteopathic manipulative treatment.

×
Frequency of Touch
To obtain appropriate sample sizes to measure the association between frequency of touch and empathy scores, data were parsed into high and low frequency ranges. The frequency of giving and receiving nonspecific touch (eg, hug, back-scratch) were associated with greater JSE-S empathy scores, as well as emotional and behavioral scores (P≤.01; Table 3). The frequency of receiving OMM was not associated with empathy scores. However, the frequency of providing OMM was associated with greater JSE-S, cognitive, emotional, and behavioral empathy scores, (P<.01, P<.01, P<.01, and P<.03, respectively). 
Table 3.
Comparison of Osteopathic Medical Students’ Empathy Scores by Frequency of Nonspecific and OMT-Specific Touch
JSE-S Subcomponent, %b
Touch n JSE-S Score,a Mean (SEM) Cognitive Emotional Behavioral
Nonspecific
 Give
  ≤3/wk 243 111.5 (0.8) 74.5 (0.8) 78.6 (0.8) 76.2 (0.9)
  ≥4/wk 351 114.7 (0.6)c 76.3 (0.6)c 81.8 (0.6)c 79.8 (0.7)c
 Receive
  ≤3/wk 248 117.7 (0.8) 74.6 (0.8) 78.6 (0.8) 76.6 (0.9)
  ≥4/wk 349 114.7 (0.6)c 76.3 (0.6)c 81.9 (0.6)c 79.7 (0.7)c
OMT
 Give
  <1/wk 308 111.9 (0.7) 74.2 (0.7) 79.2 (0.7) 77.4 (0.8)
   ≥1/wk 286 114.9 (0.7)c 76.9 (0.7)c 81.8 (0.7)c 79.4 (0.8)c
 Receive
  <1/wk 401 113.1 (0.6) 75.1 (0.6) 80.3 (0.6) 78.3 (0.7)
  ≥1/wk 197 114.0 (0.9) 76.4 (0.8) 80.8 (0.9) 78.3 (1.0)

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c Mann-Whitney tests with significant differences in empathy (P<.05) but small effect size (r2<0.01).

Abbreviation: OMT, osteopathic manipulative treatment.

Table 3.
Comparison of Osteopathic Medical Students’ Empathy Scores by Frequency of Nonspecific and OMT-Specific Touch
JSE-S Subcomponent, %b
Touch n JSE-S Score,a Mean (SEM) Cognitive Emotional Behavioral
Nonspecific
 Give
  ≤3/wk 243 111.5 (0.8) 74.5 (0.8) 78.6 (0.8) 76.2 (0.9)
  ≥4/wk 351 114.7 (0.6)c 76.3 (0.6)c 81.8 (0.6)c 79.8 (0.7)c
 Receive
  ≤3/wk 248 117.7 (0.8) 74.6 (0.8) 78.6 (0.8) 76.6 (0.9)
  ≥4/wk 349 114.7 (0.6)c 76.3 (0.6)c 81.9 (0.6)c 79.7 (0.7)c
OMT
 Give
  <1/wk 308 111.9 (0.7) 74.2 (0.7) 79.2 (0.7) 77.4 (0.8)
   ≥1/wk 286 114.9 (0.7)c 76.9 (0.7)c 81.8 (0.7)c 79.4 (0.8)c
 Receive
  <1/wk 401 113.1 (0.6) 75.1 (0.6) 80.3 (0.6) 78.3 (0.7)
  ≥1/wk 197 114.0 (0.9) 76.4 (0.8) 80.8 (0.9) 78.3 (1.0)

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c Mann-Whitney tests with significant differences in empathy (P<.05) but small effect size (r2<0.01).

Abbreviation: OMT, osteopathic manipulative treatment.

