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OPEN

Empathy competence and futurespecialty among medical
residents in Japan: a nationwide
cross‑sectional study
Takashi Watari 1,2,3*, Nathan Houchens 2,3, Yuji Nishizaki 4, Koshi Kataoka 4, Tomoe Otsuka 5,
Yasuhisa Nakano 5, Kota Sakaguchi 1, Yoshihiko Shiraishi 1, Kohta Katayama 6,
Hitomi Kataoka 7 & Yasuharu Tokuda 8
Empathy is essential for physicians to provide patient-centered care. Nevertheless, the degree towhich empathy varies among medical residents based on their desired future specialty remains
undetermined. This nationwide cross-sectional study compared empathy levels (Jefferson Scale ofEmpathy, JSE) of 824 year one and two postgraduate residents in Japan by intended medical specialty,
individual characteristics, and training and working environment characteristics. Empathy levels
were compared with applicants for general medicine, which emphasizes patient-centeredness. The
highest mean JSE and the highest percentage of women residents were observed in general medicine(M = 109.74; SD = 14.04), followed by dermatology (M = 106.64; SD = 16.90), obstetrics and gynecology(M = 106.48; SD = 14.31), and pediatrics (106.02; SD 12.18). Residents interested in procedure-centereddepartments (e.g. ophthalmology, orthopedics) garnered lower JSE scores. Multivariate regression
revealed that future general medicine candidates achieved the highest JSE scores (β = 6.68, 95% CI
2.39–10.9, p = 0.002). Women achieved significantly higher JSE scores than men (β = 2.42, 95% CI
0.11–4.73, p = 0.041). The results have implications for empathy training and postgraduate education
strategy in different clinical specialties.
The ability to demonstrate empathy is critically important in the physician–patient relationship. Empathic communication allows physicians to establish and maintain a connection with patients and more fully understand­them1–3. Hojat et al. proposed the following definition of empathy in the context of patient care: “Empathy is a
predominantly cognitive (rather than emotional) attribute that involves an understanding (rather than feeling)of the experiences, concerns, and perspectives of the patient, combined with a capacity to communicate thisunderstanding and an intention to help”4.
Using the Jefferson Scale of Empathy (JSE), for which validity and reliability have been established acrossmultiple populations and cultural c­ ontexts1,5–8, numerous prior studies have demonstrated the importance of
empathy for both patients and providers in various clinical and medical education settings. For example, higher
empathy in healthcare providers has been associated with fewer cardiovascular events among patients under their­care9 and better management outcomes for such conditions as diabetes mellitus, d­ yslipidemia10, and o­ besity11.
Furthermore, enhanced empathy has been correlated with a shorter duration of common cold s­ ymptoms12. In
addition to improved clinical health outcomes in patients, studies have reported that higher empathy may leadto reduced medical ­litigation13 and physician ­burnout14, and may increases physician happiness and well-being15.
Many variables appear to influence levels of empathy among healthcare providers. Among all medical professionals, women demonstrate higher empathy scores than m­ en7,16–18, which is particularly notable given that
empathy is negatively affected (i.e. reduced) over the medical training ­period19,20. In particular, levels of empathy

1
General Medicine Center, Shimane University Hospital, Izumo, Shimane, Japan. 2Medicine Service, VA Ann Arbor
Healthcare System, Ann Arbor, MI, USA. 3Department of Medicine, University of Michigan Medical School, Ann
Arbor, MI, USA. 4Medical Technology Innovation Center, Juntendo University, Bunkyo‑ku, Tokyo, Japan. 5Faculty of
Medicine, Shimane University, Izumo, Shimane, Japan. 6Department of Internal Medicine, St. Marianna University
School of Medicine, Kawasaki, Kanagawa, Japan. 7Diversity and Inclusion Center, Okayama University Hospital,
Okayama, Japan. 8Muribushi Okinawa Project for Teaching Hospitals, Okinawa, Japan. *email: wataritari@
gmail.com

