Thesis Correlation of empathy and personality traits among final year medical students in a public sector medical college A THESIS IS SUBMITTED TO UNIVERSITY OF HEALTH SCIENCES IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF Masters of Health Professional Education (MHPE) Submitted By Dr. Naeem Liaqat Supervisor Dr. Muhammad Shahzad Anwar MHPE Batch IV-B Department of Medical Education University of Health Sciences Lahore – Pakistan Certificate It is certified that this thesis is submitted based on the results of the study conducted by Dr. Naeem Liaqat and that it has not been presented before for MHPE degree. Dr. Naeem Liaqat has done this research work under my supervision. He has fulfilled all requirements and is qualified to submit the accompanying thesis for the degree of MHPE Prof. Muhammad Shahzad Anwer Supervisor MHPE Candidate II AUTHOR’s DECLARATION I, Dr. Naeem Liaqat hereby state that my MHPE thesis titled Correlation of empathy and personality traits among final year medical students in a public sector medical college is my own work and has not been submitted previously by me for taking any degree from University of Health Sciences or anywhere else in the country/world. At any time if my statement is found to be incorrect even after my Graduate the university has the right to withdraw my degree. Dr. Naeem Liaqat 30th August, 2020 III ACKNOWLEDGMENT Any research of this type cannot be completed without the help of many individuals. At this stage of completion of my research it is a great pleasure for me to acknowledge all of them who helped me and encouraged me to look forward and work hard till I achieve success. No words are noble and no sayings are worthy without praise of God, who gave me strength and capabilities to start the research and took it to the height of completion. It will be wrong if I forget to mention the prayers and sincere wishes of my family members. They all supported me at every strong and weak moment of life. My father, whose encouragement and prayers always showed me the path to achieve success at every step of my life. My special gratitude and thanks to my supervisor Dr. Muhammad Shahzad Anwar who is a dynamic personality and a great teacher. He helped me in compiling this research and guided me every time I needed any suggestions. I am very thankful to him for providing his valuable time for completion of my research. It is impossible to ignore my younger, who more than a brother helped me like my best friend in every single technical point in completion of this project. I am also thankful to all my teachers who taught me from very beginning and made me reach this level. IV At the end my special thanks to all the participants, who were part of my research. They were all great human beings who supported me by taking part in this research activity. May god give them a happy and healthy life. V DEDICATION I dedicate this research to my Parents and my family VI TABLE OF CONTENTS Certificate ............................................................................................................ ii Acknowledgement… .......................................................................................... iii Author’s Declaration …………………………………………………………iv Dedication ............................................................................................................v Table of Contents ............................................................................................... vi List of Abbreviations ........................................................................................ vii List of Tables .................................................................................................... viii List of Figures .................................................................................................... ix Abstract… ............................................................................................................x CHAPTERS Introduction .........................................................................................................1 Literature Review ................................................................................................6 Materials & Methods.........................................................................................47 Results .................................................................................................................51 Discussion ...........................................................................................................63 Conclusions and Recommendations.................................................................65 References...........................................................................................................68 Proforma Annexure I …………………………………………………………………....87 …………………………………………………………………93 Annexure II ………………………………………………………………….94 Annexure III …………………………………………………………………95 VII LIST OF ABBREVIATIONS BFI Big Five Inventory CS Conditioned Stimulus FFM Five-Factor Model LMX Leader-Member Exchange MRI Magnetic Resonance Imaging fMRI Functional Magnetic Resonance Imaging IRI Interpersonal Reactivity Index mPFC Medial Prefrontal Cortex sgACC Subgenual Anterior Cingulate Cortex TPJ Temporo-parietal Junction VS Ventral Striatum VIII List of Tables Table# Title Page# Table-1 Different measure for assessing Empathy 23 Table-2 Empathy scale and its values 54 Table-3 Mean scores of Empathy scale 57 Table-4 Total empathy score was compared according to gender 58 Table-5 The personalities of participants as per BFI 59 Table-6 The personality traits were compared in both groups 60 according to gender Table-7 Correlation of Empathy and BFI IX 61 List of Figures Figure# Title Page No. Figure-1 Empathy in animals 13 Figure-2 19 Figure-3 Overview of key regions associated with four forms of empathy Regions of brain involved in empathy Figure-4 Big Five personality traits 26 Figure-5 Six facets of Openness to Experience 29 Figure-6 Six facets of Extraversion 35 Figure-7 The dark triad 37 Figure-8 Six facets of Agreeableness 38 Figure-9 Six facets of Neuroticism 41 Figure-10 Six facets of Conscientiousness 43 Figure-11 Gender distribution of participants in the study 53 Figure-12 Correlation of Empathy and BFI 62 X 20 Abstract: Introduction: As the personality traits of the medical students are particularly different than those in other professions, the empathy among them may have a correlation with these traits. Given this assumption, this study was designed Objective: To measure different personality traits of medical students in a public sector medical college To measure empathy of medical students in a public sector medical college To correlate empathy with personality traits among medical students in a public sector medical college. Material and Methods: This correlational study was conducted over a period of 2 months at Rawalpindi Medical University (RMU), Rawalpindi. All medical students of final year MBBS studying at RMU were included. All the participants were given the Questionnaire which included 3 portions: 1) Biodata, 2) Tool for Big Five Invenotry (BFI), and 3) Tool for Empathy (Interpersonal Reliability Index). All data was analyzed using SPSS version 26. Results: A total of 270 students were included in the study. The mean age of participants was found to be 22.35 ± 1.16 years (Range: 19-26 years). They were divided into two groups and most of the participants (56.7%) had age ≥22 years (Table 1). Most of the participants were female in this study (Figure 1). The total mean Empathy score was found to be 61.60 ± 10.99. Maximum score was observed for Perspective-taking subscale XI followed by Fantasy subscale, personal distress and Empathic concerns. The mean score was higher for total empathy score and all its subscales among those Age ≥22 years. total empathy scale and its all subscales were higher among female participants than male. This difference was significantly higher in the subscale of Empathic concern (p=0.044), Personal distress (p=0.019) and Total empathy score (0.014). The personalities of participants were assessed in 5 scales as per BFI and total scores are given in table 6. The highest mean score was noted for Openness (34.41) and Agreeableness (32.77). In all five domains, personalities were comparable and no significant difference was observed in two age groups. It was found that females were having significantly more Extroversion than males (p=0.038). Females also had higher score in Agreeableness, Conscientiousness, Neuroticism and Openness than male, however this difference was not significant. Total empathy score and its subscales were correlated with personality traits and it showed moderate to week correlation with all personality traits. The strongest positive correlation was found between personal distress subscale and Neuroticism (r=0.488), followed by perspective taking and Agreeableness (r=0.350) and empathic concern and Openness (r=0.341). The strongest negative correlation was found between personal distress and Conscientiousness (r= -0.267), personal distress and Extroversion (r= -0.189) and perspective taking and Extroversion (r= -0.134). Conclusion: It is concluded that Empathy and personality had a significant correlation. These results can help to us to design individualized programs to improve empathy in medical students. So I recommend more training sessions for medical students to incorporate Empathy among them keeping in consideration their personality traits. Keywords: XII Medical students; Empathy; Personality traits; Correlation; Big five; Interpersonal Reliability Index XIII Introduction: Empathy is ability of physician to understand the feelings and perspective of patients and to understand the situation through which he/she is passing through. It is a complex phenomenon which enables the physician to understand the feelings of patient and respond them accordingly maintaining the respect, altruism and sympathetic behavior (Epley et al. , 2004). In medical practice, role of empathy can never be over-emphasized. It definitely improves compliance of patients, their trust upon the physician and patientdoctor relationship. This better patient-doctor relationship ultimately turns up into better patient outcomes and clinical results (Derksen et al. , 2013, Jordan and Foster, 2016). Empathy improves patient’s satisfaction and facilitates early and accurate diagnosis. Patients in many studies have reported lesser distress, better and more comfortable zone and trust over the doctor, when doctor is more empathetic (Zachariae et al. , 2003) As both domains of empathy including affective and cognitive have been understood deeply and in a better way now by medical personnels and educationists, so importance of empathy has increased among curriculum designers and they consider it important to create an environment conducive to learn empathy. Therefore, recently, the medical educationists have put forward their attention towards this important aspect and there is a continuous focus to impart empathy into medical students and to teach them empathy as part of curriculum (Mooradian et al. , 2011). The word "personality" is derived from the Latin word “persona”, which means “mask”. Personality of any person usually refers to the differences in particular and 1 individual ways of thinking, feeling and behaving. A trait on the other hand is a distinguishing quality or characteristic, so personality trait is basically a particular feature attributed to a person with a specific personality type. Personality type refers to the psychological classification of different types of people. However, there is a clear-cut difference between personality types and personality traits. Personality type is a grouping based on shared characteristics, and personality trait is a specific quality. Everybody is born with a different and distinct personality. It is not humanly possible to assess all aspects of a personality and categorize it. Previously Gordon Allport has listed even few thousand personality traits, a person could have. However, few attempts have been made and most of the researchers are now agreed that five traits or personality types when combined give a clearer picture of the personality of a person (McCrae and Costa, 2003). This combination of five traits is called a five-factor model or sometimes as Big Five traits. The five factors have been defined as Openness, Conscientiousness , Extroversion, Agreeableness, and Neuroticism, usually abbreviated as OCEAN