×
Student Personality Traits
Items measuring personality traits were correlated to JSE-S empathy scores and subcomponents of empathy. Egalitarianism, assessed by the level of agreement with the statement, “We should do what we can to equalize health care for different groups,” was positively correlated with JSE-S empathy scores (R=0.365; P<.001), with strong associations to cognitive empathy (R=0.348, P<.001), emotional empathy (R=0.318, P<.001), and behavioral empathy (R=0.247, P<.001). Medical authoritarianism and elitism, measured by the level of agreement with the statements, “Conscientious patients deserve better health care than those with self-inflected problems” and “Those who contribute the most to society should get better health care,” respectively, were negatively correlated to all empathy scores (P<.05). 
First-Year Students at the Beginning and End of the 2016-2017 Academic Year
One hundred eleven first-year students provided a unique identification number when surveyed at the beginning and end of the 2016-2017 academic year, allowing us to compare their responses. There was a slight reduction in mean (SEM) empathy scores in this group of students from the beginning to the end of the academic year (117.8 [0.7] and 116.1 [1.0], respectively; P=.11; r2=0.02). The reduction was due to a significant decline in mean (SEM) behavioral empathy scores from the beginning to the end of the year (P<.001; r2=0.17) in both men (85.0 [1.1] and 78.6 [1.7], respectively; P=.001; r2=0.20) and women (86.5 [1.3] and 81.9 [1.7], respectively; P=.008; r2=0.15), as well as mean (SEM) emotional empathy scores in men (P=.02; r2=0.09). However, cognitive empathy significantly increased in female students (P=.02; r2=0.11). At the end of the year, first-year students who provided unique identifiers at the beginning and end of the academic year had significantly higher mean (SEM) JSE-S empathy scores than the first-year students who did not (116.1 [1.0] and 111.3 [1.6], respectively; P=.02; r2=0.03). Mean (SEM) emotional and behavioral empathy scores were also higher in first-year students who provided identification codes than those who did not (emotional: 83.4 [0.9] and 79.2 [1.4], respectively; P=.02; r2=0.03) (behavioral: 80.0 [1.2] and 73.5 [1.8], respectively; P<.01; r2=0.05), but not mean (SEM) cognitive empathy scores (77.6 [1.0] and 74.8 [1.5], respectively; P=.14; r2=0.01). 
Survey Completion Method
When the survey was distributed at the end of the 2015-2016 academic year and students had to rely on personal time to complete it, the response rate was approximately 10% (data not shown). When class time was provided to complete the survey at the end of the 2016-2017 academic year with an incentive program, the response rate was approximately 75%. Students who had to complete the survey during their personal time had a significantly higher mean (SEM) empathy score than students who were given time in the classroom (118.0 [1.1] and 113.4 [0.5], respectively; P<.001; r2=0.02). When data were separated by gender, the ratio of male to female responses was 33:50 (0.66) for the personal time survey and 342:256 (1.34) for the class time survey. When accounting for the influence of gender, mean scores for overall, cognitive, emotional, and behavioral empathy were significantly higher in the students who completed the survey during their personal time than students who completed the survey during class time (P=.01, P=.04, P=.03, and P=.02, respectively); however, the effect size was small (partial η2<0.01). 
Discussion
Results of the current study support the hypothesis that favorable impressions of OMM are positively correlated with student empathy as well as the cognitive, emotional, and behavioral subcomponents of empathy. At baseline, the osteopathic medical students had a comparable mean empathy score (114.2) to those reported in studies that examined osteopathic (113.6)21 and allopathic (115.5)10 medical students. Our cross-sectional data support previous studies demonstrating that empathy scores have greater durability among osteopathic medical students,21,25 but they also suggest that empathy scores may attenuate during clinical training in osteopathic medical students as demonstrated with allopathic medical students.10,26,28 
Interest in and Use of OMM
When educators advocate for reform in medical training, eroding empathy levels make for a fair bargaining chip. The threat of declining empathy levels in medical students has caused the American Association of Colleges of Osteopathic Medicine to mandate that empathy be cultivated and assessed as an essential medical education outcome.29 A number of methods to foster empathy in students and residents have been proposed,30,31 all of which reflect the belief that empathy can be enhanced with the direct participation of the learner. 
