This study indicated that more than half (57.1%) of fourth-to sixth-year medical students understudy had below-average empathy levels, as indicated by a median TEQ score (IQR) of 44 (40–48). Comparing the level of empathy discovered in our study with those reported by prior study, it was similar to the one found by a study in Malaysia [30]. However, our level of empathy was lower than those found by a study in Turkey [31]. These variances might be due to differences in population ethnicity, and culture. In this study, a statistically significant difference in the total score of empathy level was detected between medical students according to clinical-year level (P-value = 0.039) for univariate analysis. However, after adjusting for other variables in multivariate analysis, we didn’t found a statistically significant difference between groups. This might indicate that level of empathy was not reduced with clinical training, like those found by the prior studies [11, 30, 31]. Moreover, the study of empathy among medical students, conducted at a Korean medical school, also revealed that later years of training were associated with significantly better empathy [32].

In terms of empathy subgroups, empathy encompasses cognitive and affective or emotional dimensions. The cognitive dimension refers to ‘the ability to understand the patient’s inner experiences and perspectives, and a capability to communicate this understanding’ [33]; whereas, the affective dimension refers to ‘the ability to imagine the patient’s emotions and perspectives [34]. In this study, the assessment of emotion comprehension in others and altruism showed the highest empathy subgroup score; whereas, behaviors engaging higher-order empathic responding exhibited the lowest empathy subgroup score; especially in the sixth-year level. This might imply that most medical students were able to understand the patient’s inner experience and imagine their emotions or perspectives. However, they might lack the ability to express or transfer their empathy toward others.

It was agreed that effective expression of empathy or good communication skills on the part of physicians should enable them to convey their actual feelings or experiences to patients. Physicians who are poor communicators, and inept at expressing their feelings properly might be misunderstood by patients and people around them [35]. Then, the development and operation of empathy could be promoted by increasing: hands-on-experiences, possibilities to experience the patient’s point of view, and offering patient contact early in the curriculum. Besides these factors, students need support in reflecting on their actions, behavior, and experiences with patients. Additionally, instructors need time and opportunities to reflect on their communication with and treatment of patients, on their teaching behavior, and on their function as role models for treating patients empathically and preventing stress [10].

In this study, statistically significant differences in empathy levels were detected between male and female medical students. Females had statistically significant higher scores of empathy than males; this was similar to those reported by prior studies [30, 31, 36]. Regarding gender differences, educational intervention in all gender groups should be a cause for concern, because enhancing empathy levels will sequentially promote patient care [36]. All medical students should be educated in a way that they learn both scientific concepts of medicine, communicate with patients, and also learn how to empathize with them. They must learn how to treat patients, not just treat their diseases (37). Hence, medical school curriculums should go in the right direction, by focusing more on teaching adequate communication and interaction behaviors by covering all genders [10, 38].

As for mental health and burnout syndrome, this study identified the majority of clinical-year medical students revealed fair to good mental health, there was only 29.6% of them had poor mental health. The most common perceived stresses were medical course and examination, learning environments, and relationships with friends. Moreover, based on burnout syndrome, no one had a low personal accomplishment, and the majority of them perceived high personal accomplishment; even though they had high emotional exhaustion and high depersonaliszation scores. Additionally, statistically significant protective factors in regards to empathy levels were: female gender, good mental health, and low levels of depersonalization. Consequently, there were medical students with lower empathy levels without an association to all burnout dimensions. Medical students who had poor mental health and a high level of depersonalization, having high mental distance from one’s feelings, might have negative feelings and attitudes toward patients, together with negative school and/or work experiences. This may be one of the causes in regards to negative emotion expression or having low empathy levels [39].

Concerning the effect of gender in regards to the brain and human behavior and more specifically about empathy development; evidence suggests that there is male vs. female differences in connection to the capacity for empathy. Females are portrayed as being more nurturing and empathetic, while males are portrayed as being less emotional and more cognition based. These differences may affect how males and females’ respond in regards to the different roles that they may have [40]. According to these evidence, males may show higher levels of depersonalization or more mental distance from their feelings vs. females. This means that males may present as less empathic vs. females.

Finally, our medical education curriculum and educational environment should be reviewed, and the practical experiences should be made less stressful and promote good mental health for medical students [10]. Additionally, it should devote more time to empathy education to prevent the decrease in empathy levels, increase empathy [36], and develop the evidence-based guidelines on improving mental well-being in the workplace, prevention of depersonalization, or mental distance between medical students and patients in all genders and all educational phases.

This study had a few strengths and limitations worth mentioning. To our knowledge, this is the first study that explored mental health, and burnout, as potential associating factors with the level of empathy among Thai, clinical-year medical students. However, this study had some limitations. It was a cross-sectional survey and utilized self-administered questionnaires; therefore, some misunderstanding regarding the intended meaning of the questions might have occurred. Nevertheless, to minimize this, questionnaires with good reliability were utilized (good Cronbach’s alpha coefficient values). Regarding alcohol consumption and substance use, this study was limited by the aggregated data of substance use, because in Thailand all substances are illegal except kratom, THC, and CBD oil, alcohol drinking. Thus, we asked about history of substance abuse and alcohol drinking separately. Another drawback was that our data was quantitative, and the sample size was restricted to only medical students who graduated from one medical school. Hence, this dataset may not fairly represent the situation of all Thai medical students throughout the country.

Henceforward, studies are recommended to include all medical students attending all the faculties of medicine in Thailand. Therefore, a comprehensive multi-center study should be conducted. Moreover, other studies should employ more qualitative methods, survey medical students longitudinally, and include control groups.

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