INTRODUCTION
The American Association of Medical Colleges emphasizes in its medical school educational learning objectives that “physicians must be compassionate and empathetic when caring for patients”[1]. Similarly, one of the medical ethics principles advocated by the American Medical Association states, “physicians should be dedicated to providing competent medical care in the spirit of compassion and respect for the dignity and rights of the individual”[2]. These statements underscore that beyond the fundamental elements of professional knowledge and skills, it is crucial for qualified physicians to be empathetic. Empathy is associated with beneficial outcomes for both patients and healthcare professionals, including increased patient compliance with treatment, reduced medical malpractice complaints, and improved physician health, happiness, and job satisfaction[3], as well as decreased burnout, personal distress, depression, and anxiety[4-6]. Furthermore, patients’ perception of the clinician’s empathy is positively correlated with better health outcomes[7,8]. Doctors’ empathy can reduce healthcare costs since patient-centered communication can yield more accurate and comprehensive information, facilitate accurate diagnoses, and reduce unnecessary expenditure on supplementary tests[9]. Two previous studies have shown that empathetic abilities tend to be higher during the early stages of students’ education. However, their empathetic abilities significantly decreases when they enter the clinical practice phase and interact with patients[10,11]. In Tavakol et al[12] study, students reported that empathy education should be emphasized in medical schools, especially in the later years. This may be attributed to a bias in the curriculum that places a greater focus on clinical and biomedical education while overlooking empathy education. Empathy education is crucial for nurturing empathy, interpersonal skills, and communication abilities among medical students. Therefore, these findings may facilitate discussions on improving and balancing medical school curricula. Personality is a significant independent variable that modulates empathy and consists of three elements: Self-awareness, cognition, and emotion. Personality represents the sum of a person’s stable and unique psychological characteristics, that is, an individual’s psychological profile. It is defined as the enduring thoughts, feelings, attitudes, habits, and patterns of behavior that distinguish a person from others in different situations. The five-factor model of personality is the most commonly used personality dimension model[13] and includes the following five dimensions: Openness (imaginative, creative, curious, and breadth of mind), conscientiousness (organized, responsible, punctual, achievement-oriented, and reliable), extroversion (energetic, friendly, talkative, and gregarious), agreeableness (compassionate, friendly, or hostile), and neuroticism (worrier, anxious, impulsive, and insecure). Resilience is a protective factor that makes individuals more resistant to adverse events and can lead to positive developmental outcomes. Resilience represents positive adaptation following stressful situations, encompasses mechanisms for coping with and overcoming challenging experiences, and reflects an individual’s capacity to effectively adapt to change, endure the adverse effects of stressors, and prevent significant functional impairment. The ability to bounce back from challenges is a crucial aspect of psychological well-being and adaptation[14]. While the existing literature has explored the relationship between the Big Five personality traits and empathy, as well as that between resilience and the Big Five personality traits[15,16], the mediating role of resilience in the relationship between the Big Five personality traits and empathy has not been verified. Within the context of undergraduate dental students, this gap presents an opportunity for new research to contribute to our understanding of the complex interplay among these variables. Globally, 6%-21% of dental patients report severe fear of dentists[17]. Dental phobia is a psychological disorder characterized by an intense fear of dentists and dental treatment. This fear is often rooted in unpleasant dental experiences, concerns about pain or discomfort, and other factors. Patients with dental phobia are more likely to delay necessary check-ups and treatments, potentially leading to delayed or exacerbated conditions[18,19]. Patient-centered communication can prevent delays in dental treatment[18], help patients overcome their fears, provide information, establish trust, alleviate anxiety, and collaboratively create treatment plans. Dentists and healthcare teams should listen to patients’ needs and concerns to provide the best medical care. Recognizing the crucial contribution of empathy to treatment compliance is a potential goal for cultivating empathy skills among dental students, which are essential for providing better medical care and improving patient experiences. Compared to other medical specialties, dentistry includes a high degree of procedural invasiveness, close physical proximity, and repeated exposure to patients’ fear and anxiety during the treatment. Epidemiological studies have reported that 6%-21% of dental patients experience severe dental fear, leading to treatment avoidance, heightened pain perception, and reduced treatment compliance[17-19]. Therefore, dentists need to perform technically demanding procedures while facilitating patients’ emotional regulation through communication, reassurance, and empathic engagement. Therefore, early development of empathic capacity is particularly critical for dental students. Insufficient empathy may exacerbate patient anxiety and compromise treatment cooperation, whereas excessive emotional involvement without adequate psychological regulation may increase students’ vulnerability to stress and burnout. These unique clinical and emotional demands make dental students an especially relevant population for examining the psychological mechanisms underlying empathy and identifying modifiable factors such as resilience that may support sustainable empathic practice. Consequently, we conducted a cross-sectional survey among dental students to achieve three objectives: (1) Assess the level of empathy among dental students; (2) Explore the correlation between the Big Five personality traits, resilience, and empathy; and (3) Investigate the mediating role of resilience in the relationship between the Big Five personality traits and empathy.