or CANOE. These five factors describe the essential traits that are the building blocks of a personality. All these five factors are not just a word; rather they describe a whole personality behind ever trait (Babaei et al. , 2018). In order to assess these five traits, man tools are available including Big Five Inventor (BFI), Neo Personality Inventor, International Personality Item Pool and self-reported questionnaires. However, most famous and most validated is BFI (Hamby et al. , 2016). BFI also called five factor model is a fundamental concept that evolved with the efforts of a number of psychologists. Ernest Tupes and Raymond Christal narrowed down 2 various aspects of personality traits into five basic factors which they labeled: "surgency", "agreeableness", "dependability", "emotional stability", and "culture". Warren Norman subsequently relabeled "dependability" as "conscientiousness" (Funicelli, 2012). Big five traits in their present form are as follows: Extraversion: This parameter compares an extrovert person with an introvert person. Extraversion depicts assertiveness, sociability, and talkativeness. A person with a low score on extraversion may be regarded as cold/aloof and one with high score may be considered attention-seeking and domineering/bossy. Agreeableness: simply defines helpful and trusting nature of a person which make him/her a socially acceptable figure. Contrary to that a person with low agreeableness may be regarded as a social outcast or argumentative personality. Conscientiousness: high score shows that a person is always prepared and plans beforehand. Low score is indicator of a spontaneous behavior. Openness: gives a picture of how much a person is receptive for intellectual ideas, and variety of experience. People with high score on this are said to eventually achieve “selfactualization” and those with low score are considered pragmatic or even conservative. Neuroticism: A person on its lower pole is considered emotionally stable and one on upper pole is thought to be a nervous person (McCrae and Costa Jr, 1999). It has been shown in researches that different personality traits are associated with certain behaviors, learning process and aptitudes. Similarly, personality traits have been studies with empathy in some studies previously. In a study conducted on Portuguese medical students, it was found that agreeableness and openness are more associated with empathy. (Costa et al. , 2014). In another study conducted on first year 3 medical students, empathy was associated with higher sociability and lower aggressive hostility (Hojat et al. , 2005). In another study on Chinese medical students, it was fond that agreeableness was strongly associated with higher empathy scores (Song and Shi, 2017). Among medical students in Pakistan, limited studies have been done to assess empathy and both of these studies have shown variable results (Bangash et al. , 2013, Imran et al. , 2013). In a study (Costa, Alves, 2014) conducted on Portuguese medical students, it was found that agreeableness and openness are more associated with empathy. In a study (Song and Shi, 2017) including 560 medical students from China, authors administered Big Five Invenotry (BFI) and Interpersonal Reactivity Index (IRI) to determine a correlation among these. They found they Agreeableness was strongly associated with empathic concern and moderately associated with perspective taking. Neuroticism was strongly associated with personal distress and moderately associated with perspective taking. Also, Openness was moderately associated with perspective taking and personal distress. In a study, authors included one hundred &fifty medical students to determine the correlation between empathy and personality traits. They found there was a significant correlation between empathy and each of the five domains of personality. Note that for neuroticism, the correlation was inverse, while for the other four domains, the correlation was positive. In a study by Magalhaes et al, (Magalhaes et al. , 2012), authors included 350 students from consecutive six classes entering in the medical school. They used JSPE scale for determining the empathy and correlated it with personality traits. They found that total 4 score of JSPE scale was positively associated with Openness, Agreeableness and Conscientiousness. In a study authors (Lourinho and Severo, 2013) have found a strong positive correlations between the total score of IRI with agreeableness and openness. Regarding the subscales of empathy, they found that personal distress was positively associated with Neuroticism and Empathetic Concern was positively correlated with Extraversion. To my knowledge, no study has been conducted on medical students to assess their personality traits in Pakistan. Medical students are the future doctors and need to be trained to the best in order to improve our healthcare services. And as per dramatic rise in conflicts among doctors and patients in our society, it is imperative to assess the level of empathy of our future physicians and as well their personality traits. In order to formulate empathy promoting culture for our medical students in our country with its own culture and social setup, the first step may be to determine the personality traits and current level of empathy of our medical students. The manuscript will be a pilot project looking at empathy and personality traits of medical students in their final year of studies in a public sector medical college and mat serve as a baseline for future work in this area. By understanding personality traits, students can be provided with appropriate support during counselling and assistance in improving their communication skills in order to prepare them better for future challenges arising in our county. 5 Literature Review Empathy Empathy is the ability to step outside of your own bubble and into the bubbles of other people. (C. Joybell) Have compassion and empathy in your heart. Many people are suffering deep emotional anguish beneath the surface of their lives, and smile even as they hurt inside. (Jim Palmer) The usage of term “empathy’ is not very old and dates back to a century almost, but this concept had been a. part of medical practice since ages. Though being an old concept, there hasn’t been a consensus yet over its definition and there had been around 50 definitions in the literature (Cuff et al. , 2016). This was described for the first time in English by the British critic and author, Vernon Lee, who explained the word “empathy”. Definition of Empathy: As there are certain types of empathy, therefore, in defining it, same problem has been faced and consideration whether it is primarily a cognitive construct, an affective construct or both. Another issue in understanding the empathy concerns had been the process by which a person understands and shares other’s mental states. Frans de Waal defines it as: ‘the capacity to be affected by and share the emotional state of another, assess the reasons 6 for the other's state, and identify with the other adopting his or her perspective’ (PerezManrique and Gomila, 2018). Baron-Cohen & Wheelwright define empathy as “…the drive or ability to attribute mental states to another person/animal, [which] entails an appropriate affective response in the observer to the other person’s mental state”. In these terms, empathy is comprised, not just understanding and feeling another's perspective, yet additionally reacting after understanding the feeling of the beholder. Empathy definition must include caring for other people as well as the desire for helping others, understand the emotions and feelings of other person and making no difference between oneself and others. Some authors believe empathy as being able to have the matching of emotions of other people, while others think that empathy means to have a soft corner towards other persons. Having empathy means to understand that the decision making is a complex process and among many factors influencing decision making, past experiences, upbringing and thought process play an important role. Once we understand this concept, it becomes easy to understand other person which might be taking an illogical decision as per our understanding. Perspective taking is understanding the emotional condition of other person and identifying their story and narrative (for example understanding of the feelings, or cognitive empathy) (Dadds et al. , 2009), which brings to the observer’s mind shared representations of those emotions automatically. Carrying these common thoughts to mind prompts a comparable empathetic state in both (De Waal, 2008).This is known as emotional empathy (Dadds, Hawes, 2009) or empathic concern (Baron-Cohen and 7 Wheelwright, 2004). Another important concept which is an integral part of this definition is emotional reactivity, which is the physiological response of the person to the emotions of others (Baron-Cohen and Wheelwright, 2004). There are some other terms at the same time which are associated with empathy but have a slightly different meanings and understandings. Compassion is defined as an emotion which we feel when we see someone in a need for help and it motivates us to help others. Sympathy is a feeling of care and understanding for someone in need. Similarly pity and emotional contagion are different than empathy. Pity is a sympathetic feeling which is felt when someone saws others in distress or difficulties as they can’t solve their problems rather feel “sorry’ for them. Classification of Empathy: There are broadly three types of empathy: a) Affective empathy b) Cognitive empathy c) Somatic empathy i) Affective empathy: It is sometimes also called as emotional empathy as it is a capacity to understand the emotions of other persons. It can further be classified into Empathic concern and Personal distress. Empathic Concern: it is the feeling of sympathy or compassion after seeing someone in problem or distress Personal distress: It is a the feeling of distress and discomfort after 8 watching others in difficult situations and sufferings. It is important to narrate that feeling of emotions or distress or compassion don’t necessariy explain the problems and situations of other persons, rather it is a self-distress after seeing others in trouble. More empathic concern, there is more desire to help others and it has been evident while observing people to help injured or unknown suferers on a raod although the injured person is stranger, they try to help them. ii) Cognitive empathy: It is the capacity to understand the other’s perspective. Affective and cognitive empathy are different concepts as one deals with that the emotions while other is understanding the situation of other person. So, if a person has a strong cognitive empathy, he may not have that strong emotional empathy. A common example which may be narrated is that after seeing someone in trouble during a road traffic accident, some person may move forward to help which others may start crying at their own place. So, both of these concepts may be held together, or may be different ratios of these be present in a person. There are 2 main types of cognitive empathy: Perspective Taking: to understand and adopt other’s perspective Fantasy subscle: tendency to fantasize or idealize others situation Scope of empathy and related factors: a) Empathy in animals A significant literature has shown that concept of empathy is not only limited to humans; rather it is found in animals and neuroscience has proven this concept. Many reports saying that Dolphins had saved human beings from drowning and other animal 9 attacks is an example. Empathy is conveyed through spindle cells and they have been found three times in number among aquatic mammals like Cetaceans than humans which makes them social friendly and gives them the awareness of feeling of others (Bekoff, 2009). Animals, whether free or kept in zoo, have shown empathetic behavior. Rats have shown their empathy to make a struggle to help their mates trapped. Different tales like Dolphins saving their mates from trapping, gentleness of Elephants and other animals have been narrated since ages (Perez-Manrique and Gomila, 2018). Palagi E and Norsica tested three hypothesis, self-protection hypothesis, victim-protection hypothesis, relationship-repair hypotheses among Aonobos by collecting data over 10 years duration. They also looked into the factors which affect the distribution of these traits. They reported that the consolation seen