As shown in the current study and others,21,25 osteopathic medical students appear to possess durable empathy throughout medical school. As an extension of this finding, we found that students who embraced the osteopathic philosophy and provided frequent OMT had higher levels of empathy than those who did not. Considering the distinct features of OMT and the osteopathic medical profession's devotion to early hands-on engagement with patients,21 it would seem reasonable to speculate that early patient interaction has an effect on the durability of empathy. To provide effective OMT, one must learn how to assess somatic dysfunction (cognition), incorporate psychosocial dimensions (emotions), and apply touch therapeutically (behavior) to relive somatic dysfunction, discomfort, and pain. Early and consistent exposure to working with patients may expedite student maturation, a conclusion supported by Handford et al,32 in which empathy proficiency is a function of clinical exposure rather than medical didactics. Furthermore, there is converging evidence that osteopathic physicians3,33 and students34 are perceived as more empathetic than their allopathic counterparts. The correlational results do not provide definitive evidence of the effectiveness of OMM training on empathy but do provide sufficient face validity to warrant further study. 
Empathy Decline: Academic vs Clinical Training
More than a decade of research on the topic of empathy in allopathic institutions indicates that empathy significantly erodes during medical school and in residency training.1,10,35,36 In light of these findings, we ran grouped comparisons designed to identify differences between empathy levels of students during academic and clinical training. Although our findings support this decline, the effect size was small (η2=0.01) compared with moderate effects reported in allopathic students.10 These data suggest that empathy may decline more aggressively in allopathic students than osteopathic students. Retrospective and larger national studies are warranted to verify these findings. 
Despite medical students’ initial enthusiasm37 and the mandate for medical curriculum to nurture human qualities, it is ironic that students graduate from medical school more cynical than when they enter. When attributing this phenomenon to a high work-load,38 massive debt-to-income ratios,39 unspoken mistreatment,40 accumulated burden of distress,41 and an overall worsening learning environment,42 it may become a matter of survival that physicians become less empathetic. This self-surviving explanation corresponds with neurophysiologic studies on physicians that demonstrate a suppression of the pain matrix43 and the mirror neuron system,44 which enables identification with others. These findings provide strong evidence that a neuronal “break switch” may prevent significant emotional arousal to protect physicians against over-identification and personal distress. Interestingly, suppression of emotional empathy may have beneficial consequences to cognitive empathy, as it frees up cognitive resources necessary for clinical problem solving.41 
A 2017 study45 measured empathy levels in allopathic medical students using the JSE-S and the Questionnaire of Cognitive and Affective Empathy (QCAE). The QCAE was introduced in 2011 with a novel battery of questions designed to measure multiple components of cognitive as well as emotional empathy. Using a linear growth model for analysis, the predicted JSE-S scores declined with medical school duration, supporting previous literature.45 However, the predicted measures for certain components of cognitive and emotional empathy in the QCAE increased during medical training. The discrepancy between JSE-S and QCAE results validates the need to assess the subcomponents of empathy, as they may allow for more subtle changes in empathy to be observed over time. The contradictory findings from the JSE-S and QCAE should be examined and vetted with additional studies. 
Neurologic Implication to Enhancing Empathy
The theoretical model presented in this study recognizes important differences in the neurologic underpinning involved in cognitive, emotional, and behavioral empathy. Because cognitive empathy recruits brain regions typically associated with executive control (eg, cingulate, prefrontal cortex46), cognition is likely to be amenable to plasticity. It follows that cognitive empathy is a function of learning and experience and can be trained through communication techniques and decision-making.47-50 In contrast, because emotional brain regions were the first to emerge during ontogeny and are primarily driven by subconscious reflexes (eg, subcortical regions), emotional empathy may represent the least malleable of all the subcomponents. Nevertheless, the cognitive and emotional components may work symbiotically to facilitate behavioral empathy. The paradox of emotional empathy is that it is not inherently negative but requires skills in emotional regulation to achieve balance between inspiring altruistic behavior and inhibiting distressful overarousal. Increasing physician empathy with deliberate, neurologically informed training may be a helpful approach to enhance the professionalism and compassion that are hallmarks of medicine. 
