Empathy in medical students as related to specialty interest, personality, and perceptions of mother and father

Abstract

This study was designed to examine relationships between empathy, specialty interest, personality and perceptions of mother and father. Participants were 422 first-year medical students who completed the Jefferson Scale of Physician Empathy (JSPE), and the Zuckerman–Kuhlman Personality Questionnaire (ZKPQ, short form). They also reported their specialty interest and their perceptions of early relationships with their parents. Results showed that women outscored men on the empathy scale. Also, we found that higher scores on the JSPE were associated with students’ interest in people-oriented specialties (as opposed to procedure- and technology-oriented specialties), higher level of satisfaction with early maternal relationship, higher sociability and lower aggressive-hostility scores. Controlling for gender and social desirability did not change the general pattern of findings.

Full text

Empathy in medical students as related to specialty
interest, personality, and perceptions of mother and father
Mohammadreza Hojat
a,*
, Marvin Zuckerman
a,b
, Mike Magee
c
,
Salvatore Mangione
a
, Thomas Nasca
a
, Michael Vergare
a
, Joseph S. Gonnella
a
a
Jefferson Medical College of Thomas Jefferson University, Center for Research in Medical Education and
Health Care, 1025 Walnut Street, Philadelphia, PA 19107, USA
b
University of Delaware, Newark, DE 19716, USA
c
Pfizer, Inc. New York, NY 10017, USA
Received 27 January 2004; received in revised form 1 April 2005; accepted 18 April 2005
Available online 1 July 2005
Abstract
This study was designed to examine relationships between empathy, specialty interest, personality and
perceptions of mother and father. Participants were 422 first-year medical students who completed the Jef-
ferson Scale of Physician Empathy (JSPE), and the Zuckerman–Kuhlman Personality Questionnaire
(ZKPQ, short form). They also reported their specialty interest and their perceptions of early relationships
with their parents. Results showed that women outscored men on the empathy scale. Also, we found that
higher scores on the JSPE were associated with studentsÕinterest in people-oriented specialties (as opposed
to procedure- and technology-oriented specialties), higher level of satisfaction with early maternal relation-
ship, higher sociability and lower aggressive-hostility scores. Controlling for gender and social desirability
did not change the general pattern of findings.
Ó2005 Elsevier Ltd. All rights reserved.
Keywords: Empathy; Specialty; Personality; Mother; Father
0191-8869/$ - see front matter Ó2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.paid.2005.04.007
*
Corresponding author. Tel.: +1 215 955 9459; fax: +1 215 923 6939.
E-mail address: mohammadreza.hojat@jefferson.edu (M. Hojat).
www.elsevier.com/locate/paid
Personality and Individual Differences 39 (2005) 1205–1215

1. Introduction
Although empathy has been discussed as an important element in therapeutic relationships in
psychoanalysis and psychotherapy, empirical research on empathy in the patient care environ-
ment is scarce due to the ambiguity in conceptualization and definition of the term (Price & Arch-
bold, 1997; Stephan & Finlay, 1999; Thornton & Thornton, 1995) as well as an absence of a
psychometrically sound instrument specific for measuring empathy among medical students
and physicians (Evans, Stanley, & Burrows, 1993; Kunyk & Olson, 2001).
There are several research tools for measuring empathy in the general population (e.g., HoganÕs
empathy scale, (Hogan, 1969) DavisÕs Interpersonal Reactivity Index, IRI, (Davis, 1983), and
Mehrabian and EpsteinÕs emotional empathy (Mehrabian & Epstein, 1972)) and among nurses
that we described elsewhere (Fields et al., 2004; Hojat, Gonnella, Mangione, Nasca, & Magee,
2003). None of these tools was specifically developed to measure empathy among medical students
or physicians and, therefore, may not capture the essence of an empathic relationship in patient
care situations. In recognition of a need for an operational measure of empathy among medical
students and physicians in patient care situations, our research team developed the Jefferson Scale
of Physician Empathy (Hojat et al., 2003, 2002c, 2001b) which will be described later.