among Bonobos may be Empathy-based phenomenon (Palagi and Norscia, 2013). Similarly, in slaughter houses, where animals are slaughtered in front of each other, stress and empathy has been observed among animals when they hear, see or smell other mates being slaughtered. This inhuman handling causes fear and stress among them. Therefore, Islam has strictly forbidden the slaughtering of animals inform of other animals (Khan et al. , 2018). As per Jean Decety, who is working as a neurobiologist at University of Chicago, empathy is not something specific to humans. According to him, there is strong evidence that empathy has deep evolutionary, biochemical, and neurological underpinnings, and that even the most advanced forms of empathy in humans are built on more basic forms and remain connected to core mechanisms associated with affective communication and social attachments (Decety, 2011). The neuroimaging has documented a circuit of brain parts involving brainstem, amygdala, hypothalamus, basal ganglia, insula 10 and orbitofrontal cortex. These parts are supposed to be taking part in human behavior, care and empathy. However, humans have a more distinct function than animals and that is the cognitive ability which helps them execute different functions, mentalizing and language (Decety, 2011). b) Empathy in children Previously it was thought that children don’t have a capacity to empathize; however, later many researchers confirmed that children do have and exhibit different levels of empathy from very younger ages. They are able to display their empathetic behaviors in a variety of ways. However, it is not easy to measure the complex processes like empathy in younger children because of their non-verbal expresses. One way of determining the empathy in children is to examine their distress while they observe others in difficulties or distress. In neonatal life, even being at first few days of life, neonates start crying when they hear cry of another neonate, which is formally labeled as “reflective crying’. They have shown more reflective crying and distress after hearing another infant’s cry than the control stimuli which included synthetic cry sounds, noise, silence, or their own cry (McDonald and Messinger, 2011). This response of cry of a neonate is not just a simple cry, but it is indicator of early development of empathy which can be expressed only in this way. In infantile age, they tend to develop a feeling of personal distress after observing others in distress. In this age, they can’t differentiate between self and others and have limited basic regulation capacity for their emotions. Young infants, usually become distressed when they observe negative emotions of other people around then and they may engage in behaviors, 11 such as self-comforting, to reduce their own distress. As they grow older and are able to differentiate between themselves and others (self-other differentiation) and are better able to express their emotions in the second year of life, there appears to be a transformation from concern for the self to a capability for concern for the others (Knafo et al. , 2008). Toddler life has been considered as one of the most important phases for development of empathy in the life of a person. In a recent study Huang H et al (Huang et al. , 2017) included 84 Chinese toddlers to observe the developmental trends of different components of empathy and factors related to development of empathy among them. Among these participants, empathetic responses were assessed while exposing them to observe three simulated distress procedures being performed on the primary care-giver, another unacquainted adult and baby doll. They measured different manifestations of empathic responding, including concern (e.g., sad look, “I’m sorry”), hypothesis testing (e.g., “What happened?”), prosocial behavior (e.g., hugs, “Are you ok?”), as well as precursors to empathy such as personal distress and self-referential behaviors (i.e., “trying on” another’s experience). Many of these behaviors underwent significant development over the second year of life, with age related increases in empathic concern, hypothesis testing, and prosocial behavior between 14 and 24 months of age. Authors concluded that empathy among toddlers contained three factors namely sympathy, personal distress and orientation. Toddlers in this age-group are thought to be other-centered rather being self-centered, so they behave whatever they observe. As the children grow and enter in pre-school age group, their cognitive empathy component develops. It may be because in this age-group, they start developing speech, can express themselves and start verbalizing, so accessors can access this component of 12 Figure 1: Empathy in animals 13 empathy also as it is difficult before this age. By this age, they are able to take another’s perspective in false belief tasks. In false belief tasks, children are exposed to an experiment in which one person enters the room and places a thing at a particular place and then leave the room. Later on, another person enters the rooms, picks that thing up and relocates it to another place and leaves the room. Now first person enters the room again and looks for that particular item and on asking the child about location, child will point to the first location where he left it. It indicates that as per theory of mind, child has a limited perspective of the situation. The trajectory of development of these character remained the same in all cultures, as shown y a meta-analysis conducted by Wellman et al (Wellman et al. , 2001). In a study conducted in 2008 by Decety J et al from University of Chicago found that children within the age group of 7 to 12 years have the tendency to feel empathy while they observe others in distress. They used functional MRI while presenting children to short videos which had animated visuals of painful and non-painful situations. Similar to adults, the neuronal pathway of empathy among these 17 children, was activated and this pathway included insula, somatosensory cortex, anterior midcingulate cortex, periaqueductal gray, and supplementary motor area (Decety et al. , 2008). c) Empathy in different genders In a general perception, and supported by many studies, female gender has more empathy than males. However, many meta-analysis, systematic reviews, randomized trials and neuroimaging have shown mixed findings with no difference in two genders. Many authors do argue that these differences which are shown to be higher among females are not spatial as they are reported to be higher in self-reported proforma and scales. Similarly, 14 females have shown higher scores on Empathy Quotient than males. Yang CY and colleagues conducted a study measuring electroencephalography determining the mu receptor suppression among both genders. They included equal number of males and females and let them experience both painful and non-painful situations. They found that although both genders showed mu receptor suppression, but it was higher among females. Also they found that this mu receptor suppression was correlated with personal distress in IRI scale of empathy. Their findings confirm the presence of higher empathy at brain level even than males (Yang et al. , 2009). d) Empathy in different environments Many environmental factors like parental relationships, parental style, brought up of a person, family structure and a lot others may have a role to play. These factors have an important impact on development of empathy. Empathy help the person to process the aggression and help promote prosocial relationships. An interesting study conducted as PhD thesis by Tisot in 2003 tried to look at different environmental factors which may have an impact on empathy development among children. Author looked at the impact of parenting style, empathy of parents and previous social experiences onto the empathy of children. All the children included in the study were assessed for effective empathy and parents of these children were requested to fill the questionnaires related to parental practices and balanced emotional empathy scale. Author found that not all parenting styles, but a few practices had a role to play in the development of empathy in children. These parental gestures and practices included the encouragement of children to think about the other’s perspectives, and teaching them to reflect in own’s feelings. It was also found that empathy had a varied 15 development depending upon the gender of the child as well as parent. Another important factor was parental warmth which had significant positive correlation with empathy, particularly in boys. And maternal warmth had a negative correlation, particularly in females (Tisot, 2003). e) Genetic role in Empathy Many genes have also been thought to be having a role in Empathy and it is not only the environmental factors which play a role. Gene 5-HTTLPR determines the sensitivity to negative emotions and it is further enhanced by the deletion variant of ADRA2b. Higher social skills and enhanced self-esteem was found among carriers of double G variant of OXTR gene. Increased and higher activation of Amygdala was seen after viewing emotionally arousing situations among those who have deletion variant of ADRA2B gene. Another gene located on Chromosome 3 has the ability to control human ability to respond to other’s emotions (Naudts et al. , 2012, Warrier et al. , 2018). f) Empathy in different countries Difference in diffent cultures and countries have been postulated and reported. An interesting question remains that why this difference in countries exists. In many countries, socializing and communication particularly on individualized or cultural basis, cultural practices may lead to different levels of empathy. In a study published in Journal of Cross16 Cultural Psychology in 2016, authors aimed to determine the cultural variation of empathy. They included 104,365 participants from 63 countries globally and found that levels of empathy do vary from country to country. They found that those countries who have higher levels of empathy also had higher levels of Conscientiousness, self-esteem and prosocial behavior. Among included countries in the survey, they found that highest levels of empathy included Ecuador, Saudi Arabia, Peru, Denmark and United Arab Emirates. The lowest ranking countries in this survey found were Bulgaria, Poland, Estonia, Venezuela and Lithuania (Chopik et al. , 2017). Neuroscientific basis of empathy: The ability of a person to understand and process the emotions has a particular basis and this neural channel has been understood well due to better imaging studies. Similarly, the process of empathy can be delineated and explained in a better way. It has been observed that people who have a higher empathy as detected by certain tests and measures, have busy mirror neurons and their pathways. Emotional empathy for negative emotion is associated with activity in dorsal mid- anterior cingulate cortex (dmACC) and amygdala; emotional empathy for positive emotion is associate with activity in medial prefrontal cortex (mPFC); cognitive empathy (mentalizing) is associated with activity in mPFC, temporo-parietal junction (TPJ) and precuneus; and empathic concern is associated with activity in amygdala, ventral striatum (VS), subgenual anterior cingulate cortex (sgACC), and periaqueductal gray (PAG). In a recently publish meta-analysis in 2019, Xiong RC et al had the objective to determine the signal pattern of empathy in the brains caused by facial expressions of pain. 17 They included a total of 178 participants from 8 trials and found that anterior cingulate cortex (BA32), anterior central gyrus (BA44), fusiform gyrus, and insula (BA13) were the main regions of the brain which were positively activated (Xiong et al. , 2019). For activation of empathy and its response, both affective and cognitive empathy need to be activated and interestingly both pathways are interlinked in these tasks. Affective domain of empathy may be disrupted by some disorders of psychopathic traits while cognitive domain is affected in autism. In a study, it had been found that lesions involving ventromedial prefrontal cortex lead to impairment in the cognitive domain while lesion in the inferior frontal gyrus leads to impairment of affective domain (Shamay-Tsoory et al. , 2009). The ventromedial prefrontal gyrus plays an important role in integration of both components of empathy during response to mental state of others. Many emotional