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array:24 [ "pii" => "S2254887419300256" "issn" => "22548874" "doi" => "10.1016/j.rceng.2018.09.009" "estado" => "S300" "fechaPublicacion" => "2019-03-01" "aid" => "1564" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2018" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2019;219:73-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S001425651830239X" "issn" => "00142565" "doi" => "10.1016/j.rce.2018.09.002" "estado" => "S300" "fechaPublicacion" => "2019-03-01" "aid" => "1564" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2019;219:73-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 59 "formatos" => array:2 [ "HTML" => 39 "PDF" => 20 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original</span>" "titulo" => "Ética y empatía: relación entre razonamiento moral, sensibilidad ética y empatía en estudiantes de medicina" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "73" "paginaFinal" => "78" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Ethics and empathy: The relationship between moral reasoning, ethical sensitivity and empathy in medical students" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1184 "Ancho" => 1512 "Tamanyo" => 60857 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Relación entre puntuación del <span class="elsevierStyleItalic">Problem Identification Test</span> (PIT) de sensibilidad ética y el curso académico.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "O. Yuguero, M. Esquerda, J. Viñas, J. Soler-Gonzalez, J. Pifarré" "autores" => array:5 [ 0 => array:2 [ "nombre" => "O." "apellidos" => "Yuguero" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Esquerda" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Viñas" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Soler-Gonzalez" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Pifarré" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887419300256" "doi" => "10.1016/j.rceng.2018.09.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419300256?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S001425651830239X?idApp=WRCEE" "url" => "/00142565/0000021900000002/v1_201902270613/S001425651830239X/v1_201902270613/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2254887419300219" "issn" => "22548874" "doi" => "10.1016/j.rceng.2018.11.012" "estado" => "S300" "fechaPublicacion" => "2019-03-01" "aid" => "1604" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Rev Clin Esp. 2019;219:79-80" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 7 "formatos" => array:2 [ "HTML" => 3 "PDF" => 4 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Internal Medicine and its future in health systems. Positioning Statement of the Spanish Society of Internal Medicine and the Portuguese Society of Internal Medicine" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "79" "paginaFinal" => "80" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La Medicina Interna y su futuro en los sistemas de salud. Posicionamiento de la Sociedad Española de Medicina Interna y de la Sociedad Portuguesa de Medicina Interna" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Zapatero Gaviría, L. Campos, R. Gómez Huelgas, J. Araújo Correia, J. Díez-Manglano, V. Barreto" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Zapatero Gaviría" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Campos" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Gómez Huelgas" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Araújo Correia" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Díez-Manglano" ] 5 => array:2 [ "nombre" => "V." "apellidos" => "Barreto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256518303254" "doi" => "10.1016/j.rce.2018.11.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256518303254?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419300219?idApp=WRCEE" "url" => "/22548874/0000021900000002/v1_201902270625/S2254887419300219/v1_201902270625/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2254887419300177" "issn" => "22548874" "doi" => "10.1016/j.rceng.2018.06.007" "estado" => "S300" "fechaPublicacion" => "2019-03-01" "aid" => "1548" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2019;219:67-72" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Getting to know internal medicine mentors: New training requirements" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "67" "paginaFinal" => "72" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Conociendo a los tutores de Medicina Interna: nuevas necesidades para la formación" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 946 "Ancho" => 1584 "Tamanyo" => 87178 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Topics covered in the residents’ interviews.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Moreno Díaz, M. Aranda Sánchez, A. González Munera, P. Demelo Rodríguez, D. Martín Iglesias, C. Macía Rodíguez, C. Muñoz Muñoz, G. Ortiz Llauradó, M. Lorenzo López Reboiro, F. Salgado Ordóñez" "autores" => array:10 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Moreno Díaz" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Aranda Sánchez" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "González Munera" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Demelo Rodríguez" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Martín Iglesias" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "Macía Rodíguez" ] 6 => array:2 [ "nombre" => "C." "apellidos" => "Muñoz Muñoz" ] 7 => array:2 [ "nombre" => "G." "apellidos" => "Ortiz Llauradó" ] 8 => array:2 [ "nombre" => "M." "apellidos" => "Lorenzo López Reboiro" ] 9 => array:2 [ "nombre" => "F." "apellidos" => "Salgado Ordóñez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256518301966" "doi" => "10.1016/j.rce.2018.06.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256518301966?