zma001662 10.3205/zma001662 urn:nbn:de:0183-zma0016625 article Artikel Vergleich von Empathie-Profilen Medizinstudierender zu Studienbeginn und in der fortgeschrittenen klinischen Phase des Studiums Schrötter Schrötter Susanne S

Universitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Gehlsheimer Str. 20, D-18147 Rostock, GermanyUniversitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Rostock, Germany

Universitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Gehlsheimer Str. 20, 18147 Rostock, DeutschlandUniversitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Rostock, Deutschland

susanne.schroetter@uni-rostock.de author Kropp Kropp Peter P

Universitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Rostock, Germany

Universitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Rostock, Deutschland

peter.kropp@med.uni-rostock.de author Müller Müller Britta B

Universitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Rostock, Germany

Universitätsmedizin Rostock, Institut für Medizinische Psychologie und Medizinische Soziologie, Rostock, Deutschland

britta.mueller@med.uni-rostock.de author German Medical Science GMS Publishing House

Düsseldorf

610 empathy emotion regulation medical studies patient satisfaction burnout Empathie Emotionsregulation Medizinstudium Patient*innenzufriedenheit Burnout empathy Empathie 20230207 20230920 20231114 20240215 engl germ This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). 2366-5017 41 1 GMS Journal for Medical Education GMS J Med Educ 7 Hintergrund: Der Nationale Kompetenzbasierte Lernzielkatalog Medizin (NKLM) formuliert Empathie als grundlegende ärztliche Kompetenz. Basierend auf einem multidimensionalen Konzept ärztlicher Empathie wurden Empathie-Profile Medizinstudierender zu Studienbeginn und im 9. Semester identifiziert und verglichen, um Schlussfolgerungen für die Konzeption effektiver Lehrangebote generieren zu können.Methode: In einer Querschnittstudie wurde mittels Saarbrücker Persönlichkeitsfragebogen zu Empathie (SPF-IRI) bei Medizinstudierenden (1. Semester: N=192/9. Semester: N=221) die selbstbeurteilte Empathie erhoben. Für die Datenanalyse wurde ein Two Stage Clustering durchgeführt.Ergebnis: Drei inhaltlich sinnvoll abgrenzbare Empathie-Profile wurden identifiziert: 1. reflektierte, funktionale Empathie, 2. unreflektierte, belastende Empathie und 3. Distanzierung und Vermeidung. Studierende im 9. Semester zeigten überwiegend die Neigung zu unreflektierter, belastender Empathie. Nur ein Drittel schien fähig zu sein, sich empathisch auf Patient*innen einzulassen und dabei gleichzeitig die eigenen Emotionen angemessen regulieren und sich so vor emotionaler Überlastung schützen zu können. Schlussfolgerung: Eine ausreichend reflektierte und funktionale Empathie kann bei Medizinstudierenden weder zu Studienbeginn vorausgesetzt werden, noch scheinen bestehende Lehrangebote diese hinreichend auszubilden. Empathie sollte daher als zu stärkende Kompetenz im gesamten Studienverlauf implementiert werden. Dabei spielt die Emotionsregulation eine Schlüsselrolle. Background: The National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) cites empathy as a basic competence for medical doctors. Based on a multidimensional concept of clinical empathy, empathy profiles of medical students at the start of their training and in the 9th semester were identified and compared in order to draw conclusions for the conception of effective course offers.Method: Using the Saarbrücker Personality Questionnaire on Empathy (SPF-IRI), self-rated empathy was recorded in a cross-sectional study of medical students (1st semester: N=192/9th semester: N=221). Two Stage Clustering was performed for data analysis.Result: Three empathy profiles which could be meaningfully delineated by content were identified: 1. reflected, functional empathy, 2. unreflected, burdensome empathy and 3. distancing and avoidance. Students in the 9th semester mostly tended toward unreflected, burdensome empathy. Only one-third appeared capable of feeling empathy with patients while at the same time adequately regulating their own emotions and thus protecting themselves from emotional overload. Conclusion: An adequately reflected and functional empathy among medical students can neither be assumed at the start of their training, nor do existing course offers appear to provide sufficient training for this. Empathy should thus be implemented as a competence which needs to be promoted over the entire course of study. Emotion regulation plays a key role. 1. Introduction1.1. BackgroundThe National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) cites empathy as a basic superordinate</PlainText></TextGroup> competence <TextGroup><PlainText>for doctors, which should be continuously</PlainText></TextGroup> promoted <TextGroup><PlainText>over the entire course of medical training</PlainText></TextGroup> &#91;<Hyperlink href="https:&#47;&#47;nklm.de&#47;zend&#47;menu">https:&#47;&#47;nklm.de&#47;zend&#47;menu</Hyperlink>&#93;. Its high relevance for the quality of medical care and patient satisfaction has been empirically proven <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>. The observed improvement in therapy outcomes is attributed primarily to the creation of confidence between doctor and patient <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>. A connection between empathy and job satisfaction <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>, resilience <TextLink reference="12"></TextLink>, burnout prophylaxis and well-being <TextLink reference="11"></TextLink>, <TextLink reference="13"></TextLink>, <TextLink reference="14"></TextLink>, <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink> among doctors has also been demonstrated in numerous studies. Moreover, empathy is also considered beneficial with respect to the capacity for teamwork, leadership competence and constructive conflict behaviour <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink> &#8211; desirable competencies for cooperation in the complex interprofessional teams customarily found in the clinical setting. </Pgraph><Pgraph>At the same time, the doctor-in-training is expected to show professional distance &#91;<Hyperlink href="https:&#47;&#47;nklm.de&#47;zend&#47;menu">https:&#47;&#47;nklm.de&#47;zend&#47;menu</Hyperlink>&#93; and is warned about sympathy, since that impairs clinical neutrality, the objectivity of diagnostics and treatment, and personal resilience <TextLink reference="20"></TextLink>. A connection between empathy and burnout due to high emotional demands of the profession has also been the subject of empirical studies, both for doctors <TextLink reference="12"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="23"></TextLink> and medical students <TextLink reference="24"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>. It is assumed that an unreflected flow of empathic emotions coupled with the potentially high frequency of emotional situations in everyday routine increases the experience of stress. Moreover, there is a clear tendency in research literature to attribute more professionality to technically-experienced, rational and emotionally-distanced doctors than to sympathetic doctors <TextLink reference="3"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>, <TextLink reference="30"></TextLink>, <TextLink reference="31"></TextLink>, <TextLink reference="32"></TextLink>, <TextLink reference="33"></TextLink>. This results in a field of tension which is reflected in the discussion about the definition of clinical empathy. </Pgraph><SubHeadline>1.2. Clinical empathy </SubHeadline><Pgraph>A mostly cognitive understanding of doctors&#8217; empathy is widespread in research on medical education <TextLink reference="34"></TextLink>. It assumes an objective, rational and intellectual process of understanding the experiences, feelings and viewpoints of patients, which is frequently called perspective taking <TextLink reference="35"></TextLink>, coupled with the competence to communicate this understanding in a supportive manner <TextLink reference="5"></TextLink>, <TextLink reference="32"></TextLink>, <TextLink reference="36"></TextLink>, <TextLink reference="37"></TextLink>. On the other hand, emotional involvement of the doctor, as an affective component of empathy, is taken to be detrimental to good clinical practice and is rejected <TextLink reference="3"></TextLink>, <TextLink reference="20"></TextLink>, <TextLink reference="31"></TextLink>, <TextLink reference="38"></TextLink>. </Pgraph><Pgraph>Contrary to this, our study is a multidimensional approach which views empathy as a complex construct combining affective and cognitive components with the capability of being able to regulate empathically elicited emotions and thus influence the empathic behaviour of the moment <TextLink reference="39"></TextLink>, <TextLink reference="40"></TextLink>. It offers the possibility of viewing the various components of empathy separately and thus reflect on effective and satisfactory behaviour for a doctor