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among healthcare providers may be higher in departments emphasizing patient-centeredness. For instance, a US
study found that primary care physicians were the most e­ mpathic3,21. Prior studies have reported that, among
medical students, a high degree of empathy is strongly associated with interest in primary-care-related fields
generally and general medicine in ­particular22,23.
Conversely, various studies across countries have demonstrated that empathy is lower among procedureoriented physicians, such as s­ urgeons21–24. However, relative levels of empathy among physicians in each specialty
may also be influenced by training and professional practice experience, as well as by the external environment(e.g. litigation, conflicts with patients). Beyond the role of s­ ex21, the relationship between the career path of aresident and empathy levels may be related to such factors as their respective training environments, working
conditions, and the presence of a mentor.
However, to the best of our knowledge, there is limited research exploring the correlation between residents’empathy and their intended specialty before specialty t­ raining22–24. General medicine, characterized by practitioners with notable empathic capacities, has a brief history in Japan, having been officially recognized as a specialty
only in 2­ 01825,26. Because of a lack of scientific evidence, it is necessary to clarify the extent to which empathy
is found among trainees who are planning to join different future specialties in Japan, a country in which the
medical system, payment structure, physician salary, and cultural backgrounds are distinct from the Westerncultures in which previous studies were ­conducted3,16,22–24.
The primary objective of this study is to ascertain whether empathy levels among medical residents in Japandiffer according to their anticipated specialty choice. Thus, we compared empathy levels based on the characteristics of residents, training environments, and working environments. The second objective was to explore
empathy levels among applicants for general medicine in Japan, a specialty that emphasizes the principle ofpatient-centeredness.

Methods

Participants and data collection. This was a nationwide, cross-sectional study. Between January 18,
2021, and March 31, 2021, we used an electronic survey request to enroll first-year (PGY-1) and second-year(PGY-2) postgraduate residents in Japan who had recently completed the General Medicine In-Training Examination (GM-ITE). The study design followed the STROBE guidelines.

The Japanese postgraduate clinical training system. In the Japanese training system, after graduat-

ing from 6 years of medical school, residents must complete 2 years of mandatory rotational training before
proceeding to a specialist medical program over 24 months. The seven rotational trainings consist of internal
medicine, surgery, rural community medicine, obstetrics and gynecology, pediatrics, psychiatry, and anesthesiology, along with some elective p­ rograms27. During the first two postgraduate years, trainees, who are called“residents” or “junior residents,” use this period to choose their future specialties. Subsequently, they usually
train in one of 19 major specialties in the third year after graduation. There is no competition (i.e. participatingin matches against specialty training programs), and most residents are free to proceed to later training according to their medical ­interests28,29.

General medicine in‑training examination. The GM-ITE is a multiple-choice, 80-question clinicalexamination that assesses general medical knowledge and its application in accordance with the core curriculumof the training program of the Ministry of Health, Labor, and Welfare of ­Japan30. More than 50% of all resident
physicians take this exam a­ nnually30,31. The examination scope comprehensively covers the most frequent topics to be mastered during essential training regarding internal medicine, surgery, anesthesiology, emergency
medicine, pediatrics, psychiatry, obstetrics and gynecology, and ­others30. Upon completion of the examination,
candidates are provided feedback based on their relative scores and detailed explanations for each question.
Data collection. After the culmination of the GM-ITE, the research participants were asked to further
contribute voluntarily. Consent was procured prior to the execution of a self-administered electronic questionnaire, encompassing queries pertaining to the training hospital milieu, pertinent information about the resident,
and their chosen future ­specializations31. Additional questions included the number of emergency room shifts
per month, duty shifts per month, hours worked per week, hours of self-study time, and the average numberof inpatients in their care. Information on each hospital’s basic characteristics was obtained from the Resident
Electronic Information System website and Foundation for Medical Training. The classification of hospital characteristics into urban and regional cities was based on previous ­studies31.
Exclusion criteria. Among all participants (1019) who remained after completing the GM-ITE, 134 were
excluded (118 did not undertake the subsequent survey; 16 did not consent). After another 61 respondents were
excluded for other reasons (Fig. 1), a total of 824 participants were included in the analysis.
Statistical analysis. The JSE total score was used as the primary outcome (independent variable). To assess

the internal consistency of reliability of the JSE, we calculated Cronbach’s alpha; to estimate effect size, we calculated Cohen’s d from the t test differences between the two groups. Standard descriptive statistics were used to
calculate the number, percentage, mean, median, and interquartile range (IQR) of each variable in the dataset.
The chi-square test or Fisher’s exact test was used to compare categorical data. Additionally, multivariate linear regression analysis was performed to examine factors associated with total scores on the JSE, which were
adjusted based on clinical relevance and previous studies. We also examined variance inflation factors (VIF) to