Empathy in patient care is defined as: ‘‘a cognitive attribute that involves an ability to under-
stand the patientÕs inner experiences and perspective and a capability to communicate this under-
standing.’’ (Hojat et al., 2002c, p. 1564). Empathy can be linked to other variables such as gender,
personality measures, early experiences with parents and the family environment, and later social-
educational experiences. The gender differences in favor of women, in perception of emotions
(Brown & Dunn, 1996) and in empathic understanding (Litvack-Miller, McDougall, & Romney,
1997) have been observed in children and adults alike (Eisenberg & Strayer, 1987; Hojat et al.,
2002a, 2002b, 2001b).
Many developmental scholars have proposed that the quality of early relationships with parents
is a significant factor in the development of a capability for interpersonal relationships. In the
studies of early interpersonal relationships, and particularly in the original formulation of attach-
ment theory (Bowlby, 1982) the emphasis was placed on relationships with the mother who is usu-
ally a primary caregiver in all primate species. The role of the father in the majority of these
studies has been overlooked (Hojat, 1998).
Some empirical data provide a reason for the greater emphasis placed on maternal over pater-
nal roles in the developmental research. Collins and Read (1990) found that perceptions of the
warm caregiving style of the mother were significantly correlated with higher self-esteem, better
social adjustment, and more trust and altruism but such associations were not found for fathers.
In a more recent study with medical students, it was found that perception of positive early rela-
tionships with the mother was a predictor of personality attributes such as higher self-esteem,
more satisfactory peer-relationships, less loneliness, less depression, less anxiety, and more resil-
iency in dealing with stressful life events, but such associations were not found for perceptions
of early relationships with the father (Hojat, 1998). In another study with physicians in residency
training (Hojat, Glaser, & Veloski, 1996), a significant link was found between perceptions of
early relationships with the mother and the clinical competence area of interpersonal relations
and attitudes but such was not found with perceptions of early relationships with the father.
1206 M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215

Empathy is a personal attribute that is relevant to interpersonal relationships. Therefore,
significant correlations between empathy scores and personality measures of human relation-
ships are expected. For example, one would expect a positive link between empathy and per-
sonality factors that promote interpersonal relationships such as sociability and general
activity. Conversely, negative links between empathy and personality traits that hamper inter-
personal relationships such as aggression, hostility, neuroticism, and impulsiveness would be
expected.
A number of factors contribute to medical studentsÕchoice of specialty. For example, role mod-
els, market forces, societal demands, influence by family, friends and others, educational experi-
ences, and personal qualities can contribute individually or interactively to the choice. It is
common in medical education research to classify specialties into ‘‘people-oriented’’ (e.g., primary
care specialties such as family medicine, general internal medicine, general pediatrics), ‘‘technol-
ogy-oriented’’ (e.g., pathology, radiology, anesthesiology) or ‘‘procedure-oriented’’ (e.g., surgery
and surgical subspecialties) (Hojat et al., 2002b, 2002c, 2001a; Lieu, Schroeder, & Altman, 1989)
It would be reasonable to expect that those who are attracted to the ‘‘people-oriented’’ specialties
would be more interpersonally oriented than those who are attracted to ‘‘technology’’ or ‘‘proce-
dure-oriented’’ specialties.
1.1. Purpose
This study, approved by the Institutional Review Board, was designed to test the following four
research hypotheses involving the empathy scale used in this study:
1. Women would outscore men on empathy.
2. Medical students who are interested in pursuing people-oriented specialties would score
higher on empathy than their classmates who are interested in the procedure-oriented or
technology-oriented specialties.
3. Students who perceive a high level of satisfaction with early maternal relationships would
score higher on empathy than those with lower levels of satisfaction, but no relationships
between empathy and perceived paternal relationships would be found.
4. Empathy scores will be positively related to measures of sociability and activity, and nega-
tively to measures of impulsive sensation seeking, aggression-hostility, and neuroticism.