which includes both distance from and empathy for patients &#8211; and yet protects against emotional overload. Gleichgerrcht and Decety differentiate four interacting dimensions: </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">empathic arousal (sharing the affective state of <TextGroup><PlainText>another), </PlainText></TextGroup></ListItem><ListItem level="1" levelPosition="2" numString="2.">empathic understanding (formation of an explicit mental representation of the emotional state of another person), </ListItem><ListItem level="1" levelPosition="3" numString="3.">empathic concern (feeling other-oriented emotions for someone in need as motivation to maintain the interaction) and </ListItem><ListItem level="1" levelPosition="4" numString="4.">emotion regulation (the control of one&#8217;s own emotions and motivation) <TextLink reference="13"></TextLink>. </ListItem></OrderedList></Pgraph><Pgraph>Affective and cognitive dimensions here are thus closely connected to one another and exert reciprocal influence <TextLink reference="39"></TextLink>, <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>. It is assumed that cognitive understanding is always coupled with emotional resonance &#8211; albeit to various extents <TextLink reference="10"></TextLink>. Whether the doctor&#8217;s sharing or reflecting the emotions leads to other-focussed empathic concern or to self-focussed emotional distress and overburdening (personal distress) <TextLink reference="35"></TextLink>, <TextLink reference="43"></TextLink>, is determined by self-other-differentiation <TextLink reference="44"></TextLink>. According to numerous studies, the capability of differentiating between one&#8217;s own and others&#8217; emotions, rather than identifying with them <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="46"></TextLink>, is coupled with a decrease in stress perception <TextLink reference="45"></TextLink>, <TextLink reference="47"></TextLink>, <TextLink reference="48"></TextLink>, <TextLink reference="49"></TextLink>, <TextLink reference="50"></TextLink>, <TextLink reference="51"></TextLink>. Studies have shown that self-other differentiation can be trained and its strengthening can enable a balance between professional distance and human warmth <TextLink reference="52"></TextLink>. </Pgraph><Pgraph>On the other hand, if doctors&#8216; empathy is reduced to the cognitive dimensions it would mean an unreflectied suppression of emotions &#8211; which is coupled in the literature with the onset of exhaustion and burnout <TextLink reference="15"></TextLink>, <TextLink reference="36"></TextLink>, <TextLink reference="53"></TextLink>. Moreover, emotional distancing has the risk of developing indifference or cynicism toward patients in the long run <TextLink reference="21"></TextLink>, <TextLink reference="54"></TextLink>, <TextLink reference="55"></TextLink>. A purely cognitive conception of empathy often leads to reliance on learned communication techniques which are considered empathic. Without emotional resonance, they risk becoming feigned empathy which is perceived by the other person as such, and which can lead to dissatisfaction on both sides in the interaction <TextLink reference="32"></TextLink>, <TextLink reference="41"></TextLink>.</Pgraph><Pgraph>In summary, it can be concluded that emotional distancing from patients can just as well be the cause of emotional stress, dissatisfaction and burnout among doctors as uncontrolled and unreflected empathic emotions, while reflected and emotion-regulated empathy appears coupled with greater professional satisfaction and burnout prophylaxis <TextLink reference="11"></TextLink>, <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>, <TextLink reference="14"></TextLink>, <TextLink reference="15"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="51"></TextLink>. Interventions for promotion of empathy should thus be directed to a reflected and functional dealing with one&#8217;s own empathic perception instead of to unspecific increasing of empathy. </Pgraph><SubHeadline>1.3. Empathy in medical training</SubHeadline><Pgraph>International studies over the past 20 years on changes in empathy during medical training operationalised empathy mostly as a global, cognitive construct, measured in the criteria empathic, not empathic or the extent of empathy <TextLink reference="34"></TextLink>. They showed different results (see attachment 1 <AttachmentLink attachmentNo="1"/>): both a significant reduction, especially in the clinical phase with the associated patient contact <TextLink reference="56"></TextLink>, <TextLink reference="57"></TextLink>, <TextLink reference="58"></TextLink> as well as stability over the years of training <TextLink reference="11"></TextLink>, <TextLink reference="59"></TextLink>, <TextLink reference="60"></TextLink>, <TextLink reference="61"></TextLink>. A significant increase was observed less often and ascribed to additional interventions to promote empathy <TextLink reference="62"></TextLink>, <TextLink reference="63"></TextLink>, <TextLink reference="64"></TextLink>. Medical training thus does not appear to offer an adequate framework in every case to promote this competence. </Pgraph><SubHeadline>1.4. Query</SubHeadline><Pgraph>The interest of the present study addressed the question whether and in what aspects medical students at the start of their training differ in their empathy from students in the advanced clinical phase of training, in order to gain evidence for generating a conceptualization of teaching contents and interventions to promote empathy during medical training. Starting from a multidimensional empathy concept and study results which delineated specific effects on doctors of the various dimensions of empathy, the hypothesis was formulated that typical empathy profiles can be identified which differ significantly in characterization between the 1<Superscript>st</Superscript> and the 9<Superscript>th</Superscript> semester. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="1. Einleitung"> <MainHeadline>1. Einleitung</MainHeadline><SubHeadline>1.1. Hintergrund</SubHeadline><Pgraph>Der Nationale Kompetenzbasierte Lernzielkatalog Medizin (NKLM) formuliert Empathie als grundlegende &#252;bergeordnete &#228;rztliche Kompetenz, die im Verlauf des gesamten Medizinstudiums kontinuierlich vermittelt werden soll &#91;<Hyperlink href="https:&#47;&#47;nklm.de&#47;zend&#47;menu">https:&#47;&#47;nklm.de&#47;zend&#47;menu</Hyperlink>&#93;. Ihre hohe Relevanz f&#252;r die Qualit&#228;t der medizinischen Versorgung und die Zufriedenheit von Patient&#42;innen ist empirisch belegt <TextLink reference="1"></TextLink>, <TextLink reference="2"></TextLink>, <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>, <TextLink reference="5"></TextLink>. Die beobachtete Verbesserung der Therapieergebnisse wird dabei vor allem auf die Schaffung von Vertrauen zwischen &#196;rzt&#42;in und Patient&#42;in zur&#252;ckgef&#252;hrt <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>, <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>. Auch ein Zusammenhang zwischen Empathie und Arbeitszufriedenheit <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>, Resilienz <TextLink reference="12"></TextLink>, Burnoutprophylaxe und Wohlbefinden <TextLink reference="11"></TextLink>, <TextLink reference="13"></TextLink>, <TextLink reference="14"></TextLink>, <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink> bei &#196;rzt&#42;innen wurde in zahlreichen Studien best&#228;tigt. Zudem gilt Empathie als f&#246;rderlich in Bezug auf Teamf&#228;higkeit, F&#252;hrungskompetenz sowie konstruktives Konfliktverhalten <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink> &#8211; w&#252;nschenswerte Kompetenzen f&#252;r die im klinischen Setting &#252;bliche Zusammenarbeit in komplexen interprofessionellen Teams.