Limitations
This study has several limitations. Survey data are unique to MWU/CCOM and may not reflect the national study51 currently underway. Future longitudinal studies with paired analysis will provide greater statistical power and confidence in data interpretation. The categorization of the JSE-S items into subcomponents of empathy were not equally distributed and, therefore, correlations to behavioral empathy have less power. 
Future Research
Results of this study replicated a body of research that shows that women possess higher levels of empathy than men.24,52 But self-report paradigms are anomalous because responses often foster bias toward gender-role stereotypes and desirability.53 Because emotionality and sensitivity are both part of the stereotypical feminine role,54 women could be more willing than men to portray themselves as empathetic. Although researchers agree on the conceptual importance of gender,41 the method for statistically accounting for this effect is relatively absent in most research. Accordingly, covarying for gender is a desirable experimental practice to prevent potential statistical artifacts, or errors caused by the instrument of observation,45,55 especially when the ratio of men and women is disproportionate in the study population, as in the current study. 
In an ad-hoc analysis, we compared levels of empathy of students who sacrificed personal time to complete the survey (end of the 2015-2016 academic year) with those who were given class time (end of the 2016-2017 academic year). Under self-sacrificing conditions, response rates were significantly lower and scores for empathy and subcomponents were significantly higher. Therefore, future research should be cognizant to how deployment methods may influence response rates and shape the way we interpret results. 
Conclusion
Our cross-sectional data support previous studies that show that empathy does not decline across school years, but the findings bring into question whether differences are unveiled when comparing academic and clinical years. The importance of empathy in medical practice has highlighted the necessity of medical schools to create a climate conducive to fostering empathy in medical students. Therefore, recent studies have called greater attention to the implementation of curriculum changes designed to promote empathy or slow the decline of empathy among medical students. More speculative is the possibility that the relationship between empathy and OMT may influence students’ empathy level throughout their osteopathic medical training and, possibly, beyond. 
Acknowledgments
We acknowledge Karen J. Nichols, DO, and the MWU/CCOM for their support for this research project. We also acknowledge Haley Hoffman, OMS IV; Michelle Knees, OMS IV; and Robert Murphy, MS, for their expert technical assistance and Peg Lechner; Kurt P. Heinking, DO; Beth Longenecker, DO; Perry Marshall, DO; and Nathan Ernst for their assistance with in-class empathy surveys. 
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Table 1.
Empathy and Osteopathic Manipulative Medicine: Results on the JSE-S by Year in Osteopathic Medical School
Aug 2016 Spring 2017, by Class Spring 2017, Grouped
Characteristic OMS I OMS I OMS II OMS III OMS IV OMS I-IV OMS I-II OMS III-IV
Class Size 209 209 200 197 195 801 409 392
Male-Female Ratio 1.55 1.55 1.22 1.26 2.10 1.49 1.38 1.61
Respondents, No. (%) 191 (91) 187 (89) 139 (70) 159 (81) 113 (58) 598 (75) 326 (80) 272 (69)
 Male, No. 114 110 74 82 76 342 184 158
 Female, No. 77 77 65 77 37 256 142 114
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
JSE-S Score,b Mean (SEM) 117.9 (0.6) 114.2 (0.9) 115.1 (1.0) 112.5 (1.0) 111.2 (1.2) 113.4 (0.5) 114.6 (0.7) 112.0 (0.7)
 Male 116.4 (0.8) 111.3 (1.3) 114 (1.4) 108.9 (1.5) 109.6 (1.6) 110.0 (0.7) 112.5 (0.9) 109.3 (1.1)
 Female 120.0 (0.8) 118.2 (1.1) 116.1 (1.5) 116.4 (0.9) 114.4 (1.6) 116.6 (0.6) 117.2 (0.9) 115.8 (0.8)
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
 Subcomponent, %c
  Cognitive 76.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Emotional 85.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Behavioral 85.1 (0.7) 77.3 (1.1) 80.9 (1.1) 77.9 (1.1) 77.3 (1.3) 78.3 (0.6) 78.9 (0.8) 77.7 (0.8)