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Respondents after GM-ITE, n=1019
Excluded, n=134- Informed consent not obtained (n = 16)- Dropout (n = 118)

Informed consent obtained, n=885
Excluded, n=61
Inappropriate or insufficient answers- No answer for expected future specialties (n = 2)
- No answer for working hours (n = 5)
- No answer for the average number of inpatientsin charge (n = 24)- No answer for ED duty times (n = 3)
- No answer for study time (n = 2)
- No answer for mentor (n = 25)

Participants, n= 824

Figure 1.  Flow diagram for study participants.
confirm the absence of multicollinearity. Finally, sensitivity analysis was performed by incorporating random
effects (i.e. hospital-level variables and resident-level variables) in the multiple regression analysis. All tests were
two-tailed, and statistical significance was set at p < 0.05. All analyses were performed using STATA (Stata Corp.
2015, Stata 17 Base Reference Manual).

Ethical considerations. Ethical approval for this research was obtained from the Ethical Review Commit-

tee of Japan Organization of Advancing Medical Education Program, JAMEP, No. 21-7. All participants provided written informed consent before participating in the study in accordance with the Declaration of Helsinki.

Results

A total of 824 residents who consented to participate in the study were included in the analysis (PGY-1 = 364,
PGY-2 = 460). Cronbach’s alpha was 0.85. Table 1 shows the characteristics of the hospital training sites andresidents. Most (81.4%) were trained in community hospitals, 71% were trained in rural areas, and more than
90% of training hospitals had more than 300 beds (mean [M] 552.36, SD 218.8). At the resident level, 28.0% of
respondents were women, 55.8% PGY-2, and approximately 70% were on duty in the emergency department 3–5
times monthly, with the most common response of being in charge of 5–9 patients at a time. Sixty-eight percent
of residents reported having at least one mentor. The mean GM-ITE score was 46.29 out of a total possible scoreof 80, and the mean JSE score was 103.61 (SD 15.0%). Women’s JSE scores were significantly higher than thoseof men (women M = 105.66, SD 14.08; men M = 102.81, SD 15.25; p = 0.01).
Table 2 shows the average JSE score and the percentage of women residents in each department of interest(19 primary areas and others not yet decided). Internal medicine, which encompasses many subspecialties, suchas cardiovascular, respiratory, gastrointestinal, and collagen disease, had the highest number, with 325 residents(JSE M = 104.60, SD = 14.56), accounting for 39.4% of all residents. Surgery had the next highest number ofresidents at 90, which accounted for 10.9% of all residents (JSE M = 103.39, SD = 15.32). The department with thehighest empathy was general medicine (JSE M = 109.74, SD = 14.04), followed by dermatology (JSE M = 106.64,
SD = 16.90), obstetrics and gynecology (JSE M = 106.48, SD = 14.31), and pediatrics (JSE M = 106.02, SD = 12.18).
Lower JSE scores were frequently found in procedure-oriented departments, including ophthalmology (JSE
M = 96.00, SD = 11.99), orthopedics (JSE M = 99.21, SD = 14.34), radiology (JSE M = 99.35, SD = 13.69), anesthesiology (JSE M = 100.16, SD = 14.25), and urology (JSE M = 101.18, SD = 15.15). Except for general medicine,
the top medical specialties with the highest JSE scores (dermatology, obstetrics and gynecology, and pediatrics)
also had significantly higher percentages of women physicians. Conversely, orthopedics and surgery had significantly lower percentages of women physicians. Anesthesiology was characterized by a high percentage ofwomen (47.0%) but lower JSE scores (M = 103.61, SD = 15.0) than specialty areas.
Table 3 compares future general medicine candidates with those of other specialties. The results showed nosignificant differences in hospital-level variables. However, future general medicine candidates were less likely toinclude PGY-2 residents (40.0%, p = 0.020) and less likely to have a mentor (46.0%, p = 0.028). In addition, they
had significantly higher GM-ITE scores and significantly higher JSE scores than residents of other specialties
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ALL, n = 824 (% or SD)
Hospital-level variables
Hospital type (%)
University