</Pgraph><Pgraph>Gleichzeitig wird von angehenden &#196;rzt&#42;innen professionelle Distanz &#91;<Hyperlink href="https:&#47;&#47;nklm.de&#47;zend&#47;menu">https:&#47;&#47;nklm.de&#47;zend&#47;menu</Hyperlink>&#93; erwartet und vor Mitgef&#252;hl gewarnt, da es die klinische Neutralit&#228;t, die Objektivit&#228;t in Diagnostik und Behandlung sowie die pers&#246;nliche Belastbarkeit einschr&#228;nke <TextLink reference="20"></TextLink>. Auch ein Zusammenhang zwischen Empathie und Burnout aufgrund der beruflich erh&#246;hten emotionalen Anforderungen wurde in empirischen Studien thematisiert, sowohl f&#252;r &#196;rzt&#42;innen <TextLink reference="12"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>, <TextLink reference="23"></TextLink> als auch f&#252;r Medizinstudierende <TextLink reference="24"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>. Es wird davon ausgegangen, dass ein unreflektiertes Ablaufen empathischer Emotionen in Verbindung mit der potentiellen H&#228;ufung emotionaler Situationen im Berufsalltag das Belastungserleben verst&#228;rkt. Zudem l&#228;sst sich in der Forschungsliteratur eine deutliche Tendenz finden, technisch versierten, rationalen und emotional distanzierten &#196;rzt&#42;innen mehr Professionalit&#228;t zuzusprechen als einf&#252;hlsamen Mediziner&#42;innen <TextLink reference="3"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>, <TextLink reference="30"></TextLink>, <TextLink reference="31"></TextLink>, <TextLink reference="32"></TextLink>, <TextLink reference="33"></TextLink>. Daraus ergibt sich ein Spannungsfeld, das sich in der Diskussion um die Definition &#228;rztlicher Empathie widerspiegelt. </Pgraph><SubHeadline>1.2. &#196;rztliche Empathie </SubHeadline><Pgraph>Weit verbreitet in der medizinischen Ausbildungsforschung ist ein &#252;berwiegend kognitives Verst&#228;ndnis von &#228;rztlicher Empathie <TextLink reference="34"></TextLink>. Es geht von einem objektiven, rationalen und intellektuellen Prozess des Verstehens der Erfahrungen, Gef&#252;hle und Ansichten von Patient&#42;innen aus, was h&#228;ufig als Perspektiv&#252;bernahme (perspective taking) <TextLink reference="35"></TextLink> bezeichnet wird, verbunden mit der Kompetenz, dieses Verst&#228;ndnis in unterst&#252;tzender Weise zu kommunizieren <TextLink reference="5"></TextLink>, <TextLink reference="32"></TextLink>, <TextLink reference="36"></TextLink>, <TextLink reference="37"></TextLink>. Eine emotionale Beteiligung der &#196;rzt&#42;innen, als affektive Komponente von Empathie, gilt stattdessen als nachteilig f&#252;r eine gute klinische Praxis und wird abgelehnt <TextLink reference="3"></TextLink>, <TextLink reference="20"></TextLink>, <TextLink reference="31"></TextLink>, <TextLink reference="38"></TextLink>. </Pgraph><Pgraph>Grundlage dieser Studie ist dagegen ein multidimensionaler Ansatz, der Empathie als ein komplexes Konstrukt betrachtet, das affektive und kognitive Komponenten mit der F&#228;higkeit verbindet, die empathisch ausgel&#246;sten Emotionen regulieren zu k&#246;nnen, und so das aktuelle empathische Verhalten beeinflusst <TextLink reference="39"></TextLink>, <TextLink reference="40"></TextLink>. Er bietet die M&#246;glichkeit, die verschiedenen Komponenten von Empathie getrennt zu betrachten und so &#252;ber eine wirksame und befriedigende &#228;rztliche Haltung nachzudenken, die sowohl Distanz zu und Empathie f&#252;r Patient&#42;innen einschlie&#223;t &#8211; und dabei vor emotionaler &#220;berw&#228;ltigung sch&#252;tzt. Gleichgerrcht und Decety unterscheiden vier interagierende Dimensionen: </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">empathic arousal (das Teilen des affektiven Zustandes einer anderen Person), </ListItem><ListItem level="1" levelPosition="2" numString="2.">empathic understanding (die Bildung einer expliziten mentalen Darstellung des emotionalen Zustands dieser Person), </ListItem><ListItem level="1" levelPosition="3" numString="3.">empathic concern (die empathische Anteilnahme als Motivation zur Aufrechterhaltung der Interaktion) und </ListItem><ListItem level="1" levelPosition="4" numString="4.">emotion regulation (die Kontrolle der eigenen Emotionen und Motivation) <TextLink reference="13"></TextLink>. </ListItem></OrderedList></Pgraph><Pgraph>Affektive und kognitive Dimensionen sind hier also eng miteinander verkn&#252;pft und beeinflussen sich wechselseitig <TextLink reference="39"></TextLink>, <TextLink reference="40"></TextLink>, <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>. Es wird davon ausgegangen, dass kognitives Verstehen immer mit emotionaler Resonanz verbunden ist &#8211; wenn auch in unterschiedlichem Ausma&#223; <TextLink reference="10"></TextLink>. Ob das Teilen oder Spiegeln der Emotionen auf Seite der &#196;rzt&#42;in zu fremd-fokussierter empathischer Anteilnahme (empathic concern) oder zu selbst-fokussierter emotionaler Bedr&#228;ngnis und &#220;berforderung (personal distress) f&#252;hrt <TextLink reference="35"></TextLink>, <TextLink reference="43"></TextLink>, wird entscheidend durch die Selbst-Andere-Differenzierung (self-other-differentiation) beeinflusst <TextLink reference="44"></TextLink>. Die F&#228;higkeit, zwischen den eigenen und fremden Emotionen unterscheiden zu k&#246;nnen, statt sich damit zu identifizieren <TextLink reference="41"></TextLink>, <TextLink reference="42"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="46"></TextLink>, ist laut zahlreicher Studien mit einer Senkung des Belastungserlebens verbunden <TextLink reference="45"></TextLink>, <TextLink reference="47"></TextLink>, <TextLink reference="48"></TextLink>, <TextLink reference="49"></TextLink>, <TextLink reference="50"></TextLink>, <TextLink reference="51"></TextLink>. Studien haben gezeigt, dass sie trainierbar ist und ihre St&#228;rkung eine Balance von professioneller Distanz und menschlicher N&#228;he erm&#246;glichen kann <TextLink reference="52"></TextLink>. </Pgraph><Pgraph>Wird &#228;rztliche Empathie hingegen auf kognitive Dimensionen reduziert, bedeutet das eine unreflektierte Unterdr&#252;ckung von Emotionen - was in der Literatur mit dem Auftreten von Ersch&#246;pfung und Burnout in Verbindung gebracht wird <TextLink reference="15"></TextLink>, <TextLink reference="36"></TextLink>, <TextLink reference="53"></TextLink>. Au&#223;erdem birgt emotionale Distanzierung das Risiko, l&#228;ngerfristig Gleichg&#252;ltigkeit oder Zynismus gegen&#252;ber Patient&#42;innen zu entwickeln <TextLink reference="21"></TextLink>, <TextLink reference="54"></TextLink>, <TextLink reference="55"></TextLink>. Eine rein kognitive Auffassung von Empathie l&#228;sst zudem h&#228;ufig auf erlernte Kommunikationstechniken zur&#252;ckgreifen, die als empathisch gelten. Ohne emotionale Resonanz bergen sie die Gefahr fassadenhafter Empathie, die vom Gegen&#252;ber als solche durchschaut wird und in der Interaktion auf beiden Seiten zu Unzufriedenheit f&#252;hren kann <TextLink reference="32"></TextLink>, <TextLink reference="41"></TextLink>.</Pgraph><Pgraph>Zusammenfassend l&#228;sst sich schlussfolgern, dass emotionale Distanzierung von Patient&#42;innen ebenso Ursache von psychischer Belastung, Unzufriedenheit und Burnout von &#196;rzt&#42;innen sein kann, wie unkontrollierte und unreflektierte empathische Emotionen, w&#228;hrend reflektierte und emotionsregulierte Empathie mit einer gr&#246;&#223;eren Berufszufriedenheit und Burnoutprophylaxe verbunden zu sein scheint <TextLink reference="11"></TextLink>, <TextLink reference="12"></TextLink>, <TextLink reference="13"></TextLink>, <TextLink reference="14"></TextLink>, <TextLink reference="15"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="51"></TextLink>. Interventionen zur Empathief&#246;rderung sollten daher auf einen reflektierten und funktionalen Umgang mit dem eigenen empathischen Erleben ausgerichtet sein, statt auf unspezifische Empathiesteigerung. </Pgraph><SubHeadline>1.3. Empathie im Medizinstudium</SubHeadline><Pgraph>Internationale Studien der letzten 20 Jahre zur Ver&#228;nderung von Empathie w&#228;hrend der medizinischen Ausbildung operationalisierten Empathie &#252;berwiegend als ein globales, kognitives Konstrukt, das in den Kriterien Anwesenheit (empathisch), Abwesenheit (nicht empathisch) oder Ausma&#223; gemessen wurde <TextLink reference="34"></TextLink>. Sie zeigten unterschiedliche Ergebnisse (siehe Anhang 1 <AttachmentLink attachmentNo="1"/>): sowohl einen signifikanten R&#252;ckgang, besonders in der klinischen Phase und dem damit verbundenen Patient&#42;innenkontakt <TextLink reference="56"></TextLink>, <TextLink reference="57"></TextLink>, <TextLink reference="58"></TextLink> als auch Stabilit&#228;t &#252;ber die Studienjahre <TextLink reference="11"></TextLink>, <TextLink reference="59"></TextLink>, <TextLink reference="60"></TextLink>, <TextLink reference="61"></TextLink>. Eine signifikante Zunahme wurde seltener beobachtet und mit zus&#228;tzlichen Interventionen zur F&#246;rderung von Empathie in Verbindung gebracht <TextLink reference="62"></TextLink>, <TextLink reference="63"></TextLink>, <TextLink reference="64"></TextLink>. Das Medizinstudium scheint also nicht in jedem Fall den angemessenen Rahmen zu bieten, diese Kompetenz zu f&#246;rdern. </Pgraph><SubHeadline>1.4. Fragestellung</SubHeadline><Pgraph>Das Erkenntnisinteresse der vorliegenden Untersuchung galt der Frage, ob und in welchen Aspekten sich Medizinstudierende zu Studienbeginn in ihrer Empathie von Studierenden in der fortgeschrittenen klinischen Phase des Studiums unterscheiden, um Hinweise f&#252;r die Konzeptualisierung von Lehrinhalten und Interventionen zur F&#246;rderung von Empathie im Medizinstudium generieren zu k&#246;nnen. Ausgehend von einem multidimensionalen Empathiekonzept und Studienergebnissen, die f&#252;r die verschiedenen Empathiedimensionen jeweils spezifische Auswirkungen auf &#196;rzt&#42;innen aufzeigten, wurde die Hypothese aufgestellt, dass sich typische Empathie-Profile identifizieren lassen, die sich in ihrer Auspr&#228;gung zwischen dem 1. und 9. Semester signifikant unterscheiden. </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="2. Method"> <MainHeadline>2. Method</MainHeadline><SubHeadline>2.1. Design</SubHeadline><Pgraph>In a written survey, medical students at the University of Rostock filled out a self-rating questionnaire. The student&#8217;s participation was anonymous and voluntary. The Ethics Commission of the University Medicine Rostock had granted a positive vote. </Pgraph><SubHeadline>2.2. Sample</SubHeadline><Pgraph>In the study period from 03&#47;2018 to 02&#47;2019, 432 medical students were questioned at the end of obligatory courses. The response rate was 95.6&#37;. Thus, a sample of 413 students was available for statistical analyses, of whom 192 were in the 1<Superscript>st</Superscript> semester and 221 in the 9<Superscript>th</Superscript> semester. 