a Two surveys were sent in the 2016-2017 academic year: the first in August 2016 to first-year osteopathic medical students (OMS I) and the second in April, May, or June 2017, depending on the class, to all osteopathic medical students (OMS I-IV).

b The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140. Higher scores indicate greater empathy. Scores on the JSE-S were significantly higher among female than male participants in each class year (P<.05). No significant differences were found in JSE-S scores between classes. In the grouped classes, compared with clinical classes (OMS III-IV), academic classes (OMS I-II) had a significantly higher JSE-S score and cognitive and emotional subcomponents (P≤.02), but effect sizes were small (partial η2=0.01).

c The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

Table 1.
Empathy and Osteopathic Manipulative Medicine: Results on the JSE-S by Year in Osteopathic Medical School
Aug 2016 Spring 2017, by Class Spring 2017, Grouped
Characteristic OMS I OMS I OMS II OMS III OMS IV OMS I-IV OMS I-II OMS III-IV
Class Size 209 209 200 197 195 801 409 392
Male-Female Ratio 1.55 1.55 1.22 1.26 2.10 1.49 1.38 1.61
Respondents, No. (%) 191 (91) 187 (89) 139 (70) 159 (81) 113 (58) 598 (75) 326 (80) 272 (69)
 Male, No. 114 110 74 82 76 342 184 158
 Female, No. 77 77 65 77 37 256 142 114
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
JSE-S Score,b Mean (SEM) 117.9 (0.6) 114.2 (0.9) 115.1 (1.0) 112.5 (1.0) 111.2 (1.2) 113.4 (0.5) 114.6 (0.7) 112.0 (0.7)
 Male 116.4 (0.8) 111.3 (1.3) 114 (1.4) 108.9 (1.5) 109.6 (1.6) 110.0 (0.7) 112.5 (0.9) 109.3 (1.1)
 Female 120.0 (0.8) 118.2 (1.1) 116.1 (1.5) 116.4 (0.9) 114.4 (1.6) 116.6 (0.6) 117.2 (0.9) 115.8 (0.8)
 Male-female ratio 1.48 1.43 1.14 1.06 2.05 1.34 1.30 1.39
 Subcomponent, %c
  Cognitive 76.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Emotional 85.7 (0.6) 76.5 (0.8) 76.7 (1.0) 74.5 (0.9) 74.1 (1.1) 75.6 (0.5) 76.6 (0.6) 74.3 (0.7)
  Behavioral 85.1 (0.7) 77.3 (1.1) 80.9 (1.1) 77.9 (1.1) 77.3 (1.3) 78.3 (0.6) 78.9 (0.8) 77.7 (0.8)

a Two surveys were sent in the 2016-2017 academic year: the first in August 2016 to first-year osteopathic medical students (OMS I) and the second in April, May, or June 2017, depending on the class, to all osteopathic medical students (OMS I-IV).

b The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140. Higher scores indicate greater empathy. Scores on the JSE-S were significantly higher among female than male participants in each class year (P<.05). No significant differences were found in JSE-S scores between classes. In the grouped classes, compared with clinical classes (OMS III-IV), academic classes (OMS I-II) had a significantly higher JSE-S score and cognitive and emotional subcomponents (P≤.02), but effect sizes were small (partial η2=0.01).