98 (11.9%)

University branch

55 (6.7%)

Community

671 (81.4%)

Hospital location (%)
Urban

239 (29.0%)

Rural

585 (71.0%)

Number of beds

Mean 552.36 (SD 218.8)

Resident-level variables
Sex (%)
Men

593 (72.0%)

Women

231 (28.0%)

PGY (%)PGY-1

364 (44.2%)

PGY-2

460 (55.8%)

ED duties per month (%)
None

37 (4.5%)

1–2

130 (15.8%)

3–5

587 (71.2%)

6 or more

70 (8.5%)

Average number of inpatients in charge (%)
0–4

220 (26.7%)

5–9

497 (60.3%)

10–14

78 (9.5%)

15 or more

29 (3.5%)

Resident duty hours per week (%)
59 or fewer

298 (36.2%)

60–79

333 (40.4%)

80 or more

193 (23.4%)

Have mentor(s)?
Yes

561 (68.1%)

No

263 (31.9%)

Jefferson scale of empathy

103.61 (15.0%)

GM-ITE score46.29 (7.3%)

Table 1.  Background factors and resident characteristics. PGY postgraduate years, GM-ITE general medicine
in-training examination, ED emergency department.

(general medicine JSE M = 109.74, SD = 14.04; other specialty M = 103.2, SD = 14.96; effect size Cohen’s d = 0.436,
p = 0.003).
Finally, multiple linear regression analyses were performed using all the above hospital-level and residentlevel variables to determine whether they were relevant factors for the JSE scores (Table 4). The VIF for all items
ranged from 1.04 to 1.48, with a mean of 1.14. Among these, only the coefficients found for women (β = 2.42,
95% CI 0.10–4.7328; p = 0.041) and future general medicine candidates (β = 6.68, 95% CI 2.39–10.9; p = 0.002)
were statistically significant. Finally, a sensitivity analysis was performed, testing various in- and out-of-specialty
and item variables. However, only the above variables for women and general medicine were significant, while
the other variables, including resident- and hospital-level factors, were not significantly linked with JSE scores.

Discussion

This study used a nationwide cross-sectional survey across Japan to assess variations in empathy levels amongresidents (PGY-1 and PGY-2) based on their intended future specialty. The findings, measured using the JSE,
revealed disparities in empathy levels correlated with future specialty choices before residents’ specialty training,with the highest levels observed in those leaning toward the choice of general medicine. In addition, after adjusting for the training environment and resident level, general medicine was associated with significantly higher
empathy scores among the 19 primary medical specialties as well as with a higher number of women majoringin the field. The Cronbach’s alpha of the JSE was high for medical students (0.80) and physicians (0.80) in the US(0.84), which is comparable to the level reported for medical students (0.80) and physicians (0.81) in Japan; thisstudy demonstrated similar results (0.84)20,21. Our discussion focuses on three areas to help frame our results: (1)Scientific Reports |Vol:.(1234567890)(2023) 13:13742 |https://doi.org/10.1038/s41598-023-41011-w

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n

Mean

SD

Women (%)

General medicine

50

109.74

14.04

28.0%

p-value
0.996

Dermatology

31

106.64

16.90

51.6%

0.003
< 0.001

Obstetrics and gynecology

48

106.48

14.31

58.3%

Pediatrics

64

106.02

12.18

39.1%

0.041

Psychiatry

65

105.23

16.81

30.8%

0.609

Rehabilitation*

14

105.17

16.41

28.6%

1.0

Emergency medicine

60

104.86

14.41

28.3%

0.957

Internal medicine

325

104.60

14.56

28.0%

0.986

Pathology*

10103.80

11.54

20.0%

0.734
0.027

Otorhinolaryngology*

20

103.66

11.43

50.0%

Others*19

103.44

15.92

31.6%

0.797

Surgery90

103.39

15.32

16.7%

0.011

Plastic surgery*17102.35

17.88

29.4%

1.0

Neurosurgery*

21

102.28

11.87

23.8%

0.808

Clinical laboratory*

1

102.00

n/a

0.0%

1.0

Not yet decided

55

101.26

13.65

30.9%

0.623

Urology30

101.18

15.15

20.0%

0.318

Anesthesiology

49100.16

14.25

46.9%

0.002

Radiology*

20

99.35

13.69

20.0%

0.615

Orthopedics

51

99.21

14.34

15.7%

0.043

Ophthalmology*

17

96.00

11.99

29.4%

1.000

Table 2.  Jefferson scale of empathy mean scores and proportion of women according to future specialty
among Japanese resident physicians. *Fisher’s exact test for proportion of women doctors; otherwise, the chisquared test was used. Bold font indicates statistically significant differences.

differences in empathy by specialty, (2) potential explanations for high empathy levels among general medicine
candidates, and (3) potential explanations for high empathy among women.