63.9&#37; of the sample were women. </Pgraph><SubHeadline>2.3. Measuring instrument</SubHeadline><Pgraph>The Saarbr&#252;cker Personality Questionnaire (SPF-IRI) <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, the German version of the Interpersonal Reactivity Index (IRI), which is frequently used in international education research, was used <TextLink reference="47"></TextLink>, <TextLink reference="65"></TextLink>. This includes both emotional and cognitive components, as well as emotion regulation <TextLink reference="46"></TextLink>. It thus accorded with the multidimensional understanding of empathy in this study. </Pgraph><Pgraph>The SPF consists of four items for each of the dimensions <Mark2>perspective taking (PT), empathic concern (EC), fantasy scale (FS)</Mark2> and <Mark2>personal distress (PD)</Mark2>.</Pgraph><Pgraph>The scale <Mark2>perspective taking (PT)</Mark2> measures the cognitive capability of seeing a situation from the perspective of another person <TextLink reference="67"></TextLink>, <TextLink reference="65"></TextLink>. The <Mark2>fantasy scale (FS)</Mark2> covers the tendency to enter into the emotional world of fictional figures in films or novels and is considered a measure of the strength of emotionality <TextLink reference="65"></TextLink> and expression of general empathic reaction readiness <TextLink reference="21"></TextLink>.The scale empathic concern (EC) measures the tendency to other-oriented feelings &#8211; like warmth, sympathy and care &#8211; for people in emotional emergency situations <TextLink reference="67"></TextLink>, <TextLink reference="65"></TextLink>. The scale <Mark2>personal distress (PT)</Mark2>, on the other hand, is intended to measure the experience of self-focussed feelings, such as the feeling of discomfort, pressure or restlessness in the face of the negative experiences and feelings of others <TextLink reference="67"></TextLink>, <TextLink reference="65"></TextLink> and makes statements about self-other-differentiation and emotion regulation <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>. </Pgraph><Pgraph>The 16 items are answered on a 5-point Likert scale <TextGroup><PlainText>(1&#61;&#8220;doesn&#8217;t apply at all&#8221;</PlainText></TextGroup>; 5&#61;&#8220;applies completely&#8221;). </Pgraph><SubHeadline>2.4. Statistical procedures</SubHeadline><Pgraph>To be able to compare the two study semesters to one another, we used descriptive procedures, mean (<Mark2>M</Mark2>), standard deviation (<Mark2>SD</Mark2>) as well as inferential statistical analyses. </Pgraph><Pgraph>Following Altmann&#8217;s <TextLink reference="45"></TextLink> suggestion, the recorded data were arranged using cluster analysis to form as similar groups as possible with high intracluster-homogeniety and low intercluster-homogeniety, resulting in identification of characteristic subgroups of students with typical, individually differentiable empathy profiles (combination of the four empathy dimensions) <TextLink reference="70"></TextLink>, <TextLink reference="71"></TextLink>. For this, we used two cluster analysis procedures <TextLink reference="45"></TextLink>, <TextLink reference="72"></TextLink>, hierarchical cluster analysis <TextLink reference="73"></TextLink> and k-means clustering <TextLink reference="74"></TextLink>. Then the cluster affiliation was inferential-statistically examined in dependence on semester and gender. </Pgraph><Pgraph>The significance level was set at 5&#37; for all analyses performed. The Statistical Package for Social Sciences Version 24 (SPSS 24) was used for all analyses. Compliance with the requirements for the statistical procedure was tested before proceding. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="2. Methode"> <MainHeadline>2. Methode</MainHeadline><SubHeadline>2.1. Design</SubHeadline><Pgraph>Medizinstudierende der Universit&#228;t Rostock f&#252;llten in einer schriftlichen Befragung einen Selbstbeurteilungsfragebogen aus. Die Studierenden nahmen anonym und freiwillig teil. Ein positives Votum der Ethik-Kommission der Universit&#228;tsmedizin Rostock lag vor. </Pgraph><SubHeadline>2.2. Stichprobe</SubHeadline><Pgraph>Im Untersuchungszeitraum 03&#47;2018-02&#47;2019 wurden 432 Medizinstudierende am Ende obligatorischer Lehrveranstaltungen befragt. Die R&#252;cklaufquote betrug 95,6&#37;. Den statistischen Analysen lag damit eine Stichprobe von insgesamt 413 Studierenden zugrunde, darunter 192 im 1. Semester und 221 im 9. Semester. 63.9&#37; der Stichprobe waren Frauen. </Pgraph><SubHeadline>2.3. Messinstrument</SubHeadline><Pgraph>Eingesetzt wurde der Saarbr&#252;cker Pers&#246;nlichkeitsfragebogen (SPF-IRI) <TextLink reference="65"></TextLink>, <TextLink reference="66"></TextLink>, die deutsche Version des in der internationalen Ausbildungsforschung h&#228;ufig angewandten Interpersonal Reactivity Index (IRI) <TextLink reference="47"></TextLink>, <TextLink reference="65"></TextLink>. Dieser erfasst sowohl emotionale und kognitive Komponenten, als auch die Emotionsregulation <TextLink reference="46"></TextLink>. Damit wird er dem mehrdimensionalen Empathieverst&#228;ndnis dieser Arbeit gerecht. </Pgraph><Pgraph>Der SPF enth&#228;lt je vier Items zu den Dimensionen <Mark2>perspective taking (PT), empathic concern (EC), fantasy scale (FS)</Mark2> und <Mark2>personal distress (PD)</Mark2>.</Pgraph><Pgraph>Die Skala <Mark2>perspective taking (PT)</Mark2> misst die kognitive F&#228;higkeit, eine Situation aus der Perspektive einer anderen Person betrachten zu k&#246;nnen <TextLink reference="67"></TextLink>, <TextLink reference="65"></TextLink>. Die Skala<Mark2> fantasy scale (FS)</Mark2> erfasst die Tendenz, sich in die Gef&#252;hlswelt fiktiver Figuren in Filmen oder Romanen hineinzuversetzen und gilt als ein Ma&#223; f&#252;r die St&#228;rke von Emotionalit&#228;t <TextLink reference="65"></TextLink> und Ausdruck allgemeiner empathischer Reaktionsbereitschaft <TextLink reference="21"></TextLink>. Die Skala <Mark2>empathic concern (EC)</Mark2> misst die Tendenz zu fremdorientierten Gef&#252;hlen &#8211; wie W&#228;rme, Mitgef&#252;hl und Besorgnis &#8211; f&#252;r Menschen in emotionalen Notsituationen <TextLink reference="67"></TextLink>, <TextLink reference="65"></TextLink>. Die Skala <Mark2>personal distress (PT)</Mark2> soll dagegen das Erleben selbstfokussierter Gef&#252;hle messen, wie das Empfinden von Unbehagen, Bedr&#228;ngnis oder Unruhe angesichts negativer Erfahrungen und Gef&#252;hle anderer <TextLink reference="67"></TextLink>, <TextLink reference="65"></TextLink> und trifft damit Aussagen &#252;ber Selbst-Andere-Differenzierung und Emotionsregulation <TextLink reference="68"></TextLink>, <TextLink reference="69"></TextLink>. </Pgraph><Pgraph>Die 16 Items werden mittels einer 5-stufigen Likert-Skala beantwortet (1&#61;&#8222;trifft gar nicht zu&#8220;; 5&#61;&#8222;trifft v&#246;llig zu&#8220;). </Pgraph><SubHeadline>2.4. Statistische Verfahren</SubHeadline><Pgraph>Um die beiden Studiensemester untereinander vergleichen zu k&#246;nnen, kamen deskriptive Verfahren, Mittelwert (<Mark2>M</Mark2>), Standardabweichung (<Mark2>SD</Mark2>) sowie inferenzstatistische Analysen zur Anwendung. </Pgraph><Pgraph>Der Anregung Altmanns <TextLink reference="45"></TextLink> folgend, wurden die erhobenen Daten mittels Clusteranalyse zu m&#246;glichst &#228;hnlichen Gruppen mit hoher Intracluster-Homogenit&#228;t und geringer Intercluster-Homogenit&#228;t zusammengefasst und so charakteristische Teilgruppen von Studierenden mit typischem, voneinander unterscheidbarem Empathie-Profil (Kombination der vier Empathie-Dimensionen) identifiziert <TextLink reference="70"></TextLink>, <TextLink reference="71"></TextLink>. Daf&#252;r kamen zwei Verfahren der Clusteranalyse zum Einsatz <TextLink reference="45"></TextLink>, <TextLink reference="72"></TextLink>, die hierarchische Clusteranalyse <TextLink reference="73"></TextLink> und das k-Means-Clustering <TextLink reference="74"></TextLink>. Anschlie&#223;end wurde die Clusterzugeh&#246;rigkeit in ihrer Abh&#228;ngigkeit von Semester und Geschlecht inferenzstatistisch untersucht.</Pgraph><Pgraph>Das Signifikanzniveau wurde f&#252;r alle angewandten Analysen auf 5&#37; festgelegt. Bei allen Analysen kam das Statistical Package for Social Sciences Version 24 (SPSS 24) zur Anwendung. Die Erf&#252;llung der Voraussetzungen f&#252;r die statistischen Verfahren wurde vorab gepr&#252;ft.