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419300177?idApp=WRCEE" "url" => "/22548874/0000021900000002/v1_201902270625/S2254887419300177/v1_201902270625/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Ethics and empathy: The relationship between moral reasoning, ethical sensitivity and empathy in medical students" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "73" "paginaFinal" => "78" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "O. Yuguero, M. Esquerda, J. Viñas, J. Soler-Gonzalez, J. Pifarré" "autores" => array:5 [ 0 => array:3 [ "nombre" => "O." "apellidos" => "Yuguero" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "M." "apellidos" => "Esquerda" "email" => array:1 [ 0 => "mesquerda@ibb.url.edu" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Viñas" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Soler-Gonzalez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Pifarré" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Facultad de Medicina, Universitat de Lleida, Lleida, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Institut Borja Bioètica, Universitat Ramon Llull, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sant Joan de Déu Terres de Lleida, Lleida, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "GSS-Hospital Universitari Santa Maria, Lleida, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ética y empatía: relación entre razonamiento moral, sensibilidad ética y empatía en estudiantes de medicina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1203 "Ancho" => 1532 "Tamanyo" => 62669 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Relationship between the Kohlberg P score (overall maturity) and academic year.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bioethics is an established discipline in academic settings, with a deep, implemented theoretical body, professional specialists and specific debate settings. The pending bioethical challenges of the 21st century include the full integration of bioethics in all professional settings and its consolidation in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">High-quality clinical practice includes not only improving expertise in scientific and technical aspects but also communication, managing values, ethical sensitivity and skills for assessing and managing ethical conflicts. A number of authors, such as Sheehan et al.,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> have reported that increased moral reasoning is associated with higher quality care; moreover, difficulties in managing the patient's values and concerns can result in a deficient clinical practice. The greater the empathy, the better the clinical practice and quality and the less the burnout.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A recent article indicated that physicians’ ethical development and communication skills play an essential role in high-quality care, safety and patient's quality of life but questions whether the current medical curriculum is truly effective in ensuring appropriate training in ethics and communication.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">4</span></a> The acquisition of ethical and communication skills should be a key factor in medical education.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However, numerous studies have suggested that medical students undergo very few changes in their expected moral development.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6–12</span></a> A number of studies have even shown regression in moral development during medical training, the so-called “ethical erosion”.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">According to Kohlberg's theory of moral reasoning,<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14,15</span></a> there is significant improvement in the moral reasoning stages of young adults, with rapid progression toward conventional thinking and the start of postconventionalism. However, various studies have shown that medical students, who correspond to this young adult era, do not show the expected moral progression for their age and even regress.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6–13</span></a> In the Spanish setting, one of the pioneering studies conducted at the University of Zaragoza, Spain, compared students from Zaragoza and Qatar, progressively and before and after their training in bioethics without finding moral growth.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Studies have also assessed the ethical competency of medical students in a more applied manner through “case studies”, which sought to assess “ethical sensitivity”, defined as “the ability or capacity to recognize the presence of an ethical or moral problem in a clinical case”.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a> Various authors have used vignettes to measure the development of ethical sensitivity and have achieved a good degree of validity and reliability.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">17–20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As with ethical competency, numerous studies have shown a significant reduction in the empathy of medical students during their academic career.<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">21–25</span></a> The reduction is more pronounced in men, in students with greater initial empathy, greater empathic stress or with a greater preference for their particular specialty. A number of studies, however, have shown an increase in empathy during medical training<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">26</span></a> or with appropriate training strategies.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general, there appears to be a confluence between ethical development and empathy, such that the socialization of healthcare professionals combines the acquisition of appropriate values, attitudes and behaviors,<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a> suggesting a relationship between ethical medicine and empathic medicine. Hoffman described theoretically how the development of empathy and prosocial behavior, in the setting of children and adolescents, is related to ethical and moral development.