2. Method
2.1. Participants
Study participants were 422 first-year students (in 2002 and 2003) at a private medical school in
Philadelphia, Pennsylvania, USA, representing 95% of all entering classes in that time period.
There were 215 men (51%) and 207 (49%) women in the study sample, who voluntarily completed
the survey in the orientation day.
M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215 1207

2.2. Instruments
The following research instruments were used in this study.
2.2.1. The Jefferson Scale of Physician Empathy (JSPE)
This scale was developed to measure empathy among medical students and physicians. The
JSPE was constructed based on an extensive review of the literature, followed by pilot studies with
samples of medical students, residents, practicing physicians and nurses. Both qualitative (Delphi
technique) and quantitative (psychometrics) methods were used in the development and refine-
ment of the JSPE (Hojat et al., 2002c, 2001b).
The JSPE includes 20 items answered on a 7-point Likert-type scale (1 = Strongly Disagree,
7 = Strongly Agree). Psychometric evidence in support of the construct validity was reported (Ho-
jat et al., 2002c, 2001b). The scale contains three factors of ‘‘perspective taking’’, ‘‘compassionate
care’’, and ‘‘standing in the patientÕs shoes’’ that were determined by factor analysis. Also, criterion-
related validity (convergent and discriminant), internal consistency reliability (coefficient of alpha
in the 0.80 s), and test-retest reliability (r= 0.65 with 3–4 month interval between test) of the scale
have been reported (Hojat et al., 2003, 2002c, 2001b). The JSPE scores can range from a minimum
of 20 to a maximum of 140. The higher the score, the more empathic a personÕs orientation.
Two versions of the JSPE are available. One which was used in this study is the studentÕs ver-
sion (S-Version) developed for measuring studentsÕorientation toward empathetic relationships
with patients. A sample item is: ‘‘Physicians should try to stand in their patientÕs shoes when pro-
viding care to them.’’ Another slightly modified version was developed for practicing health pro-
fessionals (HP-Version) to measure their empathy in actual patient care situations (Hojat et al.,
2003, 2002c). (Copies of both versions are available from the authors.)
2.2.2. The Zuckerman–Kuhlman personality questionnaire—short form (ZKPQ-S)
This personality questionnaire was developed to measure basic factors of personality or temper-
ament that have a strong biological-evolutionary basis (Zuckerman, 2002). There are five person-
ality scales in this questionnaire: (1) Impulsive Sensation Seeking (ImpSS), described as a
tendency to act quickly on impulse without thinking, often in response to a need for thrills and
excitement. (2) Neuroticism-Anxiety (N-Anx), described as a tendency to be tense and become
easily upset. (3) Aggression-Hostility (Agg-Host), described as a tendency to express verbal
aggression, and show rudeness, thoughtlessness, vengefulness, spitefulness, a quick temper and
impatient behavior. (4) Sociability (SY), described as a tendency to interact with others, enjoying
being with others and intolerance for social isolation. (5) Activity (Act), described as a tendency to
be active, to prefer challenging work, and impatience or restlessness when there is nothing to do.
In addition, there is another scale called ‘‘Infrequency’’ in the ZKPQ that was developed to detect
intentionally false answers by identifying subjects making responses unlikely to be true. This scale
is intended only to screen out invalid test records and can be considered as an indicator of social
desirability tendency.
2.2.3. Specialty interest survey
StudentsÕspecialty interest was determined by asking them to choose one of the four groups of
physician–patient encounters that matched their interest. The groups were as follow: (A) Proce-
1208 M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215

dure-oriented specialties defined as performing specialized diagnostic procedures or basic applied
laboratory research and major contact with colleagues not patients, primarily hospital based (e.g.,
radiology, pathology). (B) Technology-oriented specialties defined as performing highly skilled
and specialized therapeutic techniques or procedures, serving as an expert consultant, primarily
hospital based with some office activities (e.g., orthopedic surgery, neurosurgery, ophthalmology).