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="3. Results"> <MainHeadline>3. Results</MainHeadline><SubHeadline>3.1. Empathy profiles in 3 clusters</SubHeadline><Pgraph>Complete data sets were available from 391 students for two-stage clustering. In the first step, the number of clusters and a baseline classification were determined by hierarchical clusters. Stepwise fusion of the assignment elements based on Euclidian distance and error-square increase resulted in three to five clusters which were statistically appropriate. This solution was optimized using the k-means method in the second step. Three meaningful, independently delineated clusters could be identified by non-hierarchical new arrangement of the original classification. The numerical distribution of the students to clusters 1 and 2 was optimally equal and was acceptable for cluster 3, since none of the groups was double the size of the others. </Pgraph><Pgraph>With respect to the four dimensions on which the cluster formation was based, three empathy profiles could be described for content (see table 1 <ImgLink imgNo="1" imgType="table"/> and figure 1 <ImgLink imgNo="1" imgType="figure"/>).</Pgraph><Pgraph>Compared to the other clusters, cluster 1 showed the lowest values in <Mark2>personal distress (PD)</Mark2>, coupled with the highest values in <Mark2>empathic concern (EC), perspective taking (PT)</Mark2> and <Mark2>fantasy scale (FS)</Mark2>, whereby the values in<Mark2> perspective taking (PT)</Mark2> were somewhat higher than in <Mark2>empathic concern (EC)</Mark2>. This permits assumption of reflected and functional empathy. </Pgraph><Pgraph>Compared to the other clusters, cluster 2 showed the highest degree of <Mark2>personal distress (PD)</Mark2>, a slightly elevated degree of <Mark2>empathic concern (EC) </Mark2>and a rather low degree of <Mark2>perspective taking (PT)</Mark2> and <Mark2>fantasy scale (FS)</Mark2>. This indicates unreflected, burdensome empathy. </Pgraph><Pgraph>Cluster 3 is characterized by lower-than-average values in all four dimensions, whereby the low degree of <Mark2>empathic concern (EC)</Mark2> was particularly conspicuous. This indicates distancing and avoidance of empathy-promoting interactions.</Pgraph><SubHeadline>3.2. Comparison of the empathy profiles in dependence on semester and gender</SubHeadline><Pgraph>Arrangement of the cluster composition by the demographic data gender, age and semester is shown in table 2 <ImgLink imgNo="2" imgType="table"/>. </Pgraph><Pgraph>The cluster affiliation correlated significantly with the variables Semester, &#967;<Superscript>2</Superscript>(2)&#61;19.0, p&#60;.001, and gender, &#967;<Superscript>2</Superscript>(2)&#61;19.06, p&#60;.001, but not with the variable age &#967;<Superscript>2</Superscript>(4)&#61;9.35, p&#61;.053. Cluster 1 consisted of 70.7&#37; women, 55.6&#37; of the persons were students in the 1<Superscript>st</Superscript> semester. In cluster 2, 68.5&#37; of the persons were women and 67.5&#37; were in the 9<Superscript>th</Superscript> semester. Cluster 3 consisted of 55.3&#37; men and 54.2&#37; students in the 1<Superscript>st</Superscript> semester.</Pgraph><SubHeadline>3.3. Comparison of the semesters in relation to the empathy profiles</SubHeadline><Pgraph>Comparison of the 1<Superscript>st</Superscript> and 9<Superscript>th</Superscript> semesters based on cluster affiliation showed the following result (see figure 2 <ImgLink imgNo="2" imgType="figure"/>): In the 1<Superscript>st</Superscript> semester, cluster 1was the most marked, followed by cluster 3 and cluster 2. In the 9<Superscript>th</Superscript> semester, most of the students belonged to cluster 2, followed by cluster 1 and cluster 3. </Pgraph><Pgraph>The additional examination of the influence of gender showed clear differences between male and female students with respect to their cluster affiliation (see figure 3 <ImgLink imgNo="3" imgType="figure"/>).</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="3. Ergebnisse"> <MainHeadline>3. Ergebnisse</MainHeadline><SubHeadline>3.1. Empathie-Profile in 3 Clustern</SubHeadline><Pgraph>F&#252;r das Two Stage Clustering lagen vollst&#228;ndige Datens&#228;tze von 391 Studierenden vor. Im ersten Schritt wurden durch hierarchisches Clustern zun&#228;chst die Anzahl der Cluster und eine Ausgangsklassifikation bestimmt. Durch schrittweise Fusion der Zuordnungselemente anhand der euklidischen Distanz und mittels Fehlerquadratzuwachs ergaben sich statistisch angemessen drei bis f&#252;nf Cluster. Diese L&#246;sung wurde im zweiten Schritt mit Hilfe der k-Means-Methode optimiert. Durch nicht-hierarchische Neuordnung der urspr&#252;nglichen Klassifizierung konnten drei sinnvoll voneinander abgrenzbare Cluster identifiziert werden. Die zahlenm&#228;&#223;ige Verteilung der Studierenden auf die Cluster 1 und 2 war optimal gleichm&#228;&#223;ig und auch f&#252;r Cluster 3 akzeptabel, da keine der Gruppen doppelt so gro&#223; war wie die anderen.</Pgraph><Pgraph>In Bezug auf die vier Dimensionen, die der Clusterbildung zugrunde lagen, konnten drei Empathie-Profile inhaltlich beschrieben werden (siehe Tabelle 1 <ImgLink imgNo="1" imgType="table"/> und Abbildung 1 <ImgLink imgNo="1" imgType="figure"/>).</Pgraph><Pgraph>Cluster 1 wies relativ zu den anderen Clustern die niedrigsten Werte in <Mark2>personal distress (PD)</Mark2> auf, verbunden mit den h&#246;chsten Werten in <Mark2>empathic concern (EC), perspective taking (PT)</Mark2> und <Mark2>fantasy scale (FS)</Mark2>, wobei die Werte in <Mark2>perspective taking (PT)</Mark2> etwas h&#246;her ausfielen als in <Mark2>empathic concern (EC)</Mark2>. Dies l&#228;sst auf eine reflektierte und funktionale Empathie schlie&#223;en. </Pgraph><Pgraph>Cluster 2 zeigte die relativ zu den anderen Clustern h&#246;chste Auspr&#228;gung in <Mark2>personal distress (PD)</Mark2>, leicht erh&#246;hte Auspr&#228;gung in <Mark2>empathic concern (EC)</Mark2> und eher geringe Auspr&#228;gung in <Mark2>perspective taking (PT)</Mark2> und <Mark2>fantasy scale (FS)</Mark2>. Dies deutet auf eine unreflektierte, belastende Empathie hin. </Pgraph><Pgraph>Cluster 3 zeichnete sich durch unterdurchschnittliche Werte in allen vier Dimensionen aus, wobei besonders die geringe Auspr&#228;gung in<Mark2> empathic concern (EC)</Mark2> auffiel. Dies spricht f&#252;r Distanzierung und Vermeidung in empathiefordernden Interaktionen.</Pgraph><SubHeadline>3.2. Vergleich der Empathie-Profile in Abh&#228;ngigkeit vom Semester und Geschlecht</SubHeadline><Pgraph>Die Betrachtung der Zusammensetzung der Cluster nach den demographischen Daten Geschlecht, Alter und Semester ist in Tabelle 2 <ImgLink imgNo="2" imgType="table"/> abgebildet. </Pgraph><Pgraph>Die Clusterzugeh&#246;rigkeit korrelierte signifikant mit den Variablen Semester, &#967;<Superscript>2</Superscript>(2)&#61;19.0, p&#60;.001, und Geschlecht, &#967;<Superscript>2</Superscript>(2)&#61;19.06, p&#60;.001, jedoch nicht mit der Variablen Alter &#967;<Superscript>2</Superscript>(4)&#61;9.35, p&#61;.053. Das 1. Cluster bestand zu 70.7&#37; aus Frauen. 55.6&#37; der Personen waren Studierende im 1. Semester. Im 2. Cluster waren 68.5&#37; der Personen weiblich und 67.5&#37; studierten im 9. Semester. Cluster 3 bestand zu 55.3&#37; aus M&#228;nnern und 54.2&#37; Studierenden im 1. Semester.</Pgraph><SubHeadline>3.3. Vergleich der Semester in Zugeh&#246;rigkeit zu den Empathie-Profilen</SubHeadline><Pgraph>Der Vergleich des 1. und 9. Semesters anhand ihrer Clusterzugeh&#246;rigkeit zeigte folgendes Ergebnis (siehe Abbildung 2 <ImgLink imgNo="2" imgType="figure"/>): Im 1. Semester war Cluster 1 das am st&#228;rksten ausgepr&#228;gte, gefolgt von Cluster 3 und Cluster 2. Im 9. Semester geh&#246;rten die meisten Studierenden zu Cluster 2, gefolgt von Cluster 1 und Cluster 3. </Pgraph><Pgraph>Die zus&#228;tzliche Betrachtung des Einflusses des Geschlechts ergab deutliche Unterschiede zwischen m&#228;nnlichen und weiblichen Studierenden hinsichtlich ihrer Clusterzugeh&#246;rigkeit (siehe Abbildung 3 <ImgLink imgNo="3" imgType="figure"/>).