Introduction

Empathy is considered to be one of the key formative elements in the teaching-learning processes of dental students¹ and in health sciences programs in general. In this sense, professors can be role models for their students and influence them by creating the bases for an interaction that stimulates and promotes meaningful learning, as well as prosocial bonds that contribute to the comprehensive training of their students.^1,2 A strong empathy structure in professors can lead to a greater capacity to understand the personal and social conditions of students and patients; to feel concern in response to both positive and negative emotions; and to respond with compassion without losing sight of the teaching-learning process and avoiding emotional contagion.²

The educational process is relational in nature and empathy is involved in the construction of shared meanings. In this regard, the idea of distant professors with no emotional contact with students and patients is a concept alien to the teaching-learning processes and to current considerations on the need for comprehensive training of students in higher education.^2,3

Empathy in professors (developed and put into practice in their daily practice) is an important factor that contributes significantly to the success of their students, considering that it will favor a positive climate in the classroom and in the clinical area. In this way, professors positively affect their students when they act as role models through the constant practical demonstration of the skills that are intended to be inculcated and strengthened in the training process.^4,5

Some authors^6-9 state that healthcare based on an empathetic relationship between patients and dentists results in a high degree of patient and professional satisfaction, as well as positive repercussions on the success of a treatment. It follows that the development of empathy in students should be a permanent concern in educational institutions and that this concern should be expressed through an effective and efficient policy related to the integration of empathy in the training of cross-cutting competencies in all health programs.¹⁰ Thus, the American Dental Education Association (ADEA)¹⁰ has stated that empathy is the second most important clinical competence for dentists. However, while its inclusion in the curriculum is essential, it is not sufficient to promote its development.

Empathy training implicates a process that requires preparation and time, because it is not a skill that can be improvised due to its complexity^11,12 and dynamism and because it is influenced by several factors,^11-22 including the example of professors.¹ In this regard, it is worth mentioning that the teaching-learning process of empathy has a cross-cutting nature and affects the training of all health science students.^14,15,18-23

In view of the above, it might certainly be inferred that empathy levels in professors should be higher than in students,¹ but such inference does not have to be considered an axiom. In this context, the aim of the present study is to estimate and compare empathy levels among undergraduate dental students and professors at the Universidad Central del Este (Dominican Republic).

Materials and methods

Results

The descriptive characteristics of the sample, in relation to sex and age, are presented in Table 1. Cronbach's alpha values were satisfactory (unstandardized: 0.762, standardized: 0.778), so an acceptable internal consistency was assumed.

The total Cronbach's alpha value for E was 0.778 and ranged from 0.743 to 0.797; therefore, it is inferred that the test maintained acceptable reliability. Likewise, intraclass correlation was 0.762 (F=4.203; p=0.005 95%CI: 0.718-0.802), which ratified the observed internal reliability.

Table 2 presents the results of the ANOVA analysis, which showed that there were highly significant differences between the means of E and the CC dimension (p=0.003 and p=0.008, respectively) in the area factor. In both cases, the effect size values were very satisfactory, and the differences found were large (exceeding the value of 0.16 for a two-way ANOVA). On the other hand, the power of the test exceeded the value of 0.80, which showed that the probability of committing the type II error was low. The sex factor and the interaction between area and sex factors (A*S) did not show significant differences (p>0.05). No significant differences were found in the PT and WPS dimensions (p>0.05).

Table 3 presents the results of the multiple comparison of means (Tukey's test). For E and CC, it is possible to see that there is a hierarchical order. Regarding E, students in the clinical area have the highest mean score, but it does not differ significantly from that of professors (p=0.754); at the same time, there was no statistically significant difference between the mean score of professors and students in the basic-preclinical area (p=0.143), but there were significant differences in the mean score between students in the clinical area and those in the basic-preclinical area (p<0.05). The same occurs in the CC dimension.

Finally, in the PT and WPS dimensions, there are no significant differences between the means of the three subgroups (p=0.428 and p=0.866, respectively).

Discussion

The premise that professors should have higher levels of empathy (and its dimensions) than their students was not confirmed in the present study.

According to the literature reviewed, at the time of the present study, no research was found comparing the levels of empathy among dental students and professors, with the exception of the work by Carvajal et al.,¹ who reported that, in a sample of 116 fourth and fifth year dental professors, 346 students from the basic and preclinical areas, and 189 from the clinical area, the average values for E, CC, and PT were higher among professors (E=119.09, CC=44.17, and PT=62.78) compared to students in the clinical area (E=114.95, CC=42.63 and PT=60.10); the latter were higher than those obtained by students in the basic-preclinical area in E and CC (E=109.47, CC=37.57 and PT=60.13). It is worth noting that these values were for the total number of participants in each group, that is, without stratifying by sex, and that no significant differences were found between men and women within the same group (professors and students in the clinical area and in the basic-preclinical area).

It should also be noted that in the study by Carvajal et al.,¹ the average WPS score of female students in the basic-preclinical area (11.81) was lower than that of female students in the clinical area, which in turn was similar to that of female professors (12.62 vs. 12.58), whereas in men, the score of male tutors (11.61) did not differ much from that of male students (basic-preclinical: 11.70 and preclinical: 11.36). In addition, in this dimension, female students had a higher score than male students, regardless of the area (basic-preclinical: 11.81 vs. 11.70 and clinical: 12.62 vs. 11.36).