Differences in empathy among each specialty. Previous research indicates that physicians employedin patient-centered specialties, such as general medicine, internal medicine, psychiatry, and pediatrics, exhibit
notably higher levels of empathy compared to those in procedure- and technology-centered specialties, such as
surgery, anesthesiology, plastic surgery, orthopedics, and n­ eurosurgery3,21,32. The findings of a Polish study areparticularly noteworthy as it highlights that family physicians display the highest levels of empathy, which aligns
with the current study’s observation of high empathy among Japanese g­ eneralists32. Although not directly comparable numerically to our study, as shown in Table 2, the empathy of residents who sought to train in procedureand technology-oriented departments tended to be lower. This trend was similar to previous ­studies16,22,24. Other
studies have suggested that a patient-centered communication style predicts medical error outcomes in primarycare physicians but not in surgeons, proceduralists, and technique-centered practice, and the reasons are still­unknown33. It remains unclear whether these disparate levels of empathy are due to self-selection into a specialty
or the result of their unique training effects and ­experiences17,24,34,35. In this study, the evidence highlights the differences in empathy levels depending on the specialty of interest that exist even before residents begin specialty
training. Several other studies have suggested that empathy may decrease after surgical ­training23,24. This may be
due to the unique empathic characteristics of surgeons, which differ from those in general medicine and internal­medicine24. Therefore, some training for personnel in specialties where empathy tends to be low may be helpful,and numerous educational studies have been ­reported19,20,36,37.
Potential explanations for high empathy levels among general medicine physicians. Sev-

eral previous studies have consistently demonstrated that physicians practicing in environments that prioritize
patient-centered principles exhibit elevated empathy ­levels3,21. Notably, the prospective general medicine physicians in our study displayed significantly higher empathy levels than the average residents. Since they wereresidents before embarking on their specialized training in general medicine, it is improbable that the influenceof their major program accounts for this difference. Instead, it is plausible that residents who initially chose topursue a career in general medicine may have prioritized empathy as a crucial factor in their decision-making
process. Thus, we must carefully consider the potential impact of the general internal medicine specialty certification program, which commenced in 2018, and its stated ­competencies38, as it may further illuminate theobserved higher empathy levels among general internists. The General Medicine Board-Certified Programs
include human-centered medicine and care (patient-centered medicine, family-oriented medicine and care, andcommunication to facilitate collaboration with patients and families) as the first of six ­competencies25,38,39. Thatis, residents who agree with the importance of these competencies are likely to further increase their empathy
scores by applying them to general medicine. In Japan, there is only a slight disparity in salaries among medical specialties, and the lack of competition allows residents to choose their specialty according to their medical
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Future general medicine candidate, n = 50

Others, n = 774

University

5 (10.00)

93 (12.02)

University branch

2 (4.00)53 (6.85)

Community

43 (86.00)

628 (81.14)

12 (24.00)

227 (29.33)

p-value

Hospital-level variables
Hospital type (%)

0.6481

Hospital location (%)

0.421

Urban
Rural

38 (76.00)

547 (70.67)

537.3 (241.1)

553.3 (217.4)

Men

36 (72.00)

557 (71.96)

Women

14 (28.00)

217 (28.04)

PGY-1

30 (60.00)

334 (43.15)

PGY-2

20 (40.00)

440 (56.85)

None

1 (2.00)

36 (4.65)

1–2

8 (16.00)

122 (15.76)

3–5

36 (72.00)

551 (71.19)

6 or more

5 (10.00)

65 (8.40)

0–4

17 (34.00)

203 (26.23)

5–9

26 (52.00)

471 (60.85)

10–14

5 (10.00)

73 (9.43)