</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="4. Discussion"> <MainHeadline>4. Discussion</MainHeadline><Pgraph>Based on studies of the interaction of the four dimensions <Mark2>empathic concern (EC), fantasy scale (FS), perspective taking (PT)</Mark2> and <Mark2>personal distress (PD)</Mark2> measured with the SPF, the hypothesis was formulated that, based on the recorded values, typical empathy profiles can be identified which differ in characterization between the 1<Superscript>st</Superscript> and 9<Superscript>th</Superscript> semester. This hypothesis could be confirmed. </Pgraph><Pgraph>The two stage clustering resulted in three clusters with empathy profiles which could be differentiated meaningfully from one another based on the underlying dimensions: </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">reflected, functional empathy, </ListItem><ListItem level="1" levelPosition="2" numString="2.">unreflected, burdensome empathy and </ListItem><ListItem level="1" levelPosition="3" numString="3.">distancing and avoidance. </ListItem></OrderedList></Pgraph><Pgraph>There were clear differences in the affiliation with the identified empathy profiles between the students at the start of their training and those in the 9<Superscript>th</Superscript> semester. </Pgraph><Pgraph>The capability of reflected, functional empathy (cluster 1), which was the largest cluster in the 1<Superscript>st</Superscript> semester, appeared less pronounced in both genders in the 9<Superscript>th</Superscript> semester. Studies have shown that the combination of high values in <Mark2>empathic concern (EC)</Mark2> and <Mark2>perspective taking (PT)</Mark2> with concurrent low values in <Mark2>personal distress (PD)</Mark2> is coupled in doctors with a high compassion satisfaction <TextLink reference="13"></TextLink>, professional satisfaction and effectiveness <TextLink reference="12"></TextLink>, <TextLink reference="55"></TextLink> and only rarely with problems in the interaction with patients <TextLink reference="21"></TextLink>. Overall, this empathy profile appears to meet the needs of both patients and doctors. </Pgraph><Pgraph>Students in the 9<Superscript>th</Superscript> semester showed a stronger tendency to unreflected, burdensome empathy (cluster 2) than in the 1<Superscript>st</Superscript> semester, whereby the difference among male students was particularly conspicuous. The high values in <Mark2>personal distress (PD), slightly elevated values in empathic concern (EC)</Mark2> and rather low levels in <Mark2>perspective taking (PT)</Mark2> and <Mark2>fantasy scale (FS)</Mark2> indicate unreflected processes of emotional mirroring and permit the assumption of dysfunctional emotion regulation and deficient self-other-differentiation <TextLink reference="41"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="51"></TextLink>, <TextLink reference="75"></TextLink>, <TextLink reference="76"></TextLink>. This profile is likely more often coupled with compassion fatigue, chronification of reactive stress and increased burnout risk than with efficiency and compassion satisfaction <TextLink reference="13"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="55"></TextLink>. In patient contact, high emotional distress can lead to pseudoempathic reactions or other termination of the empathic interaction <TextLink reference="41"></TextLink>, <TextLink reference="45"></TextLink> and thus to negative effects for both patient and doctor. </Pgraph><Pgraph>An increasing tendency during the study to distancing, as has been observed as an avoidance strategy to cope with increasing burden <TextLink reference="77"></TextLink> in other studies, could not be confirmed. However, the proportion of students who tended toward distancing and avoidance in studies requiring empathy (cluster 3) &#8211; that is, who show little readiness to perspective taking and empathic concern &#8211; was alarmingly high at more than 20&#37; in both semesters. This profile can lead to cynicism and indifference of the student toward patients and in the long term to professional dissatisfaction and a reduced experience of efficiency <TextLink reference="21"></TextLink>, <TextLink reference="55"></TextLink> Moreover, it bears the danger of impaired interaction, coupled with lower diagnostic accuracy, negative effects on therapy results and greater emotional stress and lower satisfaction for the patients <TextLink reference="5"></TextLink>. </Pgraph><Pgraph>The study results indicate that the majority of students in the 9<Superscript>th</Superscript> semester are not lacking empathy but primarily an adaptive capability to regulate their emotions in situations requiring empathy &#8211; coupled with the danger for patient outcome and their own well-being. The capability and willingness to react with empathy toward patients coupled with the capability of appropriately regulating their own rising emotions, thus protecting themselves against emotional overburdening appears to be present in only one-third of the students. </Pgraph><Pgraph>Various causes are plausible for this: a reduction of existing regulation capability due to the generally high workload of the students coupled with the experience of stress and time pressure in the clinical setting <TextLink reference="13"></TextLink>, <TextLink reference="21"></TextLink>, a lack of role models and a lack of positive examples in dealing with emotions <TextLink reference="77"></TextLink>, <TextLink reference="78"></TextLink>, <TextLink reference="79"></TextLink>, subjective empathy concepts with dysfunctional professional empathy expectations as well as a lack of knowledge about empathic processes and the efficacy of emotion regulation <TextLink reference="51"></TextLink>, prioritisation of biomedical knowledge <TextLink reference="79"></TextLink> and a lack of space and support for reflection and coping with the emotional challenges of the medical profession. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="4. Diskussion"> <MainHeadline>4. Diskussion</MainHeadline><Pgraph>Ausgehend von Untersuchungen zum Zusammenwirken der vier mit dem SPF gemessenen Dimensionen <Mark2>empathic concern (EC), fantasy scale (FS), perspective taking (PT)</Mark2> und <Mark2>personal distress (PD)</Mark2> wurde die Hypothese aufgestellt, dass sich anhand der erhobenen Werte typische Empathie-Profile identifizieren lassen, die sich in ihrer Auspr&#228;gung zwischen dem 1. und 9. Semester unterscheiden. Diese Hypothese konnte best&#228;tigt werden. </Pgraph><Pgraph>Das Two Stage Clustering ergab drei Cluster mit anhand der zugrundeliegenden Dimensionen inhaltlich sinnvoll voneinander abgrenzbaren Empathie-Profilen: </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">reflektierte, unbelastete Empathie, </ListItem><ListItem level="1" levelPosition="2" numString="2.">unreflektierte, belastende Empathie und </ListItem><ListItem level="1" levelPosition="3" numString="3.">Distanzierung und Vermeidung. </ListItem></OrderedList></Pgraph><Pgraph>Es zeigten sich deutliche Unterschiede in der Zugeh&#246;rigkeit zu den identifizierten Empathie-Profilen zwischen den Studierenden zu Studienbeginn und im 9. Semester. </Pgraph><Pgraph>Die F&#228;higkeit zu reflektierter, funktionaler Empathie (Cluster 1), die im 1. Semester insgesamt das gr&#246;&#223;te Cluster darstellte, erschien bei beiden Geschlechtern im 9. Semester weniger ausgepr&#228;gt. Untersuchungen haben gezeigt, dass die Kombination von hohen Werten in <Mark2>empathic concern (EC)</Mark2> und <Mark2>perspective taking (PT)</Mark2> bei gleichzeitig niedrigen Werten in <Mark2>personal distress (PD)</Mark2> bei &#196;rztinnen und &#196;rzten mit einer hohen Mitgef&#252;hlszufriedenheit (compassion satisfaction) <TextLink reference="13"></TextLink>, beruflicher Zufriedenheit und Wirksamkeit <TextLink reference="12"></TextLink>, <TextLink reference="55"></TextLink> und nur selten mit Problemen in der Interaktion mit Patientinnen und Patienten verbunden ist <TextLink reference="21"></TextLink>. Insgesamt scheint dieses Empathie-Profil sowohl den Bed&#252;rfnissen der Patient&#42;innen als auch der &#196;rzt&#42;innen gerecht zu werden. </Pgraph><Pgraph>Studierende im 9. Semester zeigten eine st&#228;rkere Tendenz zu unreflektierter, belastender Empathie (Cluster 2) als im 1. Semester, wobei der Unterschied bei den m&#228;nnlichen Studierenden besonders auff&#228;llig war. Die hohen Werte in <Mark2>personal distress (PD)</Mark2>, leicht erh&#246;hten Werte in <Mark2>empathic concern (EC)</Mark2> und eher geringe Auspr&#228;gung in <Mark2>perspective taking (PT)</Mark2> und <Mark2>fantasy scale (FS)</Mark2> deuten auf unreflektierte Prozesse emotionaler Spiegelung hin und lassen auf dysfunktionale Emotionsregulation und mangelnde Selbst-Andere-Differenzierung schlie&#223;en <TextLink reference="41"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="51"></TextLink>, <TextLink reference="75"></TextLink>, <TextLink reference="76"></TextLink>. Dieses Profil ist anstelle von Wirksamkeit und Mitgef&#252;hlszufriedenheit vermutlich h&#228;ufiger mit Mitgef&#252;hlserm&#252;dung (compassion fatigue), chronifizierendem reaktiven Stress und erh&#246;htem Burnout-Risiko verbunden <TextLink reference="13"></TextLink>, <TextLink reference="21"></TextLink>, <TextLink reference="55"></TextLink>. Im Patient&#42;innenkontakt kann die hohe emotionale Bedr&#228;ngnis zu pseudoempathischen Reaktionen oder anderweitigem Abbruch der empathischen Interaktion <TextLink reference="41"></TextLink>, <TextLink reference="45"></TextLink> und damit negativen Auswirkungen f&#252;r Patient&#42;innen und &#196;rzt&#42;innen f&#252;hren. </Pgraph><Pgraph>Eine im Studienverlauf zunehmende Tendenz zur Distanzierung, wie sie &#8211; als vermeidende Coping-Strategie zur Bew&#228;ltigung der wachsenden Belastungen <TextLink reference="77"></TextLink> &#8211; in anderen Studien festgestellt wurde, konnte nicht best&#228;tigt werden. Allerdings war der Anteil Studierender, die in Empathie fordernden Situationen zu Distanzierung und Vermeidung neigen (Cluster 3) &#8211; also wenig