states including anger, fear, social bonding and distress have a connection related to neural network in the forebrain. Some main functions of brain part taking part in empathy neuronal network are being summarized: Amygdala processes emotional stimuli Cerebellum has many roles to play. Left side of the Cerebellum processes cognitive empathy while right side has a role to play for sympathy and concerns Cingulate cortex has a role in both cognitive and affective domains of empathy Dorsomedial portion of the Thalamus processed the portions and signals for affective domain and cognitive-evaluative empathy Fusiform gyrus interprets facial portion of the emotions 18 Figure 2: Overview of key regions associated with four forms of empathy After permission from Abigail Marsh (Marsh, 2018) (attached as Annexure I) 19 Figure 3: Regions of brain involved in empathy After permission from John J. McCreary (McCreary et al. , 2018) (attached as Annexure II) 20 Inferior frontal gyrus help in the processing of comments in affective domain of empathy and also the response to other’s emotions. If a problem or lesion occurs in this portion of brain, it directly impacts the affective part of empathy (Decety, 2011, Decety, Michalska, 2008, McCreary, Marchant, 2018, ShamayTsoory, Aharon-Peretz, 2009). Measurement of Empathy: The measurement of empathy has been a difficult task as in measuring these traits has a lot of aspects which need to be taken care of like, how to measure it, who should perform this measurement and how to calculate the total empathy. For this matter, multiple scoring systems have been devised, but still this job is not easy as empathy may have a lot of perspectives. Behavioral measures for empathy require the accessors to look for either the presence of absence of certain responses and behaviors among the participants. Certain ways of determining the behavioral empathy include picture viewing paradigms, picture stories, Kids empathetic development scale and Comic Strip Scale (Neumann et al. , 2015). Physiologic responses can be determined by sophisticated equipment which can assess the response electronically using Magnetic Resonance Imaging (MRI), functional MRI (fMRI), Electroencephalography, facial Electromyography and Event-rated potentials (Neumann, Chan, 2015). Some measure of Empathy which involve paper and pencil which are easy to administer and can assess empathy. Empathy Quotient (EQ) is a self-administered questionnaire which was developed by Baron-Cohen and Wheelwright in 2004 (BaronCohen and Wheelwright, 2004). Since its development, it has translated into many languages and validated (Berthoz et al. , 2008, Castelhano-Souza et al. , 2018, Jankowiak21 Siuda et al. , 2017, Preti et al. , 2011, Zhao et al. , 2018). EQ has 60-items and it measures self-reported empathy. Each item in EQ is scored on a 4-point Likert scale ranging from 1 (strongly agree) to 4 (strongly disagree). Of these 60-items, 40 items assess the empathy as a single construct and 20-items as filler. These 20-items acting as a filler are not scored and they have been added to prevent monotony of the answers by the participants. The maximum score of EQ is 80 and higher the score, higher is the empathy. Interpersonal Reactivity Index (IRI) is a 28-item scale which accesses both emotional and affective domains of empathy. It assesses empathy in four subscales namely perspective taking, empathic concern, personal distress and fantasy. For each subscle, there are 7-items and each of these is answered on a 5-point Likert scale from 0 (does not describe me well) to 4 (describes me very well). For each subscle, the range of score is 0 to 28 and higher score denotes higher empathy (Davis, 1980). Toronto Empathy Questionnaire was devised by Spreng et al as they combined 11 previously reported questionnaires including IRI, Hogan’s Empathy Scale, Questionnaire Measure of Emotional Empathy, BEES, Scale of Ethnocultural Empathy, Jefferson Scale of Physician Empathy, Nursing Empathy Scale, Japanese Adolescent Empathy Scale, and the Measure of Emotional Intelligence. By combing all these scales, they identified 142 items and then they added 36 more items. It has been validated by the authors (Spreng* et al. , 2009). 22 Table 1: Different measure for assessing Empathy Self-reported Measures Behavioural Measures Balance Emotional EMpathy Scale Picture Viewing Paradices Neuroscientific Measures Magnetic Resonace Imaging Multidimensional Emotional empathy scale Functional Magnetic Rasonance Imaging Emotional Quotient Comic Strip Task Feeling and Thinking Scale Facial electromyography Basic empathy Scale Picture Stories Griffith empathy Measure Electroencephalogram Torronto empathy Questionaiire Questionaiire of Cognitive and Affective Empathy Kids Empathetic Development Scale 23 Event-Related Potentials The Big Five Personality Traits “When people label you by saying that you have attitude. Just tell them that you have a personality which is unshakable and unaffected by what people say about you.” Aarti Khurana “Maybe that's what a person's personality is: the difference between the inside and the outside.” Jonathan Safran Foer Wood had stated the personality of a person as the set of characteristics that distinguishes a particular person on the basis of their unique thoughts and actions (Wood and Roberts, 2006). Mischel and Shoda referred to the personality as a combination of different traits in an individual (Mischel and Shoda, 2008). A trait is a particular quality of a person and it is supposed to be fixed and invariant. It allows us to predict the stability of personality traits and to guess how a person will act in a particular situation. The term “Big Five” does not mean that five personality traits define the personality of a person only. These five domains actually represent a whole spectrum of personality charcteristics and specific qualities. However, many researchers have thought that these dimensions do not include some traits and personality aspects. To investigate the debates, Paunonen and Jackson (Paunonen and Jackson, 2000) in 2000 looked at the work of Saucier and Goldberg (Saucier and Goldberg, 1998) who had concluded that there may be more dimensions to be looked for other than Big Five. Paunonen and Jackson (Paunonen and 24 Jackson, 2000) also found some differences and variances in the behavior of human beings which they consider as important and which may have an important role to play in personality; rather they concluded that there may be plenty of dimensions which may be considered and they fall in the criterion wo be considered as factor along with Big Five. Hough LM et al stated that industrial research needs more directions and more specific traits to be seen so that they may be fit in with the ever changing needs of the society, particularly industrial organizations (Hough et al. , 2015). Smith and Canger (Smith and Canger, 2004) had narrated the importance of Big Five and presented many reasons of their importance and them being essential: (a) It permits us to divide the personality traits into a meaningful classification, (b) It also leads us to conduct researches over a particular laid down framework, and (c) It includes almost all basic characteristics of personality traits. The urge to determine the types of personality traits is not new and it dates back to the start of 20th Century when physicians started their work and tries to analyze and rate the more than 2500 individuals in the 1909 investigations of Heymans and Wiersma. Then we find some more studies related to personality traits in 1900s and later on. Since its inception, the Big Five model has undergone many changes and faced many transformations. The Big Five model by 2006 had recorded over 300 publications per year and the number keeps on rising. It enforces that this Big Five model has been extensively accepted and implicated globally in researches (Beer and Watson, 2008). Big-Five Personality Traits /Five-Factor Model (FFM) The Big Five or Five-Factor model comprises of five dimensions, namely Agreeableness, Extraversion, Openness to Experience, Emotional Stability or Neuroticism, and 25 Figure 4: Big Five personality traits Openness Conscientio usness Big Five Personality Traits Extroversion Neuroticism Agreeablenss 26 Conscientiousness. FFM is one of the most commonly narrated and used personality model in the literature (Gurven et al. , 2013, Wilt and Revelle, 2015). History and Development of Big-five Personality Traits Francis Galton in 1884 (Galton, 1884) proposed his famous “lexical hypothesis” in 1884 and he proposed that aspects of the personality of a person other than cognitive ability are also measurable as he observed similar behaviors among parents and children and between pairs of twins. He proposed that all the different qualities and differences among human being interactions may be depicted by single or few words in literateure, be it English literature or some other language. So, he searched in the dictionary for identification of the terms that may be used to explain individuals’ differences. Later on, Allport and Odbert (Allport and Odbert, 1936) revised and reduced Galton’s (Galton, 1884) described terms from the Second and Third edition of Webster’s dictionary, respectively. Alport and Odbert’s study set a base for modern personality traits. Louis Thurstone was the first person who identified personality descriptors of Galton and then Thurstone and Scedule (Thurstone and Schedule, 1952), proposed five commo factors from sixty descriptive adjectives. Then, Thurstone used identified and proposed seven factors instead of five (Thurstone and Schedule, 1952). A the same time, Cattell (Cattell, 1943) identified 35 bipolar variables and currently available five factors are produced as a derivative of these bipolar variables. Although Cattel proposed 16 personality traits after applying factor analysis out of these bipolar variables and they mentioned it several times, but most of the other authors extracted only 5 variables out of these variables. (Laher, 2013). 27 Domains of Five-factor Model and Hypothesis Development The FFM has been invariably stated as the best representation of personality traits globally and across many cultures. It comprises of five domains: (I) Openness vs. closeness to experience, (II) Extraversion vs. introversion, (III) Agreeableness vs. antagonism, (IV) Conscientiousness vs. negligence, and (V) Emotional stability vs. neuroticism. i) Openness vs. Closeness to Experience Openness to experience is a broad terminology and it has at least six definite facets including fantasy, aesthetics, feeling, actions, ideas, and values (Beaty et al. , 2016). So, more the openness, more the person is creative (i.e. fantasy facet of openness to experience), and it makes them highly amenable and attuned to new ideas. Aesthetics facet explains that openness to experience means being more perceptive, keen and inclined towards art and beauty. Individuals with high openness to experience have more inclination towards emotion as compared to those having more Closeness to experience and it falls in the “feeling” facet. Action facet of Openness to experience means that individuals are more flexible in behaviors, and they are perceptive to accept new ideas. At the same time, subjects with higher openness are more intellectual and curious. Finally, individuals who are more Open to experience, are more liberal in values. So, these persons usually raise their concerns and question the views of others more as compared to those with low Openness. On the other hand, individuals with closeness to experience have particular characteristics and they are generally more realistic, difficult to be impressed, down to earth, are not fascinated by art and beauty, and emotionally shallow. In addition, they do not try new experiences easily and they perform their tasks in a set way which has been 28 Figure 5: Six facets of Openness to Experience Fantasy Aesthetics Actions Openness to Experience Feelings Ideas Values 29 laid down before. Furthermore, they are not curious and usually they don’t like to challenge the standardized and traditional ways of doing particular tasks (Song et al. , 2017). Openness to experience is also narrated as a symbol and sign of being proactive. It is supposed that openness has a direct relationship with proactivity as more openness is directly related to higher intellectual understanding and more mental capacity. A significant relationship and association has been found