15 or more

2 (4.00)

27 (3.49)

59 or fewer

15 (30.00)

283 (36.56)

60–79

23 (46.00)

310 (40.05)

80 or more

12 (24.00)

181 (23.39)

23 (46.00)

534 (68.99)

Number of beds

0.6148Resident-level variables
Sex (%)

0.99560.0201

PGY (%)ED duties per month (%)

0.8295

Average number of inpatients in charge (%)

0.6316

Resident duty hours per week (%)

0.61320.0275

Have mentor(s)Yes

27 (54.00)

240 (31.01)

JSE

No

109.7 (14.04)

103.2 (14.96)

0.0028

GM-ITE score48.54 (7.02)

46.14 (7.31)

0.0243

Table 3.  Comparison of future general medicine candidates with the rest of the specialties. PGY postgraduateyears, GM-ITE general medicine in-training examination, ED emergency department. Bold font indicatesstatistically significant differences.

interests and ­aptitude21. While this situation may be unique and different from that in North ­America40, theapparent high level of empathy among residents who wish to pursue general medicine adds new evidence toprevious studies.

Potential explanations for high empathy among women. Numerous studies have consistently sug-gested a higher level of empathy among women physicians and medical s­ tudents3,17,21,41,42. This finding has historically been attributed to intrinsic factors (e.g. biological and evolutionary sex differences) and extrinsic factors(e.g. socialization, sex [gender] role norms, and societal expectations)21,42. In our study of medical residents, theaverage JSE scores were higher among women, which is consistent with previous studies. At least one study fromJapan also noted that among women residents, the medical specialty choice is influenced by work-life integration(e.g. perceived balance between work and childcare)21. However, we were unable to correlate the choice of specialty among women physicians with levels of empathy found among physicians in various specialties, primarily
because of the relatively low representation of women among the residents in our study.
This study has additional limitations. First, as this was a cross-sectional study, we cannot know whether
PGY-1 residents will, in fact, enter their identified future specialty as they reported in our questionnaire. The
percentage of PGY-2 residents that aspired to become general medicine physicians was slightly lower comparedto PGY-1 residents. However, the data from PGY-2 residents are more reliable because the career paths ofalmost all residents are already determined at the time of the end-of-year examinations. Second, we excluded

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95% CI
Coefficient

Lower

Upper

p-value

Hospital-level variables
Hospital type (%)
University

0 (reference)

n/a

n/a

n/a

University branch− 0.9265− 7.3645

5.51150.7775

Community− 2.4905− 7.1342

2.15310.2925Urban

0 (reference)

n/a

n/a

n/a

Rural

− 0.6059− 3.0063

2.01750.64550.000663− 0.0055

0.006810.8322

Hospital location (%)

Number of beds
Resident-level variables
Sex (%)Men

0 (reference)

n/a

n/a

n/a

Women

2.41760.10254.73280.0407

2.642

0.617

PGY (%)PGY-1

0 (reference)

PGY-2

0.5362− 1.5695None

0 (reference)

n/a

n/a

n/a

1–2

2.9464− 2.6921

8.58480.305

ED duties per month (%)

3–5

0.8515− 4.599

6.302

0.759

6 or more

1.8245− 4.6625

8.31160.5807

Average number of inpatients in charge (%)
0–4

0 (reference)

n/a

n/a

n/a

5–9

0.664

− 1.8483

3.17620.6038

10–14− 0.08924− 4.1744

3.99590.965815 or more

− 0.2595− 6.3496

5.83050.9333

Resident duty hours per week (%)
59 or fewer

0 (reference)

n/a

n/a

n/a

60–79

1.3471− 1.0903

3.78450.278

80 or more

1.5356− 1.3346

4.40590.2936Yes

0 (reference)

n/a

n/a

n/a

No

− 0.8496− 3.1144

1.4152

0.4614

Have mentor(s)?