Bereitschaft zu Perspektiv&#252;bernahme und empathischer Anteilnahme zeigen &#8211; mit &#252;ber 20&#37; in beiden Semestern bedenklich hoch. Dieses Profil kann bei den Studierenden zu Zynismus und Gleichg&#252;ltigkeit gegen&#252;ber Patient&#42;innen und damit l&#228;ngerfristig zu Berufsunzufriedenheit und reduziertem Wirksamkeitserleben f&#252;hren <TextLink reference="21"></TextLink>, <TextLink reference="55"></TextLink>. Au&#223;erdem birgt es die Gefahr gest&#246;rter Interaktion, verbunden mit geringerer diagnostischer Treffsicherheit, negativen Auswirkungen auf die Therapieergebnisse sowie st&#228;rkerer emotionaler Belastung und geringerer Zufriedenheit der Patient&#42;innen <TextLink reference="5"></TextLink>. </Pgraph><Pgraph>Die Untersuchungsergebnisse deuten darauf hin, dass es der Mehrheit der Studierenden im 9. Semester nicht an Empathie sondern vor allem an adaptiven F&#228;higkeiten fehlt, um ihre Emotionen in Empathie fordernden Situationen regulieren zu k&#246;nnen &#8211; verbunden mit der Gefahr f&#252;r das Patient&#42;innen-Outcome und das eigene Wohlbefinden. Nur bei einem Drittel schien die F&#228;higkeit und Bereitschaft, sich empathisch auf Patient&#42;innen einzulassen, gleichzeitig mit der F&#228;higkeit verbunden, die dabei entstehenden eigenen Emotionen angemessen regulieren und sich so vor emotionaler &#220;berlastung sch&#252;tzen zu k&#246;nnen. </Pgraph><Pgraph>Daf&#252;r sind verschiedene Ursachen denkbar: eine Reduzierung vorhandener Regulationsf&#228;higkeiten durch die allgemein hohe Arbeitsbelastung der Studierenden verbunden mit dem Erleben von Stress und Zeitdruck im klinischen Setting <TextLink reference="13"></TextLink>, <TextLink reference="21"></TextLink>, fehlende Rollenmodelle und fehlende positive Vorbilder im Umgang mit Emotionen <TextLink reference="77"></TextLink>, <TextLink reference="78"></TextLink>, <TextLink reference="79"></TextLink>, subjektive Empathiekonzepte mit dysfunktionalen beruflichen Empathieerwartungen sowie mangelndes Wissen &#252;ber empathische Prozesse und die Wirksamkeit von Emotionsregulation <TextLink reference="51"></TextLink>, Priorisierung biomedizinischen Wissens <TextLink reference="79"></TextLink> und fehlender Raum und Unterst&#252;tzung zur Reflexion und Bew&#228;ltigung der emotionalen Herausforderungen des Arztberufes. </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="5. Strengths and limitations"> <MainHeadline>5. Strengths and limitations</MainHeadline><Pgraph>This study is, to our knowledge, the first to identify and investigate the empathy profiles of medical students in order to record empathy in its complex multidimensionality and thus be able to point out differentiated action options.</Pgraph><Pgraph>The essential limitation of this study is its cross-sectional design, which does not enable conclusions about causality, Moreover, the empathy differences between the semesters might also be attributable to cohort effects. Based on the same selection procedure for medical training and the low age differences, we consider this bias to be negligible. Furthermore, the use of a self-rating scale bears the danger of result distortion from socially desirable or status-dependent response behaviour. </Pgraph><Pgraph>In-depth longitudinal studies should investigate the changes in doctors&#8216; empathy over the course of training and beyond. Using a mixed-method approach could offset the influence of existing teaching formats in order to enable development of effective didactic concepts. Moreover, the extent to which various interventions to promote emotion regulation influence the student&#8217;s individual empathy should be investigated. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="5. St&#228;rken und Limitationen"> <MainHeadline>5. St&#228;rken und Limitationen</MainHeadline><Pgraph>Diese Studie ist unseres Wissens die erste, die Empathie-Profile Medizinstudierender identifiziert und untersucht hat, um Empathie in ihrer komplexen Mehrdimensionalit&#228;t zu erfassen und damit differenziertere Handlungsoptionen aufzeigen zu k&#246;nnen.</Pgraph><Pgraph>Wesentliche Limitation dieser Studie ist ihr Querschnittdesign, das keine Aussagen zur Kausalit&#228;t zul&#228;sst. Zudem k&#246;nnten die Empathie-Unterschiede zwischen den Semestern auch auf Kohorteneffekte zur&#252;ckzuf&#252;hren sein. Aufgrund gleicher Auswahlverfahren zum Medizinstudium und der geringen Altersunterschiede sch&#228;tzen wir diesen Bias als gering ein. Au&#223;erdem birgt die Verwendung eines Selbstbewertungsfragebogens die Gefahr einer Ergebnisverzerrung durch sozial erw&#252;nschtes oder zustandsabh&#228;ngiges Antwortverhalten. </Pgraph><Pgraph>Weiterf&#252;hrende longitudinale Studien sollten die Ver&#228;nderungen &#228;rztlicher Empathie im Studienverlauf und &#252;ber das Studienende hinaus eruieren. Mittels eines mixed-methods-Ansatzes k&#246;nnte der Einfluss bestehender Lehrformate erhoben werden, um so effektive didaktische Konzepte entwickeln zu k&#246;nnen. Au&#223;erdem sollte untersucht werden, inwieweit verschiedene Interventionen zur F&#246;rderung von Emotionsregulation die individuelle Empathie der Studierenden beeinflussen.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="6. Conclusion"> <MainHeadline>6. Conclusion</MainHeadline><Pgraph>Doctors&#8217; empathy is understood in the framework of this study as an indispensable basis for the trusting doctor-patient relationship which is necessary on both sides </Pgraph><Pgraph>Two-thirds of the 9<Superscript>th</Superscript> semester students tended toward dysfunctional empathy or distancing, and thus presumably had inadequate adaptive emotional regulation to meet the emotional challenges of studies and patient contact. The result underlines the necessity of continuous implementation of teaching offers on strengthening empathy in the framework of a longitudinal communication curriculum. </Pgraph><Pgraph>These must not, however, be limited to learning communication techniques, but must be coupled with instructed reflection on one&#8217;s own actions, thoughts and feelings if they are to remain effective over time. Medical students should intensively address their subjective concepts of empathy and possible dysfunctional professional empathy expectations. For this, they need space and support for reflection and coping with the emotional challenges of their profession, trained, competent and empathic instructors, as well as positive examples in dealing with emotions. The self-other differentiation is considered a key resource in preventing dysfunctional empathic reactions. Since strengthening this can enable a balance between professional distance and human warmth, attention should be paid to it during the course of medical training. Greater inclusion of scientific concepts about empathy processes, emotion regulation and neurobiological empathic processes in existing medical teaching formats in various disciplines can underline the relevance of empathy as a basic competence for a medical doctor. Medical training must confront these challenges if it wants to train competent and healthy doctors. </Pgraph><Pgraph>Training of doctors&#8217; empathy should cover this in its multidimensionality and include cognitive, emotional, emotion-regulating and communication-oriented aspects. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="6. Fazit"> <MainHeadline>6. Fazit</MainHeadline><Pgraph>&#196;rztliche Empathie wird im Rahmen dieser Studie als unverzichtbare Grundlage einer vertrauensvollen und f&#252;r beide Seiten f&#246;rderlichen &#196;rzt&#42;in-Patient&#42;in-Beziehung verstanden. </Pgraph><Pgraph>Zwei Drittel der Studierenden im 9. Semester neigten zu dysfunktionaler Empathie oder Distanzierung, verf&#252;gten also vermutlich nicht &#252;ber ausreichende adaptive Emotionsregulation, um den emotionalen Anforderungen von Studium und Patient&#42;innenkontakt gerecht zu werden. Das Ergebnis unterstreicht die Notwendigkeit einer kontinuierlichen Implementierung von Lehrveranstaltungen zur Empathiest&#228;rkung im Rahmen eines longitudinalen Kommunikationscurriculums. </Pgraph><Pgraph>Diese d&#252;rfen jedoch nicht auf das Lernen von Kommunikationstechniken beschr&#228;nkt sein, sondern m&#252;ssen mit der angeleiteten Reflexion des eigenen Handelns, Denkens und F&#252;hlens verbunden werden, um nachhaltig wirken zu k&#246;nnen. Medizinstudierende sollten sich intensiv mit ihren subjektiven Empathiekonzepten und m&#246;glicherweise dysfunktionalen beruflichen Empathieerwartungen auseinandersetzen. Daf&#252;r brauchen sie Raum und Unterst&#252;tzung zur Reflexion und Bew&#228;ltigung der emotionalen Herausforderungen ihres Berufes, geschulte, kompetente und empathische Lehrende sowie positive Vorbilder im Umgang mit Emotionen. Die Selbst-Andere-Differenzierung gilt als eine Schl&#252;sselressource zur Verhinderung dysfunktionaler empathischer Reaktionen. Da ihre St&#228;rkung eine Balance von professioneller Distanz und menschlicher N&#228;he erm&#246;glichen kann, sollte ihr im Verlauf der medizinischen Ausbildung Aufmerksamkeit geschenkt werden. Eine st&#228;rkere Einbindung wissenschaftlicher Konzepte von Empathieprozessen, Emotionregulation und neurobiologischen empathischen Prozessen in bestehende medizinische Lehrformate verschiedener Fachbereiche kann die Relevanz von Empathie als grundlegende &#228;rztliche Kompetenz unterstreichen. Diesen Herausforderungen muss sich medizinische Ausbildung stellen, wenn sie kompetente und gesunde &#196;rzt&#42;innen ausbilden will.