<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">29,30</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We have found no studies that have jointly analyzed these variables in the setting of medical students. A study with Japanese medical students measured the relationship between moral development and ethical sensitivity but found no relationship between the two.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Based on our literature review, we propose the hypothesis that there is a relationship in medical students between moral, ethical and empathic development and that variables such as academic year, age and sex influence this development. The aim of this study was to describe the relationship between ethics (moral reasoning and ethical sensitivity) and empathy and their relationship with other variables such as sex, age and academic year. This relationship could help in developing more extensive and inclusive training curricula that jointly incorporate ethical and empathic development and prevent burnout, whose prevalence is high among health professionals<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> and is inversely correlated with empathy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Materials and methods</span><p id="par0055" class="elsevierStylePara elsevierViewall">A cross-sectional observational study was conducted with 193 medical students of the University of Lleida, Spain. We included all first, third, fourth and fifth-year students who attended class on the day the questionnaires were administered. Given that bioethics training in Spain is taught at the start of the sixth academic year, these students did not participate in the study because we wanted the selected students to not yet have any training in this subject. The fourth and fifth-year students were recruited from one subject they performed jointly and were analyzed jointly. Participation was anonymous and voluntary and was authorized by the center. We administered a sociodemographic questionnaire (age, sex, course, origin [rural or urban], presence of family members who were in the medical profession, desired specialty), Rest's Defining Issues Test (DIT), clinical vignettes and a cognitive and emotional empathy test (<span class="elsevierStyleItalic">Test de Empatía Cognitiva y Afectiva</span>, TECA) as the measure of empathy. The team of authors trained in psychology scored the tests.</p><p id="par0060" class="elsevierStylePara elsevierViewall">To assess the stage of moral reasoning, we employed DIT, which measures the moral development stage, and an overall moral maturity score according to the Kohlberg stages.<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14,15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">To measure ethical sensitivity, we employed Hebert's clinical vignettes,<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19,20</span></a> corresponding to 4 case studies, with standardized semiqualitative correction and validated based on the judgment of experts. In brief, the case studies consisted of (1) a 58-year-old patient who experienced a massive cerebral hemorrhage, with advance directives to not resuscitate; however, the family requests resuscitation; (2) an 80-year-old woman with progressive impairment, living alone, refuses to be admitted for an examination; (3) patient with serology indicating positive for human immunodeficiency virus who does not wish to report this to their partner; and (4) a patient with cancer for whom their family requests hiding the diagnosis and information. The vignettes were translated to Spanish. All arguments considered appropriate were scored, obtaining a score for each case and an overall score.</p><p id="par0070" class="elsevierStylePara elsevierViewall">As a measure of empathy, we employed TECA,<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a> which is a 33-item instrument to assess empathy in adults, with high psychometric validity. We chose TECA because it provides information on the cognitive and affective components of empathy using 4 sub-scales: adoption of perspectives, emotional comprehension, empathic stress and empathic happiness. TECA also offers a total score for empathy. The measure is expressed as a percentage from 0% to 100%.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We performed a descriptive analysis of the study variables. To assess the association of variables among different tests, we performed a linear correlation analysis with Pearson's correlation coefficient, as well as an analysis of variance with the Bonferroni test. A <span class="elsevierStyleItalic">p</span>-value <.05 was considered statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">We included 193 students from the Faculty of Medicine of the University of Lleida. We excluded 11 students for not entirely completing the questionnaires, which hampered the scoring.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The final sample consisted of 137 women and 45 men, with a mean age of 20.1 years (standard deviation [SD], 2.2; range, 17–35 years). Of the surveyed students, 64 were first-year students, 74 were third-year, and 53 were graduate level (fourth and fifth-year); corresponding respectively to 58% of the first-year students, 70% of third-year students and 33% to fourth and fifth-year students.</p><p id="par0090" class="elsevierStylePara elsevierViewall">One hundred eighty students completed the DIT moral reasoning test, showing a predominant Kohlberg moral stage of 4 (47.8%), followed by stage 5 (35%) and stage 3 (17.2%). The mean score measuring overall maturity was 38.2 (SD, 11.6).</p><p id="par0095" class="elsevierStylePara elsevierViewall">One hundred eighty-two students completed the clinical vignettes, with a mean of 6.4 correct arguments among the 4 cases (SD, 2.4). The mean overall empathy score on the TECA was 58.9 (SD, 26.7).</p><p id="par0100" class="elsevierStylePara elsevierViewall">We found a significant relationship between moral development and greater empathy (Pearson's <span class="elsevierStyleItalic">r</span>, 0.219; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.004) and between moral development and ethical sensitivity (<span class="elsevierStyleItalic">r</span>, 0.164; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03). Likewise, the relationship between empathy and ethical sensitivity was also significant (<span class="elsevierStyleItalic">r</span>, 0.199; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.009).