(C) Non-primary care specialties defined as providing episodic or long-term care of a certain and
limited number of medical problems and a mix of ambulatory and hospital-based practice (e.g.,
cardiology, gastroenterology, dermatology, emergence medicine, psychiatry, obstetrics/gynecol-
ogy). (D) Primary care or ‘‘people-oriented’’ specialties defined as providing first encounter
health/illness appraisal and preventative education and intervention, episodic and long-term com-
prehensive care of a wide variety of medical conditions, primarily office-based (e.g., family med-
icine, general internal medicine, general pediatrics).
2.2.4. Perceptions of satisfaction with relationships with parents questionnaire
Perceptions of early relationships with the mother were estimated by calculating an index based
on responses to the following three items: (1) To the best of your knowledge, as a child when you
had personal problems you went to your mother. (2) To the best of your memory, as a child your
mother understood you. (3) To the best of your knowledge, as a child your mother devoted suf-
ficient time to you. Each item was answered on a 4-point Likert-type scale (1 = Strongly Disagree,
4 = Strongly Agree).
Perceptions of relationships with the father were calculated by replacing the word mother with
father in each of the three aforementioned items. The alpha reliability for the measure of percep-
tions of relationships with the mother was 0.95, and for relationships with the father was 0.89
among medical students (Hojat, 1996). These items were developed to give an estimate of per-
ceived parental sensitivity (Moran, Pederson, Pettit, & Krupka, 1992). In particular, the items
were intended to measure perceptions of parents as secure bases for the child in trouble (item
1); parentsÕempathic concern and social-emotional closeness (item 2); and parentsÕattentiveness,
involvement and devotion (item 3) (Hojat, Borenstein, & Shapurian, 1990). A higher index indi-
cates a more favorable perception of the parent.
3. Statistical analyses
For gender comparison, the t-test (one-tailed) was used, and for comparing empathy scores of
students with different specialty interest, analysis of variance (ANOVA) was used, followed by
the Duncan post hoc multiple comparisons. The distribution of the indices of perceptions of
the mother and the father were extremely skewed toward higher scores. When distributions
are extremely skewed, the correlations cannot attain their maximal values, and the true relation-
ship among variables cannot be captured (Carrol, 1961). Therefore, instead of correlational
analysis, we classified the sample into three groups based on the indices of perceived relation-
ships with the mother and separately with the father. The ANOVA was used to compare empa-
thy scores among those with high (approximately one standard deviation above the mean),
moderate, or low (approximately one standard deviation below the mean) on the index of rela-
tionships with the parent.
M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215 1209

4. Results
Prior to statistical analyses, we examined the distribution of the ‘‘Infrequency’’ scale of the
ZKPQ to detect the proportion of students who gave invalid responses to the questionnaire. Data
for the students (n= 22, 4.9% of the total sample) who scored greater than 3 on this scale were
discarded from statistical analyses for the questionable validity of their record, or for carelessly
responding to the questionnaire without regard to truth (Zuckerman, 2002). The means, standard
deviations of the empathy scores and summary results of statistical analyses for the remaining
sample in different comparison groups are reported in Table 1.
4.1. Gender comparison
As shown in the table, women scored significantly higher on empathy than men (t
(420)
= 4.58,
p< 0.01). The effect size estimate for the gender difference was 0.43 (Cohen, 1987). This finding
confirmed the first hypothesis predicting higher empathy among women than men.
4.2. Specialty interest
Results reported in Table 1 indicate that students who were interested in pursuing their future
medical practice in ‘‘people-oriented’’ (primary care) (n= 104, 64% women) specialties obtained
Table 1
Comparisons of the Jefferson Scale of Physician Empathy scores for first-year medical students
Groups NM SD pGroup differences
Gender
A: Men 215 111.6 10.4 <0.01
a
B>A
B: Women 207 115.9 8.9
Specialty interest
A: Procedure Oriented 34 108.4 10.1 <0.01
b
D>B>A
B: Technology Oriented 127 112.0 10.3
C: Non-primary Care 148 114.4 9.9
D: Primary Care 104 116.6 8.6
Level of satisfaction with mother
A: High 111 116.2 9.7 <0.01
b
A>C=B
B: Moderate 219 112.3 9.3
C: Low 90 114.3 11.4
Level of satisfaction with father
A: High 98 113.8 11.5 NS
b
A=B=C
B: Moderate 212 113.6 9.0
C: Low 110 113.9 10.5
N= Number of students; M= Mean; SD = Standard deviation; NS = Non-significant.
a
By one-tail t-test.
b
By analysis of variance.