between intellect and openness (Dinc and Akcakanat, 2020). Thus, more open individuals are usually more perceptive, intelligent, rational and analytical (Judge et al. , 2002), and they tend to embrace and understand untoward and new situations and experiences (Watanabe et al. , 2011). Another important aspect of this trait is that the different facets of Openness exist together and covary with each other. For instance, subjects which are more curious tend to have higher and better imagination and more artistic. This may be due to the fact that all these three traits have the same gene responsible. It has been proposed by some authors that Openness to experience is heritable along with other facets of the Openness (Yamagata et al. , 2006). Although openness shows differential stability throughout the life of a person (Terracciano et al. , 2006), but its level may change during the lifespan and shows a particular pattern called as maturational trend (i.e. the level of openness to experience usually rises from teenage uptill third decade of life and then starts decreasing slowly). In a study by Schwaba et al, authors tried to examine the development of Openness and test their change with cultural activities like attending opera or museums. They included 7353 individuals and study spanned over 7-years in which they did 5 assessments of the personality. They found that Openness remains stable in early adulthood and then decreases 30 in midlife and old age. Also they found significant change and correlation of Openness with cultural experiences (Schwaba et al. , 2018). There has been genetic basis of Openness to experience explained by some authors. Rehman M S et al conducted a trial on 3112 individuals and tried to find association between serotonin-transporter-linked polymorphic region (5-HTTLPR) and personality traits among Swedish cohorts. They found that 5-HTTLPR was significantly associated with Openness to experience and it was particularly observed that those having a short allele had lower levels than those having long allele (Rahman et al. , 2017). Openness to experience may have many associations like it has been found by Kaufman et al to be associated with creativity and divergent thinking process. Authors included 1035 individuals in their study and they found that Openness to experience predicts creative achievement in the arts and intellect predicts creative achievement in the sciences (Kaufman et al. , 2016, Xu et al. , 2014). Moren CC et al contended that individuals with more openness to experience have better academic performance (Cárdenas Moren et al. , 2019). Alternatively, it may be narrated that those students having higher openness, read more and in broader context. Openness to experience has also been found to be associated with cardiovascular stress response processing. Soye A, O'Súilleabháin PS conducted a trial over 66 female participants and confirmed that “feeling” facet of Openness was associated with active stress activity and adaptation to cardiovascular stress (Soye and O'Suilleabhain, 2019). It is clear from the literature that people who have higher openness to experience can be recognized easily through their daily habits. In a recent study Sutu A et al have reported that individuals with higher openness to experience have higher humor and humor 31 production ability of an individual is predicted directly by openness to experience. Among two aspects of the openness (openness and intellect), it is the openness which is directly correlated with humor of a personality (Sutu et al. , 2020). In a study, Tan CS et al, included 198 undergraduates into their study and tried to found that people who had higher openness to experience, tend to have more intrinsic motivation. This intrinsic motivation led these individuals to have higher self-reported creativity (Tan et al. , 2019). Open people are reported to be having higher abilities to decorate their homes and offices. They have higher artistic skills, so they can express their preferences and capabilities in a better way (Gosling et al. , 2002). As these individuals like to explore new ideas and have tendency to look for new things, so they are more motivated to new knowledge and skills. Hogan Mj et al (Hogan et al. , 2012) in a study found that openness to experience is correlated with intelligence and a particular type of intelligence called crystallized intelligence. This intelligence is the ability of a person to use life experience sought throughout the life and then utilizing them. Openness has been narrated a multi-faceted experience and it directs a person’s response to any new experience. Individuals with less openness tend to produce a particular and set response and less likely to think out of box to create new solutions. So, they have a narrower scope to act against any new situation (Woo et al. , 2014). Marcus et al conducted an interesting study and they observed the personal websites of individuals with higher openness to assess the content, expressions and viewership of visitors. They reported that individuals with higher openness tend to have more expression and reflect their emotions on their websites (Marcus et al. , 2006). Mehl et al studied the participants of their study and their daily lives. They found that people having more openness tend to 32 spend more time in Cafes and restaurants. Another interesting finding of their study was that these people tend to use less frequently the past tense in their language and third-person pronouns (Mehl et al. , 2006). ii) Extraversion vs. Introversion Extraversion is a quality which enables individuals to be more assertive, energetic, talkative, outgoing, high spirited, cheerful, positive, ambitious, optimistic, upbeat, gregarious and active. On the other end, introverts tend to be quieter and more independent. Extraverts are inclined to seek social attention and excitement, generally spend most of their time with other people, have much more social circle and contacts, spend their leisure time in a company and for social contacting, and favour more social activities (JacquesHamilton et al. , 2019). Many positive traits and qualities have been found associated with the Extraversion. Individuals with higher Extraversion usually show better performance in jobs like sale representatives, managerial positions, and those which need better and higher degree of interpersonal skills. Harai MB et al conducted a study over students employed in a public sector university of USA. They found that extraversion had a direct relationship with job satisfaction than all other personality traits (Harari et al. , 2018). Extraversion has also been found positively associated with extrinsic career success, which had been defined as the occupational status and income. It may be explained as that extraverts have a tendency to be more successful in their lives, have better and more chances to get to higher positions and usually earn more income than those having less extraversion (Judge et al. , 1999)(Lucas and Baird, 2004). It has been noted that extraversion is significantly . . associated wi th a ggregated momentari ly positi ve affect. So, individuals with higher . . . . 33 extraversion tend to be happier in general as well as in sh ort peri ods of time (Spain et al. , . 2000). . . . . Extraverts, by their personality, have more surgency from activities and situations and tend to get higher energy from these situations. They get involved with people around them and develop a communication. They like to communicate with new people and develop new connections. Often, they are considered by others to be full of energies. They are more visible in a group, have an assertive nature and they like to talk. On the other hand, introverts have lower social engagement. They usually like to keep quiet and have low energy. Some may misunderstand them as depressed or unfriendly, but they are reserved to their own situations. They don’t like to be dominant in a group and are independent of their social world. (de Jong et al. , 2019, Du et al. , 2020). Extraversion has also been narrated as a combination of two main traits: dominance and affiliation. The dominance component means the extraverts tend to be more authoritative, want to be controlling the situations and combative. This quality helps the Extraverts to stand firmly on their opinion and positions and they tend to influence others. The affiliation component refers to their tendency to be a part of social settings and gatherings and them being more friendly. Which of these characteristic is more dominant, is debatable among researchers as some consider one component as a core to this trait while others consider the second component as the most important component (Bono and Judge, 2004). In a study by Sołtysik M et al, mountaineers were found having higher levels of Extraversion in their personality (Soltysik et al. , 2019). Extraversion has also been found having an effect on the motivatio n to process own-gender face s more deeply tha n . . . opposite-gende r faces (Morgan and Hills, 2019). . . 34 . . Figure 6: Six facets of Extraversion Gregariousnes s Friendliness Activity level Extraversion Assertiveness Cheerfulness Excitement seeking 35 Like other personality traits, extraversion also has a genetic basis. Fischer R et al found that Dopamin e genes are linke d to Extraversio n development (Fischer et al. , 2018). A . . . . p olymorphism in period circadia n cloc k (PER-3) gen e has been found to be associ ated . . . . . . wi th hi gher level s of Extraversion (Jiménez et al. , 2017). Jang and his colleagues (Jang et . . . al. , 2002) found tha t sam e gene s account ed for hi gh covari ation amo ng extraversi on’s . . . . . . . . . facets . . iii) Agreeableness vs. Antagonism This is the personality trait which determines the general response of a person to social harmony. Individuals with higher Agreeableness, are considered to be more ki nd, trusti ng, . . altruisti c, courteo us, good-natured , modes t, helpfu l, hone st, sympatheti c to others , soft . . . . . . . . hearted, and tole rant. On the other extreme, those having low scores in this domain are . more likely to be skeptical, competitive, uncaring, critical, and hostile (Bergh and Akrami, 2016). Also, these people tend to behave a selfish behavior and show less empathy. Another important aspect is that those individuals who have very low score in this domain, they have dark triad behavior which is a combination of narcissism, Machiavellianism, and psychopathy. These individuals are found to be performing more crimes and cause problems in the organization (Vize et al. , 2020). Another important hallmark quality of Agreeableness is the tendency to trust other human beings and to establish relationships with others. So, by means of this trait of the personality, any person can have a relationship with others and develop interpersonal relationship. People who score high in Agreeableness, generally are good at maintaining relationships and create less conflict in the working environments. Those with less 36 Figure 7: The dark triad Narcissism The Dark Triad Psychopathy Machiavellianism 37 Figure 8: Six facets of Agreeableness Trust Sympathy Morality Agreeableness Modesty Altruism Cooperation 38 Agreeableness generally have less tolerance and they are usually short-tempered (Bergh and Akrami, 2016). In a recently published study, authors included 2 models and tried to see the relationship of daily challenges like low income, difficult children, with the Agreeableness of the mothers. They examined three parenting styles at three stages of development of children at 6 months, 54 months old and 5th grade. They found that mothers who had high Agreeableness tend to show less harshness to their children and had more sensitivity. Also it was observed that mothers with higher Agreeableness had more supportive behavior towards harsh and difficult children (Bradley and Corwyn, 2019). In a study conducted on young age group on a sample from USA, soci al medi a use and . . soci al isolation was assessed with reference to personali ty traits and it was found that . . . agreeableness was associ ated with lower odd s of soci al i solation (Whaite et al. , 2018). In . . . . another study which included samples from both USA and China, and they found that low . . agreeablenes s and hi gh rejectio n sensi tivity were associated with wi thdrawal, fri endship . . . . . . dissatisfacti on, and adverse confli ct consequences (Wang et al. , 2017). . iv) . . . Neuroticism