c The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

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Table 2.
Comparison of Osteopathic Medical Students’ Empathy Scores by Experience and Interest in OMM
JSE-S Subcomponent, %b
Question n JSE-S Score, Mean (SEM)a Behavioral Cognitive Emotional
Do you have a DO in your family?
 Yes 57 113.3 77.6 75.2 80.9
 No 540 113.5 78.5 75.6 80.5
Do you have an MD in your family?
 Yes 224 113.0 78.8 74.9 80.1
 No 373 113.7 78.1 76.0 80.7
Were you ever treated with OMT or manual therapy before medical school?
 Yes 109 114.8 81.1c 76.1 81.5
 No 488 113.2 77.8 75.5 80.3
Did the osteopathic philosophy of treating the whole person influence your decision to attend osteopathic medical school?
 Yes 449 115.0c,d 79.1c 76.9c 82.1c,d
 No 148 108.8 76.0 71.8 75.7
Do you intend to use OMM in your future practice?
 Yes 389 115.8c,d 80.1c 77.5c 82.7c,d
 No 199 108.7 74.9 71.8 76.1
Do you practice OMM on your classmates outside of the OMM workshop?
 Yes 393 114.9c 79.4c 76.7c 81.9c
 No 204 110.7 76.4 73.5 77.8
Are you afraid to perform OMT?
 Yes 146 112.5 77.8 74.5 80.2
 No 451 113.7 78.6 76.0 80.6
Have you been successful treating others with OMT?
 Yes 486 114.4c 79.4c 76.3c 81.4c
 No 111 109.1 74.0 72.6 76.7
Do you plan on entering an OMM residency or program that encourages use/training in OMT?
 Yes 210 116.5c 81.0c 77.9c 83.4c,d
 No 387 111.8 77.0 74.4 79.0
Do you feel that OMM is a valuable method for resolving musculoskeletal problems?
 Yes 565 114.0c 78.7c 76.0c 81.1c
 No 32 104.2 72.1 68.5 71.1
Do you feel that OMM is a valuable method for resolving problems other than musculoskeletal problems?
 Yes 349 115.7c,d 79.6c 77.4c 82.8c,d
 No 248 110.3 76.6 73.1c 77.3
Do you believe that OMM is a helpful skill to build connection and rapport with patients?
 Yes 499 115.0c,d 79.5c 76.8c 82.0c,d
 No 98 105.6 72.6 69.5 73.1

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c P<.05.

d Medium effect size (r2≥0.05).

Abbreviations: OMM, osteopathic manipulative medicine; OMT, osteopathic manipulative treatment.

Table 2.
Comparison of Osteopathic Medical Students’ Empathy Scores by Experience and Interest in OMM
JSE-S Subcomponent, %b
Question n JSE-S Score, Mean (SEM)a Behavioral Cognitive Emotional
Do you have a DO in your family?
 Yes 57 113.3 77.6 75.2 80.9
 No 540 113.5 78.5 75.6 80.5
Do you have an MD in your family?
 Yes 224 113.0 78.8 74.9 80.1
 No 373 113.7 78.1 76.0 80.7
Were you ever treated with OMT or manual therapy before medical school?
 Yes 109 114.8 81.1c 76.1 81.5
 No 488 113.2 77.8 75.5 80.3
Did the osteopathic philosophy of treating the whole person influence your decision to attend osteopathic medical school?
 Yes 449 115.0c,d 79.1c 76.9c 82.1c,d
 No 148 108.8 76.0 71.8 75.7
Do you intend to use OMM in your future practice?
 Yes 389 115.8c,d 80.1c 77.5c 82.7c,d
 No 199 108.7 74.9 71.8 76.1
Do you practice OMM on your classmates outside of the OMM workshop?
 Yes 393 114.9c 79.4c 76.7c 81.9c
 No 204 110.7 76.4 73.5 77.8
Are you afraid to perform OMT?
 Yes 146 112.5 77.8 74.5 80.2
 No 451 113.7 78.6 76.0 80.6
Have you been successful treating others with OMT?
 Yes 486 114.4c 79.4c 76.3c 81.4c
 No 111 109.1 74.0 72.6 76.7
Do you plan on entering an OMM residency or program that encourages use/training in OMT?
 Yes 210 116.5c 81.0c 77.9c 83.4c,d
 No 387 111.8 77.0 74.4 79.0
Do you feel that OMM is a valuable method for resolving musculoskeletal problems?
 Yes 565 114.0c 78.7c 76.0c 81.1c
 No 32 104.2 72.1 68.5 71.1
Do you feel that OMM is a valuable method for resolving problems other than musculoskeletal problems?
 Yes 349 115.7c,d 79.6c 77.4c 82.8c,d
 No 248 110.3 76.6 73.1c 77.3
Do you believe that OMM is a helpful skill to build connection and rapport with patients?
 Yes 499 115.0c,d 79.5c 76.8c 82.0c,d
 No 98 105.6 72.6 69.5 73.1

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c P<.05.

d Medium effect size (r2≥0.05).