1210 M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215

the highest empathy mean score. The differences were statistically significant (F
(409,3)
= 7.93,
p< 0.01). The DuncanÕs post hoc mean comparison test indicated that the empathy mean score
for the students who were interested in ‘‘people-oriented’’ specialties was significantly greater than
other students who were interested in either ‘‘procedure-’’ (n= 34, 44% women) or ‘‘technology-
oriented’’ (n= 127, 32% women) specialties. The effect size estimate for mean differences between
groups interested in primary care and ‘‘procedure-oriented’’ specialties was 0.81. This is a large
effect size confirming that the obtained difference is not only statistically significant, but it is also
practically (clinically) important (Cohen, 1987; Hojat & Xu, 2004). The effect size estimate for
mean difference between students interested in primary care and technology-oriented specialties
was moderate (0.46).
These findings confirm our second hypothesis of greater empathy scores in those who are inter-
ested in ‘‘people-oriented’’ specialties compared to others.
4.2.1. Controlling for gender effect
The proportion of women interest in technology-oriented specialties (32%) was half of the per-
centage of women (64%) who were interested in the primary care specialties. The differences in
proportions of women in the aforementioned specialties were statistically significant
(v2
ð3Þ¼25.23, p< 0.01). Because of the significant gender differences we found in empathy scores
and the disproportionate gender composition among students who were interested in different spe-
cialties, we statistically controlled the effect of gender using analysis of covariance (ANCOVA) in
which gender was considered as the covariate. No significant changes in patterns of previous find-
ings were observed (adjusted F
(408,4)
= 5.71, p< 0.01). Therefore, gender had no influence on the
pattern of findings.
4.2.2. Satisfaction with parents
As shown in Table 1, the differences in empathy scores among the three groups with different
levels of satisfaction with their mothers were statistically significant (F
(417,2)
= 5.88, p< 0.01).
Those who were highly satisfied with their childhood relationships with their mother obtained
a significantly higher empathy mean score than the rest of their classmates, although the effect size
estimates of the differences were not large (<0.30). The statistically significant differences con-
firmed the third research hypothesis concerning a positive association between a higher level of
satisfaction with early relationships with the mother and empathy scores. In additional analysis
we used ANCOVA to control for gender effect on the pattern of the findings reported in Table
1, and found no significant change of results (adjusted F
(416,3)
= 5.13, p< 0.01). Satisfaction with
paternal relationships was not associated with empathy scores. These findings confirm the third
research hypothesis.
4.2.3. Empathy and personality measures
We correlated scores of the JSPE with the five personality scales of the ZKPQ. Significant cor-
relations of low magnitudes were found between empathy and Sociability (r= 0.15, p< 0.01) and
Aggression-Hostility scores (r=0.13, p< 0.01). No significant correlations were found between
empathy and the other three ZKPQ scales. These findings weakly support the fourth research
hypothesis concerning relationships between empathy and personality measures.
M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215 1211

5. Discussion
The findings of this study generally suggest that empathy among medical students is a function
of gender, and early relations with the mother. These findings are limited to one medical school,
and more research is needed to assure the generalization of these findings with a more represen-
tative sample of medical students from different schools. The results are also consistent with our
previous findings (Hojat et al., 2002a, 2002b, 2001b), and with findings reported by other
researchers (Davis, 1983; Eisenberg & Lennon, 1983; Hogan, 1969; Jose, 1989).