vs. Emotional Stability Neuroticism is the susceptibility of any person to negative emotions and thoughts. The persons who have higher neuroticism are expected to be more prone to develop guilt, paranoid, anger, self-consciousness, mood swings, disgust, depression, anxiety, fear and embarrassment and tend to perform their actions with poor control over emotions. Also, individuals with high neuroticism tend to be more self-conscious and they usually find any 39 inevitable situation as more stressful (Chang et al. , 2018, Sosnowska et al. , 2019). Individuals with higher Neuroticism usually like to avoid situations which demand their higher control of emotions, and commitment. In other words, they tend to react to any situation in an intense way and usually have negative perception to their surrounding events happening on daily basis (Driskell et al. , 2006, Smillie et al. , 2015). While those having higher emotional stability are usually better composed and have a tendency to show themselves as more confident, secure, well-adjusted, relaxed, and tend to deal better in untoward and stressful circumstances (Kandler, 2012). Emotional stability is also narrated as in indicator to predict the job performances of individuals. In a study conducted in Taiwan, in which authors included Pilots and compared their personalities with those working on ground and other military personnels taken as controls. They found that fighter pilots tend to be more Extroverts and had more emotional stability (less Neuroticism) than controls and those on ground jobs (Chang, Lee, 2018). Higher Neuroticism level has been found associated with higher risk of mental disorders. Also patients with bipolar disorders have been found having a strong association with Neuroticism (Dukalski et al. , 2019). Neuroticism is inversely related to job performance as it decreases the job satisfaction which ultimately leads to poor performance. Another important thing noted was that employees having high job satisfaction performed well even being poor workaholism. It signifies the importance of higher emotional stability in workstation performance (Mazzetti et al. , 2016). Higher Neuroticism has an association with poor mental health and physical status of any person. Neuroticism has also been found having genetic transmission. In a large study, which included 329,821 individuals from UK, 116 genetic loci for Neuroticism were 40 Figure 9: Six facets of Neuroticism Anxiety Vulnerability Anger Neuroticism Immoderation Depression Selfconsciousness 41 found o genome wide association (Luciano et al. , 2017). Dopamine genes have also been found directly linked to Neuroticism trait (Fischer, Lee, 2018). Conscientiousness vs. Negligence Conscientious means to act disciplined and dutifully. Individuals with high Conscientiousness are usually better organized, more disciplined, purposeful, detailoriented, punctual, determined, reliable, risk averse, dependable, responsible, and achievement-oriented. While those with lower conscientiousness, usually do not value prospective results and are unreliable (Costantini et al. , 2015). In literature, conscientiousness is named also as conformity, dependability and will to achieve It reflects thoroughness, planfulness, and responsibility. It is the way through which people control their impulses. Individuals with low Conscientiousness have more flexibility in their plans but at the same time are less reliable. It may also be labelled as “will to achieve” as it is found to be strongly associated with educational achievement. Egan M et al suggested in their study that fostering Conscientiousness of the students in early life may help them prevent from unemployment in future. In the organizational context, those employees who had higher conscientious showed better and stronger urge to achieve the tasks and they tend to strive more for fulfilment of their tasks and goals (Bono and Judge, 2004). Persons with higher Conscientiousness usually have planning and follow a methodical approach for every activity and usually don’t try to act spontaneously. They follow the steps and follow their plans that’s why they are usually considered as reliable. However, this quality may make them rigid and difficult to change. They tend to be perfectionist and workaholics. Higher score in Conscientiousness is considered as the best predictor of 42 Figure 10: Six facets of Conscientiousness Cautiousnes s Selfefficacy Selfdescipine Conscientiousness Achievem entstriving Orderliness Dutifullnes s 43 success in academic records. This trait has also been shown to mediate the role between amotivation and academic performance (Kertechian, 2018). Another study by Conard and Patry found that although Conscientiousness has a strong relationship with good academic record, but two factors which mediate this relationship are academic self-efficacy and test anxiety (Conrad and Patry, 2012). In a meta-analysis, Poropat AE (Poropat, 2009) found that of all the five personality traits, Conscientiousness was strongly correlated with academic performance and important thing was that this relationship was independent of the intelligence. After controlling the secondary academic performance, they found that role of Conscientiousness is as much important as of intelligence in predicting the academic performance. Wang S et al took it a step further and tried to underpin the mechanism and brain structure behind that. They included 148 high school students in their study and measured gray matter volume of their brains. They found that conscientiousness was positively associated with the gray matter volume in the bilateral superior parietal lobe and was negatively associated with the GMV in the right middle frontal gyrus (Wang et al. , 2019). Ellershaw et al. (Ellershaw et al. , 2016) noted that nursing staff with higher levels of conscientious performed significantly better than those having lower levels of conscientiousness. This quality of higher conscientiousness provides the employees to be better in their decision-making capabilities and more organized personnels, which ultimately helps them to get better job positions. Higher levels of Conscientiousness have been shown to be associated with better health and health related issues. Similarly, low levels of Conscientiousness was found having a strong correlation with low intentions towards fruit and vegetable consumption which may have a mediation role in the health of 44 an individual (Wilson et al. , 2016). Higher levels of Consciousness have also been associated with less mortality risk as these people are usually well-planned and do not get involved in salubrious health behaviours and maintain their social networks particularly related to their health (Duggan, 2016). Big-Five personality traits and its Global Application As all these personality traits are derived from language, therefore, there has been a question of applicability of FFM across different languages and cultures. Many studies have been reported to examine the cross-cultural acceptability of FFM and they have proven its generalizability. It has been attested that FFM is universal and applicable across all continents and cultures (Ion et al. , 2017). The measurement instruments of big-five personality There are a lot of tests available to assess the personality traits of a person. Many of them have proven to be having good psychometric properties. NEO and revised NEO personality inventories are one of the most comprehensive measurements of the Big-Five personality traits. Big five inventory (BFI) is also one of the most commonly employed inventories for this purpose. It is reliable and has shown higher Cronbach alpha in studies (Feldt et al. , 2014, Ward, 2017). 45 Objective: To measure different personality traits of medical students in a public sector medical college To measure empathy of medical students in a public sector medical college To correlate empathy with personality traits among medical students in a public sector medical college. 46 Material & Methods: Study Population: Final year medical students Study Duration: 2 months (November, 2020 to December, 2020) Study Sample: Final year medical students Sample Size: A total 270 subjects will be taken in this study using level of significance as 5%, power of test as 80% and population correlation coefficient of empathy and Neuroticism as 0.171 (Bertram et al. , 2016) using following formula N=[ Z∝ + Zβ 2 C ] + 3 Sampling Technique: Non-probability, consecutive sampling Study Design: Correlational study Inclusion Criteria: o Medical students of final year MBBS studying at Rawalpindi Medical College, Rawalpindi Exclusion Criteria o Students with emotional or psychotic disorders. o Partially filled proforma 47 Methodology: Instrument Tool for assessment of BFI: In this study, BFI will be used in order to assess the personality of the participants. There are 44 items in BFI, which are answered by the participants on a 5-point Likert scale, ranging from 1 to 5 as being disagree strongly, disagree a little, neither agree nor disagree, agree a little, agree strongly respectively. It assesses the personality in five traits. There are 16 questions, which are scored as reverse when analyzing the scale. The scoring of each trait is as follows, as ‘R’ denotes reverse score: Extraversion: 1, 6R, 11, 16, 21R, 26, 31R, 36 Agreeableness: 2R, 7, 12R, 17, 22, 27R, 32, 37R, 42 Conscientiousness: 3, 8R, 13, 18R, 23R, 28, 33, 38, 43R Neuroticism: 4, 9R, 14, 19, 24R, 29, 34R, 39 Openness: 5, 10, 15, 20, 25, 30, 35R, 40, 41R, 44 Ultimately BFI scores assess the personality traits in 5 dimensions: Extraversion vs. introversion Agreeableness vs. antagonism Conscientiousness vs. lack of direction Neuroticism vs. emotional stability Openness vs. closedness to experience Tool for Empathy: 48 In this study, for assessment of empathy, Interpersonal Reliability Index (IRI), will be used. There are 28-items answered on a 5-point Likert scale ranging from “Does not describe me well” to “Describes me very well”. The measure has 4 subscales, each made up of 7 different items. These subscales are: Perspective Taking – the tendency to spontaneously adopt the psychological point of view of others Fantasy – taps respondents' tendencies to transpose themselves imaginatively into the feelings and actions of fictitious characters in books, movies, and plays Empathic Concern – assesses "other-oriented" feelings of sympathy and concern for unfortunate others Personal Distress – measures "self-oriented" feelings of personal anxiety and unease in tense interpersonal settings There are some items which are score reverse in the scale. It is intended to be used as a continuous measure of empathy-related dimensions in normal populations, rather than as a categorical measure (“high empathy” versus “low empathy”). Data Collection Procedure: Data will be collected after approval from the Ethical review board. All those included in the study will be asked for consent for inclusion in the study. As the proforma is going to be anonymous, they will be told that filling the proforma means they are giving us consent for inclusion in the study. All the participant will be given the Questionnaire which will be consisting of 3 portions: 1) Biodata, 2) Tool for BFI, and 3) Tool for Empathy. The entire questionnaire will be anonymous and they will be asked to put down their signatures only 49 in the consent form for inclusion in the study in order to maintain the anonymity. Statistical Analysis: All the data will be analyzed by using SPSS version 24. The quantitative variables like age, scores of BFI and Empathy will be presented as mean ± SD. Qualitative variables like gender will be presented as frequency and percentages. Analysis of variance and twosample t-tests will be used as appropriate to test for differences in mean scores among groups. The relationship between each of the five personality scores and empathy scores will be assessed using Pearson's Correlation Coefficient. P-value ≤ 0.05 will be considered as significant 50 Results: A pilot study to determine the characteristics of tow questionnaires included in this study was done. All it is given as an Annexure III. A total of 270 students were included in the study. The mean age of participants was found to be 22.35 ± 1.16 years (Range: 19-26 years). Most of the participants were female in this study (Figure 11). Regarding Empathy score, the minimum mean score was found for Q18 which narrates “When I see someone being treated unfairly, I sometimes don't feel very much pity for them”. Maximum score was for Q22 “I would describe myself as a pretty softhearted person” (table 2). The total mean score of empathy was calculated and for its subgroups. The total mean Empathy score was found to be 61.60 ± 10.99. Maximum score was observed for Perspective-taking subscale followed by Fantasy subscale, personal distress and Empathic concerns. All data is given in table 3. Total empathy score was compared according to gender and it was found that total empathy scale and its all subscales were higher among female participants than male. This difference was significantly higher in the subscale of Empathic concern (p=0.044), Personal distress (p=0.019) and Total empathy score (0.014). All details are given in table 4. The personalities of participants were assessed in 5 scales as per BFI and total scores are given in table 5. The highest mean score was noted for Openness (34.41) and Agreeableness (32.77). 