Abbreviations: OMM, osteopathic manipulative medicine; OMT, osteopathic manipulative treatment.

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Table 3.
Comparison of Osteopathic Medical Students’ Empathy Scores by Frequency of Nonspecific and OMT-Specific Touch
JSE-S Subcomponent, %b
Touch n JSE-S Score,a Mean (SEM) Cognitive Emotional Behavioral
Nonspecific
 Give
  ≤3/wk 243 111.5 (0.8) 74.5 (0.8) 78.6 (0.8) 76.2 (0.9)
  ≥4/wk 351 114.7 (0.6)c 76.3 (0.6)c 81.8 (0.6)c 79.8 (0.7)c
 Receive
  ≤3/wk 248 117.7 (0.8) 74.6 (0.8) 78.6 (0.8) 76.6 (0.9)
  ≥4/wk 349 114.7 (0.6)c 76.3 (0.6)c 81.9 (0.6)c 79.7 (0.7)c
OMT
 Give
  <1/wk 308 111.9 (0.7) 74.2 (0.7) 79.2 (0.7) 77.4 (0.8)
   ≥1/wk 286 114.9 (0.7)c 76.9 (0.7)c 81.8 (0.7)c 79.4 (0.8)c
 Receive
  <1/wk 401 113.1 (0.6) 75.1 (0.6) 80.3 (0.6) 78.3 (0.7)
  ≥1/wk 197 114.0 (0.9) 76.4 (0.8) 80.8 (0.9) 78.3 (1.0)

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c Mann-Whitney tests with significant differences in empathy (P<.05) but small effect size (r2<0.01).

Abbreviation: OMT, osteopathic manipulative treatment.

Table 3.
Comparison of Osteopathic Medical Students’ Empathy Scores by Frequency of Nonspecific and OMT-Specific Touch
JSE-S Subcomponent, %b
Touch n JSE-S Score,a Mean (SEM) Cognitive Emotional Behavioral
Nonspecific
 Give
  ≤3/wk 243 111.5 (0.8) 74.5 (0.8) 78.6 (0.8) 76.2 (0.9)
  ≥4/wk 351 114.7 (0.6)c 76.3 (0.6)c 81.8 (0.6)c 79.8 (0.7)c
 Receive
  ≤3/wk 248 117.7 (0.8) 74.6 (0.8) 78.6 (0.8) 76.6 (0.9)
  ≥4/wk 349 114.7 (0.6)c 76.3 (0.6)c 81.9 (0.6)c 79.7 (0.7)c
OMT
 Give
  <1/wk 308 111.9 (0.7) 74.2 (0.7) 79.2 (0.7) 77.4 (0.8)
   ≥1/wk 286 114.9 (0.7)c 76.9 (0.7)c 81.8 (0.7)c 79.4 (0.8)c
 Receive
  <1/wk 401 113.1 (0.6) 75.1 (0.6) 80.3 (0.6) 78.3 (0.7)
  ≥1/wk 197 114.0 (0.9) 76.4 (0.8) 80.8 (0.9) 78.3 (1.0)

a The Jefferson Scale of Empathy medical student version (JSE-S) consists of 20 items rated on a scale of 1-7, for a total potential score range of 20-140.

b The 20 items in the JSE-S were divided based on cognitive, emotional, or behavioral content. The total potential score of the 9 cognitive items was 9-63; 7 emotional items, 7-49; and 4 behavioral items, 4-28. Scores were converted to percentages of the highest total score for each range.

c Mann-Whitney tests with significant differences in empathy (P<.05) but small effect size (r2<0.01).

Abbreviation: OMT, osteopathic manipulative treatment.

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