The findings are in agreement with other studies regarding primary care physiciansÕpatient-ori-
ented approach, (Batenburg, Smal, Lodder, & de Melker, 1999; Truax, Altmann, & Millis, 1974)
and empathy (Newton et al., 2000). The findings concerning significant differences in empathy
among medical students with different career interests are important in addressing the issue raised
in one of our previous studies (Hojat et al., 2002c) in which we found a significant difference in
empathy scores among physicians who were practicing psychiatry, general internal medicine,
emergency medicine, and family medicine and general pediatrics, compared to physicians in anes-
thesiology, orthopedic surgery, neurosurgery, and radiology.
In that study we speculated that the observed differences in empathy scores among those phy-
sicians could be explained by two reasons. First, the differences could be a reflection of physiciansÕ
personality and interpersonal orientation developed prior to medical school that prompted them
to pursue a specialty that requires a close interpersonal relationship with the patients (e.g., ‘‘peo-
ple-oriented’’ specialties).
Second, differences could be a result of training during medical education. For example, in some
medical school clerkships, in particular residency training programs (internal medicine, family
medicine, pediatrics) more emphasis is placed on interpersonal skill training and patient–physi-
cian relationships, and therefore, more empathic orientations could be expected to develop among
those exposed to interpersonal skills development education. The findings of this study suggest
that the first speculation can be feasible, although this study does not provide evidence that the
second speculation or the combined effect of both should be rejected.
The findings that perceptions of early relationships with the mother in childhood, compared to
those with the father, have a more significant link to a an indicator of pro-social behavior are con-
sistent with the tenet of the attachment theory (Ainsworth, 1985a, 1985b; Bowlby, 1982, 1988) and
with previous research findings (Baydar & Brooks-Gunn, 1991; Collins & Read, 1990; Henwood
& Solano, 1994; Hojat, 1998; Hojat et al., 1996; Rothbaum & Weisz, 1994).
According to Zuckerman (2002) the scales of the ZKPQ were developed to reflect personality
traits that have strong biological-evolutionary basis. Although empathy may have some evolu-
tionary (Page & Novak, 2002; Preston & de Waal, 2002), biological (Brothers, 1989; Wolf, Gales,
& Shane, 2001), and heritability components (Matthews, Batson, Horn, & Rosenman, 1981;
Rushton, Fulker, Neale, Nias, & Eysenck, 1986) a developmental view of empathy suggests that
empathy could also be based on early life experiences with primary care givers (Fonagy, 2001; La-
ible & Thompson, 1998). Therefore, a strong link between empathy in health care environment
and stable biologically-based personality traits may not be expected.
According to the American Board of Internal Medicine (ABIM) the ‘‘public has the right to
expect humanistic behavior in its physicians’’ (ABIM, 1983). Therefore, evaluation of physiciansÕ
humanistic qualities, including empathy, is recommended by medical professional organizations.
1212 M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215

Also, the Association of American Medical Colleges (AAMC) has included the development of
empathy among the educational objectives of medical schools (for the Web address contact the
author, MH). These recommendations combined with our previous research findings indicate that
medical studentsÕempathy scores were significantly associated with the facultyÕs evaluations of
studentsÕclinical competence in core clerkships (Hojat et al., 2002a) suggest that attention to mea-
suring and improving empathy during medical education by offering targeted programs is impor-
tant for enhancing clinical skills. Findings of the present study that the degree of empathy at the
beginning of medical education is significantly associated with specialty preference can have impli-
cations for predicting the likelihood of future career choice of medical students.
Acknowledgments
This study was supported in part by a grant from Pfizer Medical Humanities Initiative, Pfizer,
Inc. New York. The authors thank Dorissa Bolinski for her editorial assistance.
References
ABIM (1983). ABIM evaluation of humanistic qualities in the internist. Annals of Internal Medicine, 99, 720–724.
Ainsworth, M. D. S. (1985a). Attachment across the life span. Bulletin of the New York Academy of Medicine, 61,
792–812.
Ainsworth, M. D. S. (1985b). Patterns of infant–mother attachment: antecedents and effects on development. Bulletin of
the New York Academy of Medicine, 61, 771–791.