51 Further, the personality traits were compared in both groups according to gender. It was found that females were having significantly more Extroversion than males (p=0.038). Females also had higher score in Agreeableness, Conscientiousness, Neuroticism and Openness than male, however this difference was not significant (table 6). Total empathy score and its subscales were correlated with personality traits and it showed moderate to week correlation with all personality traits. The strongest positive correlation was found between personal distress subscale and Neuroticism (r=0.488), followed by perspective taking and Agreeableness (r=0.350) and empathic concern and Openness (r=0.341). The strongest negative correlation was found between personal distress and Conscientiousness (r= -0.267), personal distress and Extroversion (r= -0.189) and perspective taking and Extroversion (r= -0.134). All these details are given in table 7 and figure 12. 52 Figure 11: Gender distribution of participants in the study 71; 26% 199; 74% Male Female 53 Table 2: Empathy scale and its values Minimum Maximum Mean Std. Deviation 1. I daydream and fantasize, with some regularity, about things that might happen to .00 4.00 2.3370 1.34182 .00 4.00 2.5963 1.28329 .00 4.00 1.6481 1.30708 .00 4.00 1.1148 1.27813 .00 4.00 2.3556 1.48583 .00 4.00 2.0630 1.29041 .00 4.00 1.6407 1.32203 .00 4.00 2.6370 1.21703 .00 4.00 2.6111 1.22879 .00 4.00 2.6037 1.34219 me. 2. I often have tender, concerned feelings for people less fortunate than me. 3. I sometimes find it difficult to see things from the "other guy's" point of view. 4. Sometimes I don't feel very sorry for other people when they are having problems. 5. I really get involved with the feelings of the characters in a novel. 6. In emergency situations, I feel apprehensive and ill-at-ease. 7. I am usually objective when I watch a movie or play, and I don't often get completely caught up in it. 8. I try to look at everybody's side of a disagreement before I make a decision. 9. When I see someone being taken advantage of, I feel kind of protective towards them. 10. I sometimes feel helpless when I am in the middle of a very emotional situation. 54 11. I sometimes try to understand my friends better by imagining how things look from .00 4.00 2.6296 1.22696 .00 4.00 1.4037 1.40762 .00 4.00 1.4481 1.27132 .00 4.00 1.2407 1.24260 .00 4.00 2.2593 1.34393 .00 4.00 1.8407 1.45586 .00 4.00 2.2630 1.38812 .00 4.00 1.0481 1.29393 .00 4.00 2.0704 1.22195 .00 4.00 2.5148 1.16236 .00 4.00 2.4556 1.28034 .00 4.00 2.6407 1.24678 their perspective. 12. Becoming extremely involved in a good book or movie is somewhat rare for me. 13. When I see someone get hurt, I tend to remain calm. 14. Other people's misfortunes do not usually disturb me a great deal. 15. If I'm sure I'm right about something, I don't waste much time listening to other people's arguments. 16. After seeing a play or movie, I have felt as though I were one of the characters. 17. Being in a tense emotional situation scares me. 18. When I see someone being treated unfairly, I sometimes don't feel very much pity for them. 19. I am usually pretty effective in dealing with emergencies. 20. I am often quite touched by things that I see happen. 21. I believe that there are two sides to every question and try to look at them both. 22. I would describe myself as a pretty softhearted person. 55 23. When I watch a good movie, I can very easily put myself in the place of a leading .00 4.00 1.8444 1.42399 .00 4.00 1.8111 1.25749 .00 4.00 1.9926 1.20097 .00 4.00 2.1704 1.39324 .00 4.00 2.0630 1.22236 .00 4.00 2.4407 1.20493 character. 24. I tend to lose control during emergencies. 25. When I'm upset at someone, I usually try to "put myself in his shoes" for a while. 26. When I am reading an interesting story or novel, I imagine how I would feel if the events in the story were happening to me. 27. When I see someone who badly needs help in an emergency, I go to pieces. 28. Before criticizing somebody, I try to imagine how I would feel if I were in their place. 56 Table 3: Mean scores of Empathy scale Empathy scale Total Score Perspective taking 17.48 ± 4.26 Fantasy scale 15.50 ± 5.86 Empathic concern 14.42 ± 3.67 Personal distress 15.28 ± 5.02 Total empathy score 61.60 ± 10.99 57 Table 4: Total empathy score was compared according to gender Empathy scale Male Female P-Value Number Mean ± SD Number Mean ± SD Fantasy scale 71 14.67 ± 5.21 199 15.79 ± 6.06 0.167 Empathic concern 71 13.67 ± 3.95 199 14.6 ± 3.53 0.044 Perspective taking 71 16.73 ± 4.39 199 17.75 ± 4.19 0.082 Personal distress 71 14.08 ± 4.67 199 15.71 ± 5.08 0.019 Total empathy 71 58.60 ± 11.48 199 62.67 ± 12.02 0.014 score 58 Table 5: The personalities of participants as per BFI PERSONALITY TRAIT MEAN ± SD EXTROVERSION 23.92 ± 5.34 AGREEABLENESS 32.77 ± 5.35 CONSCIENTIOUSNESS 29.52 ± 5.50 NEUROTICISM 25.71 ± 5.80 OPENNESS 34.41 ± 5.68 59 Table 6: The personality traits were compared in both groups according to gender Personality traits Male Female P-Value Number Mean ± SD Number Mean ± SD Extroversion 71 22.80 ± 5.04 199 24.33 ± 5.40 0.038 Agreeableness 71 31.77 ± 5.72 199 33.12 ± 5.18 0.068 Conscientiousness 71 29.40 ± 5.44 199 29.56 ± 5.54 0.840 Neuroticism 71 25.50 ± 6.02 199 25.79 ± 5.73 0.721 Openness 71 33.47 ± 5.79 199 34.74 ± 5.62 0.108 60 Table 7: Correlation of Empathy and BFI Variables 1 1. Extroversion 1 2 3 4 2. Agreeableness .224** 1 3. Conscientiousness .327** .194** 1 4. Neuroticism -.411** -.194** -.375** 5. Openness .145* 6. Fantasy scale .053 .279** 5 .015 .269** .086 .350** .097 7 8 9 10 1 .185** -.043** .062 6 1 .149* .188** 1 7. Empathic concern -.057 .100 .341** .324** 1 scale 8. Perspective taking .063 -.134* .225** .202** .402** 1 scale 9. Personal Distress -.189** .008 -.064 .224** -.267** .488** -.087 .226** .293** .048 1 scale 10. Overall Empathy .227** .232** .727** .701** .609** .541** -.063 scale *Significant at the 0.05 level (two-tailed) ** Significant at the 0.01 level (two-tailed) 61 1 Figure 12: Correlation of Empathy and BFI .053 Extroversion .062 Agreeableness .015 Conscientiousness Fantasy Scale .149 Neuroticism .188 Openness Extroversion Agreeableness -.057 .269 .086 Conscientiousness Empathic concern Scale .100 Neuroticism .341 Openness Extroversion .063 .350 Agreeableness .097 Conscientiousness Perspective taking Scale -.134 Neuroticism .225 Openness -.189 Extroversion .008 Agreeableness -.267 Conscientiousness Personal Distress Scale .488 Neuroticism Openness -.087 62 Discussion: Regarding medical students, studies have shown that different personality traits are strongly correlated with empathy scales. It has been confirmed by studies from Portuguese (Magalhaes, Costa, 2012), China (Song and Shi, 2017) and America (Toto et al. , 2015). A study which included sample from four countries including China, Germany, Spain, and the United States of America found that Agreeableness and Conscientiousness were the most dominant predictors of empathy (Melchers et al. , 2016). Previously it has been shown that agreeableness, which represents the person to be having more adjustable, cooperative, understanding and helpful, is more correlated with empathy. Similarly we have noticed it to be associated with perspective taking and empathic concern. We found cognitive domain to be positively correlated with Agreeableness and Openness as some authors consider empathy as Cognitive (perspective taking and fantasy) and emotional (empathic concern and personal distress) (Song and Shi, 2017),. Emotional domain was correlated more with Agreeableness, Conscientiousness and Neuroticism. Neuroticism and Consciousness which share the feature of being less emotionally stable and becoming distressed after seeing the others in trouble, makes sense to be more associated with the emotional domain of empathy. It also shows the importance of inculcating these particular traits among medical students as the incidences of violence on healthcare workers are on the rise globally and generally, the trust over doctors has dropped drastically. In this study, perspective taking subscale of IRI was positively correlated with Extroversion, Agreeableness, Conscientiousness and Openness while it had significant negative correlation with Neuroticism. Similar findings were observed by Guilera T 63 (Guilera et al. , 2019), however, they found negative correlation with Neuroticism and Extroversion, both. A study conducted on Chinese medical students found negative correlation with Extroversion only and modest positive correlation with Agreeableness, Neuroticism, Openness and Conscientiousness (Song and Shi, 2017). Fantasy scale of IRI had positive correlation with all personality traits. However, Guilera T found its positive correlation with Openness only (Guilera, Batalla, 2019). Melchers (Melchers, Li, 2016) also found similar results. Empathic concern subscale of IRI showed week negative correlation with Extroversion and positive correlation with all other personality traits, particularly with Openness. Contrary to this, Guilera T found a positive correlation of Empathic concern and Extroversion (Guilera, Batalla, 2019). Song & Shi (Song and Shi, 2017) reported negative correlation of Empathic concern and Extroversion, like this study. However. They showed strong correlation of Empathic concern and Agreeableness (B= 0.477, P<0.01). Personal distress subscale of IRI was found moderately positively correlated with Neuroticism and negatively correlated with Extroversion, Conscientiousness and Openness. Guilera T have also found positive correlation between personal distress and Neuroticism (Guilera, Batalla, 2019). Song and Shi showed positive strong correlation of Personal Distress with Neuroticism and modest correlation with Openness (Song and Shi, 2017). In a study by MAGALHA˜ ES, (Magalhaes, Costa, 2012), who included 350 medical students from six entering classes, significant and positive correlations between total score in the JSPE scale and Openness to Experience (r¼0.22, p50.01), Agreeableness (r¼0.24, p50.01), and Conscientiousness (r¼0.14, p50.05) were found. The magnitudes of 64 correlations between personality and scores of self-reported empathy were low, ranging from _0.01 to 0.24. In a study, authors (Lourinho and Severo, 2013) had found positive significant correlations between the total score of IRI with agreeableness and openness. They had used the logistic regression model using the five dimensions NEO-FFI to predict top tercile empathy and it revealed excellent discrimination. They also found a positive correlation between PD and neuroticism, EC and extraversion and between PT and conscientiousness. In this study, Neuroticism was found having moderate correlation with personal distress. It may be expected that personality trait of Neurotic people may allow them to have higher personal distress after observing some distressing event. As these individuals usually tend to keep their emotions to themselves and avoid to share them to others, so it may be an expected outcome. As neurotics are expected to be feeling more loneliness and moody, so this domain of empathy is higher among them. Conclusion and Recommendations: This study depicted the true picture of state of Empathy and its correlation with personality traits among our future doctors. In this study, it has been concluded that Empathy and personality had a significant correlation. On the basis of this, following recommendations are being proposed: 1. These results can help to design programs to study if some individualized interventions can be planned improve the empathy in medical students. 