title: Examiner and simulated patient ratings of empathy in medical student final year clinical examination: are they useful?
abstract: BACKGROUND
  Many medical schools state that empathy is important and have curricular learning outcomes covering its teaching. It is thought to be useful in team-working, good bedside manner, patient perspective taking, and improved patient care. Given this, one might expect it to be measured in assessment processes. Despite this, there is relatively little literature exploring how measures of empathy in final clinical examinations in medical school map onto other examination scores. Little is known about simulated patient (actors) rating of empathy in examinations in terms of inter-rater reliability compared with clinical assessors or correlation with overall examination results.
  
  
  METHODS
  Examiners in final year clinical assessments in one UK medical school rated 133 students on five constructs in Objective Structured Long Examination Record (OSLER) with real patients: gathering information, physical examination, problem solving, managing the diagnosis, and relationship with the patient. Scores were based on a standardized well-established penalty point system. In separate Objective Structured Clinical Examination (OSCE) stations, different examiners used the same penalty point system to score performance in both interactional and procedural stations. In the four interaction-based OSCE stations, examiners and simulated patient actors also independently rated empathy of the students.
  
  
  RESULTS
  The OSLER score, based on penalty points, had a correlation of -0.38 with independent ratings of empathy from the interactional OSCE stations. The intra-class correlation (a measure of inter-rater reliability) between the observing clinical tutor and ratings from simulated patients was 0.645 with very similar means. There was a significant difference between the empathy scores of the 94 students passing the first part of the sequential examination, based on combined OSCE and OSLER scores (which did not include the empathy scores), and 39 students with sufficient penalty points to trigger attendance for the second part (Cohen's d = 0.81).
  
  
  CONCLUSIONS
  These findings suggest that empathy ratings are related to clinical performance as measured by independent examiners. Simulated patient actors are able to give clinically meaningful assessment scores. This gives preliminary evidence that such empathy ratings could be useful for formative learning, and bolsters the call for more research to test whether they are robust enough to be used summatively.
authors.affiliation: Hull York Medical School, John Hughlings Jackson Building, Heslington, York YO10 5DD, UK. barry.wright1@nhs.net.
authors.forename: Barry
authors.initials: B
authors.lastname: Wright
authors.forename: Jean
authors.initials: J
authors.lastname: McKendree
authors.forename: Lewys
authors.initials: L
authors.lastname: Morgan
authors.forename: Victoria L
authors.initials: VL
authors.lastname: Allgar
authors.forename: Andrew
authors.initials: A
authors.lastname: Brown
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence; D004501:Education, Medical; D004521:Educational Measurement; D004645:Empathy; D004739:England; D006801:Humans; D016544:Patient Simulation; D010817:Physician-Patient Relations; D011594:Psychometrics / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D013337:Students, Medical / Q000523:psychology*