Batenburg, V., Smal, J. A., Lodder, A., & de Melker, R. A. (1999). Are professional attitudes related to gender and
medical specialty? Medical Education, 33, 489–492.
Baydar, N., & Brooks-Gunn, J. (1991). Effects of maternal employment and child care arrangements on preschoolersÕ
cognitive and behavioral outcomes: evidence from the children of the National Longitudinal Study of Youth.
Developmental Psychology, 27, 932–945.
Bowlby, J. (1982). Attachment and loss: attachment (Vol. 1). New York: Basic Books, Notes: Original work published in
1969.
Bowlby, J. (1988). A secure base: parent–child attachment and health human development. New York: Basic Books.
Brothers, L. (1989). A biological perspective on empathy. American Journal of Psychiatry, 146, 10–19.
Brown, J., & Dunn, J. (1996). Continuities in emotional understanding from 3 to 6 years. Child Development, 67,
789–802.
Carrol, J. B. (1961). The nature of data, or how to choose a correlation coefficient. Psychometrika, 26, 347–372.
Cohen, J. (1987). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum.
Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples.
Journal of Personality and Social Psychology, 58, 644–663.
Davis, M. H. (1983). Measuring individual differences in empathy: evidence for a multidimensional approach. Journal
of Personality and Social Psychology, 44, 113–126.
Eisenberg, N., & Lennon, R. (1983). Sex differences in empathy and related capacities. Psychological Bulletin, 94,
100–131.
Eisenberg, N., & Strayer, J. (1987). Empathy and its development. Cambridge: Cambridge University Press.
Evans, B. J., Stanley, R. O., & Burrows, G. D. (1993). Measuring medical studentsÕempathy skills. British Journal of
Medical Psychology, 66, 121–133.
Fields, S. K., Hojat, M., Gonnella, J. S., Mangione, S., Kane, G., & Magee, M. (2004). Comparisons of nurses and
physicians on an operational measure of empathy. Evaluation and the Health Professions, 27, 80–94.
M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215 1213

Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: Other Press.
Henwood, P. G., & Solano, C. H. (1994). Loneliness in young children and their parents. The Journal of Genetic
Psychology, 155, 35–45.
Hogan, R. (1969). Development of an empathy scale. Journal of Consulting and Clinical Psychology, 33, 307–316.
Hojat, M. (1996). Perception of maternal availability in childhood and selected psychosocial characteristics in
adulthood. Genetic, Social, and General Psychology Monographs, 122, 425–450.
Hojat, M. (1998). Satisfaction with early relationships with parents and psychosocial attributes in adulthood: which
parent contributes more? Journal of General Psychology, 159, 203–220.
Hojat, M., Borenstein, B. D., & Shapurian, R. (1990). Perception of childhood dissatisfaction with parents and selected
personality traits in adulthood. The Journal of Genetic Psychology, 117, 241–253.
Hojat, M., Glaser, K. M., & Veloski, J. J. (1996). Associations between selected psychosocial attributes and ratings of
physician competence. Academic Medicine, 71(supplement), S58–S80.
Hojat, M., Gonnella, J. S., Mangione, S., Nasca, T. J., & Magee, M. (2003). Physician empathy in medical education
and practice: experience with the Jefferson Scale of Physician Empathy. Seminars in Integrative Medicine, 1, 25–41.
Hojat, M., Gonnella, J. S., Mangione, S., Nasca, T. J., Veloski, J. J., Erdmann, J. B., et al. (2002a). Empathy in
medical students as related to academic performance, clinical competence, and gender. Medical Education, 36,
522–527.
Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Veloski, J. J., & Magee, M. (2002b). The Jefferson Scale of
Physician Empathy: further psychometric data and differences by gender and specialty at item level. Academic
Medicine, 77, S58–S80, Notes: Supplement.
Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M., & Magee, M. (2002c). Physician empathy:
definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 159,
1563–1569.
Hojat, M., Mangione, S., Gonnella, J. S., Nasca, T. J., Veloski, J. J., & Kane, G. (2001a). Empathy in medical
education and patient care (letter). Academic Medicine, 76, 669–670.