2. It is proposed that following admission of medical students in first year of their medical college, their personality traits may be assessed and they can be grouped according to them. Following this grouping, individualized and more targeted 65 strategies may be easy to be implemented and can be applied. In this way, their empathy can be improved until they enter their practical life and it will help them to make them a more empathetic doctor and individual. 3. As empathy has higher impact over patient care and if empathy is low, patientdoctor relationship can’t develop and be compromised. At the same time, a doctor with low empathy can’t understand the perspective and feelings of the society, which is an basic pillar of medical profession. Empathy development is although a new area in medical science, however, it can’t be left behind and its importance can’t be negated. Previously it was thought to be part of hidden curriculum and it was assumed that empathy is incorporated into doctors by default. But, now many aspects of hidden curriculum are being thought to be properly addressed. Focusing on these results, it is also recommended to make changes in curriculum of medical schools as till now, no formal program is being taught to them during these five years. A dedicated course (may be small) may be added to their curriculum so as to foster this important aspect into their personalities. 4. Nobody can negate the importance of empathy in the personality development of medical students and future physicians. So, I recommend more training sessions for medical students to incorporate Empathy among them keeping in consideration their personality traits. 5. All these suggestions and proposals are doable in the context that now many medical universities exist and they can change the curriculum according to the need of the society. Considering the important of empathy and personality traits in any doctor, changes in the curriculum is direly needed and strongly recommended. 66 Limitations of the study: There were few limitations of this study which need to be acknowledged. It was a single center study so I acknowledge that its results cannot be generalized. In order to extrapolate these results, future studies with a larger sample size may be needed. 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Validation of the Empathy Quotient in Mainland China, Journal of Personality Assessment 100(3) 333-342. 86 PROFORMA Correlation of Empathy and Personality Traits among medical students in a public sector medical college Serial No: Age: ______________ years Gender: _________________ INTERPERSONAL REACTIVITY INDEX The following statements inquire about your thoughts and feelings in a variety of Situations. For each item, indicate how well it describes you by choosing the appropriate Letter on the scale at the top of the page: A, B, C, D, or E. When you have decided on your Answer, fill in the letter next to the item number. READ EACH ITEM CAREFULLY BEFORE RESPONDING. Answer as honestly as you can. Thank you. ANSWER SCALE: A B C D E DOES NOT DESCRIBE ME DESCRIBES VERY WELL ME WELL 1. I daydream and fantasize, with some regularity, about things that might happen to me. 2. I often have tender, concerned feelings for people less fortunate than me. 3. I sometimes find it difficult to see things from the "other guy's" point of view. 4. Sometimes I don't feel very sorry for other people when they are having problems. 5. I really get involved with the feelings of the characters in a novel. 6. In emergency situations, I feel apprehensive and ill-at-ease. 87 7. I am usually objective when I watch a movie or play, and I don't often get completely caught up in it. 8. I try to look at everybody's side of a disagreement before I make a decision. 9. When I see someone being taken advantage of, I feel kind of protective towards them. 10. I sometimes feel helpless when I am in the middle of a very emotional situation. 11. I sometimes try to understand my friends better by imagining how things look from their perspective. 12. Becoming extremely involved in a good book or movie is somewhat rare for me. 13. When I see someone get hurt, I tend to remain calm. 14. Other people's misfortunes do not usually disturb me a great deal. 15. If I'm sure I'm right about something, I don't waste much time listening to other people's arguments. 16. After seeing a play or movie, I have felt as though I were one of the characters. 17. Being in a tense emotional situation scares me. 18. When I see someone being treated unfairly, I sometimes don't feel very much pity for them. 19. I am usually pretty effective in dealing with emergencies. 20. I am often quite touched by things that I see happen. 21. I believe that there are two sides to every question and try to look at them both. 22. I would describe myself as a pretty soft-hearted person. 23. When I watch a good movie, I can very easily put myself in the place of a leading character. 24. I tend to lose control during emergencies. 88 25. When I'm upset at someone, I usually try to "put myself in his shoes" for a while. 26. When I am reading an interesting story or novel, I imagine how I would feel if the events in the story were happening to me. 27. When I see someone who badly needs help in an emergency, I go to pieces. 28. Before criticizing somebody, I try to imagine how I would feel if I were in their place. 89 How I am in general Here are a number of characteristics that may or may not apply to you. For example, do you agree that you are someone who likes to spend time with others? Please write a number next to each statement to indicate the extent to which you agree or disagree with that statement. 1 Disagree Strongly 2 Disagree a little 3 Neither agree nor disagree 4 Agree a little 5 Agree strongly I am someone who… 1. _____ Is talkative 15. _____ Is ingenious, a deep thinker 2. _____ Tends to find fault with others 16. _____ Generates a lot of enthusiasm 17. _____ Has a forgiving nature 3. _____ Does a thorough job 18. _____ Tends to be disorganized 4. _____ Is depressed, blue 19. _____ Worries a lot 5. _____ Is original, comes up with new ideas 20. _____ Has an active imagination 6. _____ Is reserved 21. _____ Tends to be quiet 7. _____ Is helpful and unselfish with others 22. _____ Is generally trusting 23. _____ Tends to be lazy 8. _____ Can be somewhat careless 24. _____ Is emotionally stable, not easily upset 9. _____ is relaxed, handles stress well. 10. _____ Is curious about many different things 25. _____ Is inventive 26. _____ Has an assertive personality 11. _____ Is full of energy 27. _____ Can be cold and aloof 12. _____ Starts quarrels with others 13. _____ Is a reliable worker 28. _____ Perseveres until the task is finished 14. _____ Can be tense 29. _____ Can be moody 90 30. _____ Values artistic, aesthetic experiences 31. _____ Is sometimes shy, inhibited 32. _____ Is considerate and kind to almost everyone 33. _____ Does things efficiently 34. _____ Remains calm in tense situations 35. _____ Prefers work that is routine 36. _____ Is outgoing, sociable 37. _____ Is sometimes rude to others 38. _____ Makes plans and follows through with them 39. _____ Gets nervous easily 40. _____ Likes to reflect, play with ideas 41. _____ Has few artistic interests 42. _____ Likes to cooperate with others 43. _____ Is easily distracted 44. _____ Is sophisticated in art, music, or literature 91 CONSENT FORM I acknowledge that Dr. Naeem Liaqat, has informed me in detail about the research titled “Correlation of empathy and personality traits among final year medical students in a public sector medical college”. I am also informed regarding purpose, nature, aims and objectives of the study. All the information in this study will be kept confidential and the data will be utilized only for research purpose. I give my full consent and willingness and allow Dr. Naeem Liaqat to consider me in his study. Signature: Date: 92 Annexure I 93 Annexure II 94 Annexure III Pilot study of two scales to be used All the data were entered in SPSS version 26. Regarding the initial report, following 2 qualities were assessed: Reliability Validity Reliability of IRI: After entering all data in SPSS software, reliability was assessed by calculating Cronbach’s alpha. Cronbach’s α was 0.638 when assuming one-factor model (internal consistency of the total questionnaire). It is being shown in Table 1. Then after analysis of results, deletion of Item 18 was considered, which raised the value of reliability to 0.660. Then item 12 was deleted and reliability increased to 0.686. Then item 13 was deleted and reliability was 0.702. Validity of IRI: Also, content validity of all the questions was assessed by discussing it with the students filling the proforma. There were few points found out during discussion: Question No, 2 which states that ‘2. I often have tender, concerned feelings for people less fortunate than me. Students mentioned that tender is a word which may be defficult to understant ad interpret. So I think that it must be replaced with word “warm feelings”. Reliability of BFI: The reliability of BFI was considered and it was found to be 0.755 which is in acceptable range, so it was not changed. 95 Validity of IRI: Content validity of all the questions was assessed by discussing it with the students filling the proforma. All students approved the content and suggested no change. So it was implemented as such and no change in the statements was made. 96 Table 1: Cronbach’s Alpha and Internal consistency of IRI questionnaire Scale variance if item deleted 111.343 115.160 123.225 122.175 113.673 115.170 120.874 114.565 111.655 Corrected item-total Correlation .354 .231 -.061 -.023 .230 .229 .019 .274 .385 Squared multiple correlation .302 .288 .163 .350 .332 .251 .263 .362 .337 Cronbach’s Alpha if item deleted E1 E2 E3 E4 E5 E6 E7 E8 E9 Scale mean if item deleted 55.4074 55.1481 56.0963 56.6296 55.3889 55.6815 56.1037 55.1074 55.1333 E10 E11 E12 E13 E14 E15 E16 E17 E18 E19 E20 E21 E22 E23 E24 E25 E26 E27 E28 55.1407 55.1148 56.3407 56.2963 56.5037 55.4852 55.9037 55.4815 56.6963 55.6741 55.2296 55.2889 55.1037 55.9000 55.9333 55.7519 55.5741 55.6815 55.3037 109.898 111.158 125.318 123.005 123.136 117.366 109.589 112.972 125.432 120.689 113.137 112.310 113.699 111.183 119.408 115.369 111.673 112.508 114.145 .408 .406 -.131 -.051 -.055 .137 .376 .280 -.136 .037 .351 .340 .298 .332 .079 .247 .325 .354 .294 .351 .391 .238 .237 .355 .133 .362 .383 .259 .245 .318 .333 .361 .418 .314 .223 .440 .283 .286 .608 .610 .662 .652 .652 .635 .610 .621 .660 .644 .616 .616 .620 .615 .640 .625 .616 .615 .621 97 .614 .626 .654 .650 .626 .627 .647 .623 .612 Table 1: Cronbach’s Alpha and Internal consistency of BFI questionnaire Scale mean if item deleted Scale variance if item deleted Corrected Squared item-total multiple Correlation correlation Cronbach’s Alpha if item deleted P1 146.1444 223.202 .195 .412 .752 P2 146.8000 234.183 -.055 .248 .762 P3 145.7407 222.550 .265 .291 .748 P4 146.4296 234.276 -.060 .354 .763 P5 145.7519 224.091 .246 .470 .749 P6 145.8667 225.254 .156 .403 .754 P7 145.4296 222.357 .309 .398 .747 P8 146.2000 227.551 .114 .351 .755 P9 146.1630 226.524 .150 .458 .753 P10 145.3370 219.734 .404 .392 .743 P11 145.8667 218.926 .363 .541 .744 P12 147.1556 235.017 -.078 .325 .762 P13 145.3481 218.741 .431 .432 .742 P14 145.5593 222.560 .352 .438 .746 P15 145.4259 216.446 .481 .535 .740 P16 145.7481 215.981 .465 .554 .740 P17 145.5815 219.471 .331 .442 .745 P18 146.5407 228.383 .100 .381 .756 P19 145.7741 227.930 .103 .443 .756 P20 145.4370 217.749 .437 .429 .741 P21 145.7889 229.914 .052 .410 .758 P22 145.2741 223.018 .281 .327 .748 P23 145.9778 229.784 .058 .391 .758 P24 146.3185 226.567 .134 .426 .754 P25 146.0296 218.594 .423 .512 .742 P26 146.1593 222.662 .329 .274 .746 P27 146.4074 228.451 .098 .277 .756 98 P28 145.7444 221.856 .309 .381 .747 P29 145.6519 222.228 .294 .414 .747 P30 145.4667 221.938 .311 .331 .747 P31 145.7185 222.173 .277 .400 .748 P32 145.4222 220.936 .378 .461 .744 P33 145.5407 222.420 .354 .499 .746 P34 146.1370 228.357 .104 .550 .755 P35 145.7815 226.617 .161 .270 .753 P36 146.0963 223.775 .219 .458 .750 P37 146.1667 229.322 .082 .414 .756 P38 146.1000 226.551 .149 .380 .753 P39 146.0556 232.618 -.015 .428 .760 P40 145.7704 221.308 .339 .385 .746 P41 146.0815 229.205 .079 .202 .756 P42 145.3370 219.890 .445 .575 .743 P43 145.9926 224.654 .201 .361 .751 P44 145.9444 217.629 .385 .402 .743 99