</p><p id="par0105" class="elsevierStylePara elsevierViewall">In terms of the empathy subscales, there was a significant difference between moral development and ethical sensitivity using the “adopting perspectives” scale. The students with higher scores on this scale had a higher moral stage (<span class="elsevierStyleItalic">r</span>, 0.203; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.008) and greater ethical sensitivity (<span class="elsevierStyleItalic">r</span>, 0.237; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.003).</p><p id="par0110" class="elsevierStylePara elsevierViewall">We found no significant differences between sex and moral maturity stage or ethical sensitivity. In terms of the measure of empathy, we found a significant difference in terms of sex (Student's <span class="elsevierStyleItalic">t</span>-test, 3.2; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.002), with the women showing higher scores (mean score, 60.2; SD, 25.6) than the men (mean score, 42.3; SD, 30.6).</p><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results according to academic year. We can see an increase in moral development between the first year and the rest (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The Bonferroni analysis showed only progression between the first and third year (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.002), with no improvement from the third year on.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">We found an increase in ethical sensitivity over the academic years (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>): the PIT score increased between the academic years (analysis of variance, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>.001) but only between the first and third year (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.004), with no increase from the third year on.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">We found no relationship between moral development and empathy on one hand and the rest of the variables on the other (e.g., origin, medical relatives and desired specialty).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">The present study is an approach to the joint measurement of moral development, ethical sensitivity and empathy in medical students of our setting. In this study, the overall P score, relative to the degree of moral reasoning, was similar to that of other studies.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> In terms of moral development, we found stagnation from the third year on, similar to that found in previous studies in other contexts.<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">7–10</span></a> A study that compared students from Zaragoza and Qatar<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> had similar results. The authors found a lack of progression in moral development in the third year, both in the Spanish and Qatari students.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the present sample, we found no progression in the degree of ethical sensitivity from the third year on, similar to previous studies.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">19,20</span></a> The mean overall score for the first-year students was low, because the students initially provided only one valid argument per vignette. However, a moderate score was achieved when the third-year students were assessed.</p><p id="par0140" class="elsevierStylePara elsevierViewall">We found a relationship between moral reasoning and ethical sensitivity. The only previous study in the literature, which included Japanese medical students, did not find a relationship between these variables.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> We believe that this difference lies in the fact that the objective of the study by Akabayashi et al.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> was to design a brief and objective measure to assess students and that they only used a part of the DIT, to assess moral reasoning, and a Japanese adaptation of the Hebert vignettes to measure ethical sensitivity, with different clinical scenarios than those used initially. The results of the Japanese study are therefore not entirely comparable to our study's results.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The scarce progression in moral reasoning and ethical sensitivity in our study sample confirms the “lack of ethical progression” among medical students as described by Culver et al.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> This phenomenon was not reproduced in other university studies, which observed a marked increase in moral reasoning, the so-called “college effect”.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">34</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Numerous reasons have been provided for the lack of progression in the moral and ethical evolution of medical students. Hafferty et al. emphasized the importance of the “hidden curriculum” as opposed to the explicit training in medical ethics and communication.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> For these authors, the values, attitudes and behaviors in medical education are basically learned by socializing and “In fact, what is ‘taught’ in this hidden curriculum often can be antithetical to the goals and content of those courses that are formally offered”.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> Similarly, Hren et al. observed that the hidden curriculum sometimes offers opposite values to the explicit curriculum, as well as inconsistencies and mixed messages.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a> These contradictions can affect the development of moral reasoning and empathy and lead to “ethical erosion”. Less empathy has been associated with greater burnout.