Explaining the findings of Carvajal et al.¹ is not an easy task. On the one hand, if WPS is an empathy dimension whose "function" provides the subject the ability to understand the emotions, feelings and thoughts of the other (in this case, the patient)³¹ and if, on the other hand, empathy can be considered a systemic concept,^{8,9,12,15,19,21} then these findings would mean that empathy as a system is "unbalanced," and it would be logical to infer that the professors included in the study would have difficulty when training empathy in their students (especially male tutors). In the case of this research, then, there will be the same limitations regarding the degree of ability of professors and dental students in both areas to recognize the emotions, feelings and thoughts of the patient. Nevertheless, this dimension is associated with the cognitive phase of empathy³² and, therefore, its levels could be raised by the introduction of psychological techniques that enable a cognitive restructuring of students to improve their understanding of the other.

The introduction of these techniques alone does not necessarily solve this imbalance. A process of interaction and integration of all the dimensions of empathy is also required for taking a "leap" or achieving a qualitative restructuring of the relationship between the components of the empathy system, which will allow for a better functioning of said system. This process (dynamic assembly of the three dimensions) is relatively slow and involves continuous testing of the student's improvement, not only in this dimension (WPS), but in its interaction with the other two dimensions, which will allow for an effective increase in the level of empathy.

However, the results of this work show a more complex scenario than the one described above. The consistent finding that the levels of E and CC in professors (107.12 and 35.57, respectively) are between the values of the students in the clinical area (108.96 and 36.12) and in the basic-preclinical area (102.28 and 31.12) is far from the expected idea that professors would have higher values both in E and in its 3 dimensions compared to their students.

In general, the results of the present study could indicate that the levels of E in students in both areas are essentially dependent on the values obtained in the CC dimension. At this point, it should be noted that this dimension is particularly complex and is associated with cultural and moral processes, with family functioning,^31,33-37 and the emotional phase of empathy; in other words, it is associated with the affective component of empathy.

On the other hand, it must be borne in mind that the emotions and feelings that a given individual has depend, to a large extent, on the ontogenetic development to which they have been subjected and on how ontogenetic factors interact with the development of the neural and biological bases of empathy;^36,37 this interaction occurs from the first contacts of the child with their environment, especially in the mother-child relationship.³⁸ Consequently, it can be inferred that the CC dimension is not as susceptible to being "taught" with pedagogical techniques as if it can be done with the dimensions associated with the cognitive aspect of empathy.

This means that the affective structure of an individual (and the cultural and moral aspects that derive from this structure) is more difficult to "teach" and, therefore, to be positively transformed. However, it is well known that the last window for modifying the levels of empathy in individuals is the university, since there is some consensus that neural development ends at around the age of 25³⁹ (while still considering the existence of cerebral plasticity); as a result, universities have a social responsibility to take on the training of empathy in their students.

Furthermore, the lack of significant differences in the PT and WPS dimensions among the three groups analyzed confirms that, in general, there is an intricate empathetic scenario that must be studied by the corresponding university authorities.

Professors are expected to have higher levels of empathy, as an indispensable condition, in order to transmit to their students attitudes and behaviors conducive to empathic training. If the levels of students and professors are equal, the possibility of such transmission is limited. Thus, the results of the present study directly demonstrate the need to establish urgent empathetic interventions that not only involve students. In this regard, some authors have pointed out that, given its complexity, any empathetic intervention should encompass the entire curriculum of a program and include an evaluation of professors to ensure systemic empathy training, among many other aspects.^15,40

Although it is not the aim of this paper, it is necessary to stress that due to the complexity of the empathy construct, it follows that interventions must be preceded by a precise empathic diagnosis and a clear strategy (strictly derived from the diagnosis). They should consider firstly, all possible factors that stimulate or undermine empathy or any particular dimension (indirectly manifested through the "empathy levels") and, secondly, all teaching-learning techniques capable of achieving the positive transformation of effective empathy in students and professors themselves.

Such a strategy must be able of stimulating the factors that positively develop empathy (and its dimensions) and transform or eliminate those that suppress it, and, at the same time, it must consider that its success will only be evident in the long term with all the methodological and research design implications that derive from the situation described. Accordingly, the only plausible strategy resulting from the above-mentioned background is that any empathetic intervention must be planned in an interdisciplinary manner, must include the entire curriculum, and must be present from the first to the last year of the program. In this sense, and given that the intervention is long and complex, its results can only be measured in the concrete praxis of the professional, that is, during patient care.

The limitation of the present study is that, due to its cross-sectional design, the results constitute a partial view of a dynamic phenomenon; however, they can be considered as trends of empathetic behavior in the studied groups and allow, then, to make informed inferences. In this regard, it is recommended to carry out a study with the same characteristics but of a longitudinal nature.

Conclusion

The levels of E and the CC dimension of professors do not differ from those of students in both the pre-clinical and basic areas, but the latter have higher levels of empathy than the other group. In the PT and WPS dimensions, no differences were found between the studied areas.