Hojat, M., Mangione, S., Nasca, T. J., Cohen, M. J. M., Gonnella, J. S., Erdmann, J. B., et al. (2001b). The Jefferson
Scale of Physician Empathy: development and preliminary psychometric data. Educational and Psychological
Measurement, 61, 349–365.
Hojat, M., & Xu, G. (2004). A visitorÕs guide to effect sizes: statistical versus practical (clinical) importance of research
findings. Advances in Health Sciences Education, 9, 241–249.
Jose, P. E. (1989). The role of gender and gender role similarity in readersÕidentification with story characters. Sex
Roles, 21, 713.
Kunyk, D., & Olson, J. K. (2001). Clarification of conceptualizations of empathy. Journal of Advanced Nursing, 35,
317–325.
Laible, D. J., & Thompson, R. A. (1998). Attachment and emotional understanding in preschool children.
Developmental Psychology, 34, 1038–1045.
Lieu, T. A., Schroeder, S. A., & Altman, D. F. (1989). Specialty choice at one medical school: recent trends and analysis
of predictive factors. Academic Medicine, 64, 622–629.
Litvack-Miller, W., McDougall, D., & Romney, D. M. (1997). The structure of empathy during middle childhood and
its relationship to prosocial behavior. Genetic, Social, and General Psychology Monographs, 123, 303–324.
Matthews, K. A., Batson, C. D., Horn, J., & Rosenman, R. H. (1981). ‘‘Principles in his nature which interest him in the
fortune of others...’’ The heritability of empathic concern for others. Journal of Personality, 49, 237–247.
Mehrabian, A., & Epstein, N. A. (1972). A measure of emotional empathy. Journal of Personality, 40, 525–543.
Moran, G., Pederson, D. R., Pettit, P., & Krupka, A. A. (1992). Maternal sensitivity and infant–mother attachment in a
developmentally delayed sample. Infant Behavior and Development, 15, 427–442.
Newton, B. W., Savidge, M. A., Barber, L., Cleveland, E., Clardy, J., Beeman, G., et al. (2000). Differences in medical
studentsÕempathy. Academic Medicine, 5, 1215.
Page, K. M., & Novak, M. A. (2002). Empathy leads to fairness. Bulletin of Mathematical Biology, 64, 1101–1116.
Preston, S. D., & de Waal, F. B. (2002). Empathy, its ultimate and proximate bases. Behavioral and Brain Sciences, 25,
1–20.
Price, V., & Archbold, J. (1997). WhatÕs it all about, empathy? Nurse Education Today, 17, 106–110.
1214 M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215

Rothbaum, F., & Weisz, J. R. (1994). Parental caregiving and child externalization behavior in non-clinical samples. A
meta analysis. Psychological Bulletin, 116, 55–75.
Rushton, J. P., Fulker, D. W., Neale, M. C., Nias, D. B., & Eysenck, H. J. (1986). Altruism and aggression: the
heritability of individual differences. Journal of Personality and Social Psychology, 50, 1192–1198.
Stephan, W. G., & Finlay, K. A. (1999). The role of empathy in improving inter-group relations. Journal of Social
Issues, 55, 729–743.
Thornton, S., & Thornton, D. (1995). Facets of empathy. Personality and Individual Differences, 19, 765–767.
Truax, C. B., Altmann, H., & Millis, W. A. (1974). Therapeutic relationships provided by various professionals. Journal
of Community Psychology, 2, 33–36.
Wolf, N. S., Gales, M. E., & Shane, E. (2001). The development from a modal perception to empathy communication:
the role of mirror neurons in this process. Psychoanalytic Inquiry, 21, 94–112.
Zuckerman, M. (2002). Zuckerman–Kuhlman personality questionnaire (ZKPQ): an alternative five-factor model. In
B. De Raad & M. Perugini (Eds.), Big five assessment (pp. 377–396). Seattle, WA: Hogrefe & Huber.
M. Hojat et al. / Personality and Individual Differences 39 (2005) 1205–1215 1215