<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36,37</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Offri described medical socialization as an intensely disorienting experience, in which students need to learn medicine and how to be physicians.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a> Medical students need to acquire an enormous quantity of new skills (learning hospital language and jargon, interacting with patients and their families, dealing with errors, clinical rotations and emergencies, etc.). A large part of what we have learned about ethics and patient-doctor communication is very difficult to apply to the reality of patient care. Students observe how medical mentors behave and how they interact with patients, interactions that sometimes do not correspond to what they have studied.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Other authors have identified various factors in medical education that can inhibit the moral and empathic development in clinical practice, such as academic pressure, the need to adhere to unwritten standards and rules to survive and the lack of support for ethical problems or for making them explicit.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">5,6,13</span></a> In the experience of Feudtner et al., “ethical erosion” can be related to increased cynicism, at times implicit, in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> Hafferty argues that any attempt to develop an exhaustive medical curriculum should recognize the importance of the hidden curriculum and extensive social-cultural medium.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our sample, a more mature moral sense, greater empathy and greater ethical sensitivity were highly inter-related. According to Hoffman,<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">29,30</span></a> there is a parallel between feelings and emotions on one hand and thoughts and moral principles on the other. This parallelism determines the behavioral trends. According to this theory, empathy and moral development are intimately linked, such that, in the individual's development, empathic feelings trigger moral principles and guide both behavior and decision making.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Based on our study's results, we believe it is important to consider both settings, ethical-moral and empathy, when designing and assessing the training curriculum in bioethics, so as to ensure not only ethical competency but also the development of empathy and emotional competency. The more comprehensive approach to training in ethics and communication, including the factors related to medical socialization, the development of values and attitudes<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36,39</span></a> regarding communication aspects and the hidden curriculum, all contribute to developing more ethical and empathic physicians.</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study limitations and proposals</span><p id="par0175" class="elsevierStylePara elsevierViewall">One of the study limitations was its cross-sectional and nonlongitudinal nature. Although we cannot ensure that there were no other factors that influenced the results, we found no cultural or academic differences between the different academic years. Another of the study limitations was that we did not measure the impact of bioethical training, because the main objective was to assess the relationship between variables. Lastly, the submitted results correspond to a single faculty of medicine. As a proposal for future studies, it would be important to assess the influence of teaching in bioethics on the analyzed variables, widen the sample and include various medical schools.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">The results of this study have helped us understand the characteristics of a group of medical students regarding their moral development, ethical sensitivity and empathy. We found a correlation between the 3 variables, such that students who were more mature morally presented greater ethical sensitivity and empathy. In this respect, we believe a more global and complete approach is needed for training in communication and ethics, which facilitates the acquisition of appropriate attitudes, values and behaviors, preventing ethical erosion and promoting higher quality care.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1156242" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1083481" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1156241" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0025" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1083482" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Study limitations and proposals" ] ] ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack394593" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-22" "fechaAceptado" => "2018-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1083481" "palabras" => array:6 [ 0 => "Bioethics" 1 => "Medical education" 2 => "Moral reasoning" 3 => "Ethics sensitivity" 4 => "Empathy" 5 => "Medical students" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1083482" "palabras" => array:6 [ 0 => "Bioética" 1 => "Educación médica" 2 => "Razonamiento moral" 3 => "Sensibilidad ética" 4 => "Empatía" 5 => "Estudiantes medicina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High-quality clinical practice includes not only improving clinicians’ expertise in scientific and technical aspects but also managing values, ethical sensitivity and skills for assessing and dealing with ethical conflicts. The reviewed literature suggests the presence of an “ethical erosion”, according to which ethical competence and empathy decrease or do not progress during medical training. The aim of this study was to determine the relationship between ethics (moral reasoning and ethical sensitivity) and empathy in a group of medical students and to determine the relationship with other variables such as academic year and sex.