</Pgraph><Pgraph>Die Ausbildung &#228;rztlicher Empathie sollte diese in ihrer Multidimensionalit&#228;t erfassen und kognitive, emotionale, emotionsregulatorische und kommunikationsorientierte Aspekte verbinden. </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Authors&#8217; ORCIDs</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Susanne Schr&#246;tter:<Hyperlink href="https:&#47;&#47;orcid.org&#47;0009-0004-5811-1392">0009-0004-5811-1392</Hyperlink></ListItem><ListItem level="1">Peter Kropp: <Hyperlink href="https:&#47;&#47;orcid.org&#47;0000-0001-6469-4740">0000-0001-6469-4740</Hyperlink></ListItem><ListItem level="1">Britta M&#252;ller: <Hyperlink href="https:&#47;&#47;orcid.org&#47;0000-0001-8759-2667">0000-0001-8759-2667</Hyperlink></ListItem></UnorderedList></Pgraph><SubHeadline>Authors&#8217; contributions</SubHeadline><Pgraph>The authors contributed to the preparation, organisation and performance of the study, as well as to its evaluation and to writing the present manuscript.</Pgraph><Pgraph><UnorderedList><ListItem level="1">Susanne Schr&#246;tter: Conception, preparation, performance of the study, data evaluation and data interpretation, writing the manuscript</ListItem><ListItem level="1">Peter Kropp: Performance of the study, discussion of the manuscript</ListItem><ListItem level="1">Britta M&#252;ller: Data evaluation and data interpretation </ListItem></UnorderedList></Pgraph><Pgraph>Both co-authors have read the manuscript and agree to its publication in the present form.</Pgraph><SubHeadline>Statement on the ethical standard</SubHeadline><Pgraph>Students&#8217; participation was anonymous and voluntary. They signed a written statement to this effect. The Ethics Commission of University Medicine Rostock granted a positive vote (registration number: A 2018-0052).</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Anmerkungen"> <MainHeadline>Anmerkungen</MainHeadline><SubHeadline>ORCIDs der Autor&#42;innen</SubHeadline><Pgraph><UnorderedList><ListItem level="1">Susanne Schr&#246;tter: <Hyperlink href="https:&#47;&#47;orcid.org&#47;0009-0004-5811-1392">0009-0004-5811-1392</Hyperlink></ListItem><ListItem level="1">Peter Kropp: <Hyperlink href="https:&#47;&#47;orcid.org&#47;0000-0001-6469-4740">0000-0001-6469-4740</Hyperlink></ListItem><ListItem level="1">Britta M&#252;ller: <Hyperlink href="https:&#47;&#47;orcid.org&#47;0000-0001-8759-2667">0000-0001-8759-2667</Hyperlink></ListItem></UnorderedList></Pgraph><SubHeadline>Beitrag der Autor&#42;innen</SubHeadline><Pgraph>Die Autor&#42;innen trugen zur Vorbereitung, Organisation und Durchf&#252;hrung der Studie sowie zur Auswertung und Verschriftlichung des vorliegenden Manuskripts bei.</Pgraph><Pgraph><UnorderedList><ListItem level="1">Susanne Schr&#246;tter: Konzeption, Vorbereitung, Durchf&#252;hrung der Studie, Datenauswertung und Dateninterpretation, Verschriftlichung des Manuskriptes</ListItem><ListItem level="1">Peter Kropp: Durchf&#252;hrung der Studie, Diskussion des Manuskriptes</ListItem><ListItem level="1">Britta M&#252;ller: Datenauswertung und Dateninterpretation</ListItem></UnorderedList></Pgraph><Pgraph>Beide Ko-Autor&#42;innen haben das Manuskript gelesen und sind mit seiner Publikation in der vorliegenden Form einverstanden.</Pgraph><SubHeadline>Erkl&#228;rungen zum ethischen Standard</SubHeadline><Pgraph>Die Studierenden nahmen anonym und freiwillig teil. Sie unterzeichneten diesbez&#252;glich eine schriftliche Erkl&#228;rung. Ein positives Votum der Ethik-Kommission der Universit&#228;tsmedizin Rostock lag vor (Registriernummer: A 2018-0052).</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Competing interests"> <MainHeadline>Competing interests</MainHeadline><Pgraph>The authors declare that they have no competing interests. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Interessenkonflikt"> <MainHeadline>Interessenkonflikt</MainHeadline><Pgraph>Die Autor&#42;innen erkl&#228;ren, dass sie keinen Interessenkonflikt im Zusammenhang mit diesem Artikel haben.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Di Blasi Z</RefAuthor> <RefAuthor>Harkness E</RefAuthor> <RefAuthor>Ernst E</RefAuthor> <RefAuthor>Georgiou A</RefAuthor> <RefAuthor>Kleijnen J</RefAuthor> <RefTitle>Influence of context effects on health outcomes: a systematic review</RefTitle> <RefYear>2001</RefYear> <RefJournal>Lancet</RefJournal> <RefPage>757-762</RefPage> <RefTotal>Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. 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DOI: 10.1186&#47;s12909-023-04165-9</RefTotal> <RefLink>https:&#47;&#47;doi.org&#47;10.1186&#47;s12909-023-04165-9</RefLink> </Reference> </References> <Media> <Tables> <Table format="png"> <MediaNo>1</MediaNo> <MediaID language="en">1en</MediaID> <MediaID language="de">1de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 1: Empathy profiles in three clusters</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 1: Empathieprofile in drei Clustern</Mark1></Pgraph></Caption> </Table> <Table format="png"> <MediaNo>2</MediaNo> <MediaID language="en">2en</MediaID> <MediaID language="de">2de</MediaID> <Caption language="en"><Pgraph><Mark1>Table 2: Cluster assignment by age, gender and semester</Mark1></Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Tabelle 2: Clusterzugeh&#246;rigkeit nach Alter, Geschlecht und Semester</Mark1></Pgraph></Caption> </Table> <NoOfTables>2</NoOfTables> </Tables> <Figures> <Figure format="png" height="443" width="847"> <MediaNo>1</MediaNo> <MediaID language="en">1en</MediaID> <MediaID language="de">1de</MediaID> <Caption language="en"><Pgraph><Mark1>Figure 1: Empathy-profiles in three clusters</Mark1><LineBreak></LineBreak>Cluster 1: Reflected and functional empathy, cluster 2: Unreflected and burdensome empathy, cluster 3: Distancing and avoidance</Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Abbildung 1: Empathie-Profile in drei Clustern</Mark1><LineBreak></LineBreak>Cluster 1: reflektierte und funktionale Empathie, Cluster 2: unreflektierte und belastende Empathie, Cluster 3: Distanzierung und Vermeidung</Pgraph></Caption> </Figure> <Figure format="png" height="373" width="846"> <MediaNo>2</MediaNo> <MediaID language="en">2en</MediaID> <MediaID language="de">2de</MediaID> <Caption language="en"><Pgraph><Mark1>Figure 2: Comparison of the clusters by semester</Mark1><LineBreak></LineBreak>Cluster 1: Reflected and functional empathy, cluster 2: Unreflected and burdensome empathy, cluster 3: Distancing and avoidance </Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Abbildung 2: Vergleich der Cluster nach Semesterzugeh&#246;rigkeit</Mark1><LineBreak></LineBreak>Cluster 1: reflektierte und funktionale Empathie, Cluster 2: unreflektierte und belastende Empathie, Cluster 3: Distanzierung und Vermeidung</Pgraph></Caption> </Figure> <Figure format="png" height="427" width="846"> <MediaNo>3</MediaNo> <MediaID language="en">3en</MediaID> <MediaID language="de">3de</MediaID> <Caption language="en"><Pgraph><Mark1>Figure 3: Comparison of 1</Mark1><Mark1><Superscript>st</Superscript></Mark1><Mark1> and 9</Mark1><Mark1><Superscript>th</Superscript></Mark1><Mark1> semester by cluster assignment (men and women)</Mark1><LineBreak></LineBreak>Cluster 1: reflected and functional empathy, cluster 2: unreflected and burdensome empathy, cluster 3: distancing and avoidance</Pgraph></Caption> <Caption language="de"><Pgraph><Mark1>Abbildung 3: Vergleich 1. und 9. Semester nach Clusterzugeh&#246;rigkeit (M&#228;nner und Frauen)</Mark1><LineBreak></LineBreak>Cluster 1: reflektierte und funktionale Empathie, Cluster 2: unreflektierte und belastende Empathie, Cluster 3: Distanzierung und Vermeidung<LineBreak></LineBreak><LineBreak></LineBreak><LineBreak></LineBreak><LineBreak></LineBreak></Pgraph></Caption> </Figure> <NoOfPictures>3</NoOfPictures> </Figures> <InlineFigures> <NoOfPictures>0</NoOfPictures> </InlineFigures> <Attachments> <Attachment> <MediaNo>1</MediaNo> <MediaID filename="zma001662.a1en.pdf" language="en" mimeType="application/pdf" origFilename="Attachment&#95;1.pdf" size="125205" url="">1en</MediaID> <MediaID filename="zma001662.a1de.pdf" language="de" mimeType="application/pdf" origFilename="Anhang&#95;1.pdf" size="125300" url="">1de</MediaID> <AttachmentTitle language="en">Empathy of medical students during the course of training &#8211; international study results</AttachmentTitle> <AttachmentTitle language="de">Empathief&#228;higkeit Medizinstudierender im Studienverlauf &#8211; internationale Studienergebnisse</AttachmentTitle> </Attachment> <NoOfAttachments>1</NoOfAttachments> </Attachments> </Media> </OrigData> </GmsArticle>