Future specialties
Others0 (reference)

n/a

n/a

n/a

Future general medicine candidate

6.67732.385910.9686

0.00240.1258− 0.02153

0.27320.094

GM-ITE score

Table 4.  Multivariate linear regression analysis for the Jefferson scale of empathy. PGY postgraduate years,
GM-ITE general medicine in-training examination, ED emergency department. To adjust for potential
confounders of medically significant factors associated with the Jefferson Scale of Empathy, the following
variables were incorporated in the multivariate analysis: hospital-level variables (hospital type, hospital
location, number of beds) and resident-level variables (sex, postgraduate year, ED duties per month, average
number of inpatients in charge, resident duty hours per week, study time per week, presence of a mentor(s),future general medicine candidates, and GM-ITE scores). Bold font indicates statistically significant
differences.

respondents that chose more than one specialty. The results would likely have been slightly different if they had
been included. Third, general medicine in Japan is a relatively new specialty, and the fields of general internal
medicine, hospital medicine, and family medicine overlap; hence, some residents of internal medicine might
pursue hospital medicine or general internal medicine. Fourth, the current distribution of training facilities inJapan consists of approximately 45% university hospitals and 55% city hospitals. Notably, this study’s data aresignificantly well represented by the participation of the city hospitals. This can be attributed to the pronounced
popularity of the GM-ITE among city hospitals, contributing approximately 80% of the participants, despite theinvolvement of over 630 training facilities annually. However, while there exists a disparity in the participant
ratio between university hospitals and city hospitals, the ratio of affiliations between examinees and training
participants remains nearly identical. Fifth, this study lacks specific details on the training departments chosen
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by each resident. The Japanese postgraduate clinical training requirements entail a minimum of 24 weeks ininternal medicine, 12 weeks in emergency medicine, and 4 weeks each in surgery, pediatrics, obstetrics andgynecology, psychiatry, and community medicine. However, it is essential to consider that if the residents receive
additional training in certain technology-oriented departments during the selection period, such as surgery or
anesthesiology, it could potentially impact empathy levels and, consequently, lead to different study r­ esults24.
Our survey is the first to be used nationally to reveal differences in empathy among Japanese medical residents
according to their future specialties. Our study confirms a high degree of empathy among physicians who aspire
to be general medicine physicians, a specialty that values patient-centeredness. Empathy tended to be higher
in more human-centered departments and lower in more procedure- and technology-oriented departments.
However, in multivariate analysis, only aspirations for general medicine and being a woman were linked withsignificantly higher levels of empathy. No differences were found after adjustment for other medical specialties,
training, working environment, or other factors. The findings of this study strengthen the evidence from previous
studies conducted outside of Japan. Our results may have implications of postgraduate education; for example,
empathy training strategies may be created for use in specialties wherein physicians tend to have lower empathy
scores. However, further research is needed to determine why there are differences in the levels of empathy among
applicants and to what extent these differences affect clinical practice.

Data availability

The data supporting the findings of this study are available from the corresponding author, T. W, General Medicine Center, Shimane University Hospital (e-mail. shimanegp@gmail.com), upon reasonable request.
Received: 28 February 2023; Accepted: 20 August 2023

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Acknowledgements

We thank the team members, Dr. Ichiro Kato, Dr. Seiji Odagawa, Dr. Takeshi Endo, Dr. Nobuyuki Ueno, andMrs. Kazumi Iwatani from Shimane University Hospital, General Medicine Center, for sharing their wisdom
during this research. In addition, we thank Dr. Sanjay Saint and Dr. Ashwin Gupta for their guidance and advice
in promoting clinical research in Japan.

Author contributions

T.W., T.O., N.H., Y.Ni. and Y.T. designed the study, the main conceptual ideas, and the proof outline. Y.Na., K.K.,
Y.Ni., K.S., Y.S., Y.T. collected the data via web survey on GM-ITE. T.W., K.S., Y.S. and K.K. analyzed and visualized the data. T.W., Y.N., N.H., K.K., H.K. and Y.T. aided in interpreting the results and worked on the manuscript.
T.W., Y.T., H.K., Y.S. and Y.Ni. supervised the project. T.W. wrote the whole manuscript with support from N.H.,
H.K. and Y.T. All authors discussed the results and commented on the manuscript.

Funding

This work was supported by the National Academic Research Grant Fund (JSPS KA-KENHI:20H03913). The
study sponsor had no role in the study design, data collection, analysis, or manuscript preparation.

Competing interests

The authors declare no competing interests.

Additional information

Correspondence and requests for materials should be addressed to T.W.
Reprints and permissions information is available at www.nature.com/reprints.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps andinstitutional affiliations.

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