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional observational study was conducted with 193 medical students from different academic years, who were administered a sociodemographic questionnaire, the Rest sociomoral dilemma test, clinical vignettes to measure ethical sensitivity (Problem Identification Test [PIT]) and a cognitive and emotional empathy test (<span class="elsevierStyleItalic">test de empatía cognitiva y afectiva</span>, TECA).</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We found a direct and significant relationship between moral development, ethical sensitivity and greater empathy. We detected an increase in moral reasoning and ethical sensitivity among first and third-year students, with no increase between the third year and later academic years. There were no significant differences between these variables and sex.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">This study found a correlation between moral reasoning, ethical sensitivity and empathy and a lack of progression of the first 2 variables in the last years of the medical degree.</p></span>" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0005" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La práctica clínica de calidad no incluye tan solo la mejora de conocimientos en aspectos científicos y técnicos, sino también en la gestión de valores, la sensibilidad ética y las habilidades en la valoración y manejo de los conflictos éticos. La literatura revisada sugiere la existencia de la llamada «erosión ética», según la cual la competencia ética y la empatía disminuyen, o no progresan, durante la formación médica. La finalidad del presente estudio es determinar la relación entre estas variables: ética (razonamiento moral y sensibilidad ética) y empatía en un grupo de estudiantes de medicina, así como determinar la relación con otras variables como el curso académico y el género.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material y método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional transversal realizado a 193 estudiantes de medicina de diferentes cursos. Se les administró un cuestionario sociodemográfico, escala de dilemas sociomorales de Rest, viñetas clínicas de medida de sensibilidad ética <span class="elsevierStyleItalic">(Problem Identification Test)</span> y el Test de empatía cognitiva y afectiva.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se halló una relación directa y significativa entre desarrollo moral, la sensibilidad ética y la mayor empatía. Se detectó un incremento de razonamiento moral y sensibilidad ética entre los alumnos de 1.° y 3.°, sin incremento entre 3.° y cursos superiores. No se encontraron diferencias significativas entre estas variables y el género.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En este estudio se ha hallado una correlación entre razonamiento moral, sensibilidad ética y empatía, así como una falta de progresión de las 2 primeras variables en los últimos cursos del grado de medicina.</p></span>" "secciones" => array:4 [ 0 => array:1 [ "identificador" => "abst0025" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Yuguero O, Esquerda M, Viñas J, Soler-Gonzalez J, Pifarré J. Ética y empatía: relación entre razonamiento moral, sensibilidad ética y empatía en estudiantes de medicina. Rev Clin Esp. 2019;219:73–78.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1203 "Ancho" => 1532 "Tamanyo" => 62669 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Relationship between the Kohlberg P score (overall maturity) and academic year.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1184 "Ancho" => 1512 "Tamanyo" => 59817 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Relationship between the Problem Identification Test score on ethical sensitivity and academic year.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: PIT, Problem Identification Test (measure of ethical sensitivity); SD, standard deviation.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">First year (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>64)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Third year (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>74)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Graduate level (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>53)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>191)</th><th class="td" title="table-head " align="left" valign="top" scope="col">ANOVA \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Moral development</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moral stage P score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.6 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">191 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.2 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.1<br><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Ethical sensitivity</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total PIT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.5 (2.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (2.23) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">181 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.5 (2.44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.8<br><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Empathy</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.3 (26.82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.5 (27.15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.3 (26.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">172 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (26.92) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.9<br>.119 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1974098.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Moral, empathic and ethical sensitivity development depending on the academic year.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0200" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Teaching medical ethics: some persistent questions and some responses" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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