MATERIALS AND METHODS
Procedure and sampling
This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of China Medical University. Informed consent was obtained from all the participants. Undergraduate dental students from a medical university voluntarily participated in the study and were briefed on its purpose before completing the questionnaire. The survey began with an informed consent link, and students were considered to have provided their consent by proceeding with completing the online questionnaire. Data was collected between July 1, 2023 and August 20, 2023. The authors had unrestricted access to the participants’ responses during and after data collection.
Demographic characteristics
Participants provided information about their age, sex, ethnicity, academic year, place of residence, being an only child, father’s education level, and mother’s education level.
Assessment of the Big Five personality traits
The Big Five personality traits were assessed using the Big Five Inventory[20], which comprises 44 items designed to measure five personality traits. Items are rated on a Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Higher scores indicate a higher presence of each personality trait. The Big Five Inventory has been extensively used in China owing to its strong validity and reliability[21,22]. Cronbach’s alphas for the Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness subscales in the present study were 0.674, 0.857, 0.857, 0.769, and 0.826, respectively.
Assessment of empathy
Empathy was assessed using the Interpersonal Reactivity Index (IRI)[23], a commonly utilized tool for gauging empathy tendencies among medical students. The IRI comprises four subscales, each consisting of seven items: IRI-perspective taking (IRI-PT), which assesses the ability to understand others’ psychological perspectives; IRI-empathic concern (IRI-EC), which assesses feelings of warmth and concern for others; IRI-personal distress (IRI-PD), which assesses anxiety and unease in stressful interpersonal situations; IRI-fantasy (IRI-FS), which assesses the tendency to transform one’s imaginative reactions into fictional characters. The IRI-EC and IRI-PT subscales are “other-oriented”, while the IRI-PD and IRI-FS are “self-oriented”. Each item is rated on a 5-point Likert scale, where 0 = does not describe me well and 4 = describes me very well. Higher scores indicate higher levels of empathy. Cronbach’s alpha for the IRI was 0.812 in the present study.
Assessment of resilience
The Connor-Davidson Resilience Scale[24] is a well-established tool used to assess resilience in various populations, including dental students. This scale measures aspects of resilience such as “bouncing back” and adaptability and has demonstrated strong psychometric properties. There are 25 items that are rated on a 5-point scale, where 0 = not true at all and 4 = true nearly all of the time. The total score ranges from 0 to 100, with higher scores indicating greater resilience. In the present study, Cronbach’s alpha was 0.979.
Statistical analysis
All analyses were conducted using SPSS 27.0 for Windows. Pearson’s correlation coefficients were calculated to examine the relationships between empathy, the Big Five personality traits, and resilience. Hierarchical multiple regression analysis was conducted to examine the incremental variance explained by any set of independent variables and the mediating effect of resilience. Mediation effects were evaluated using the Baron and Kenny approach and further verified using bootstrap analyses. The mediation effect is significant when the bias-corrected 95%CI for the indirect effect does not include zero. Complete mediation is inferred when the direct effect (c’) becomes non-significant after inclusion of the mediator. Before conducting the regression analysis, all continuous variables were standardized to prevent multicollinearity issues. Empathy was the dependent variable, and the independent variables were entered in three steps. In Step 1, the demographic variables were included as control variables. Dummy variables were created for ethnicity and academic year since they were categorical variables. Multicollinearity among the predictors was examined before conducting the hierarchical regression analyses. All variance inflation factor values were below the commonly accepted threshold, indicating that multicollinearity did not substantially influence the regression estimates. The Han ethnicity was set as the reference group for ethnicity. Junior high school and below was the reference group for the academic year. In Step 2, the Big Five personality traits were entered. In Step 3, resilience was entered into the equation. The analysis was conducted stepwise by entering several blocks of independent variables into the model. Standardized estimates (β), F-values, R², and R² change (ΔR²) were evaluated at each step. All statistical tests were two-tailed, and P < 0.05 was used for indicating significance. No generative artificial intelligence tools were used to prepare the manuscript.
DISCUSSION
This study emphasized an essential area in Chinese medical education requiring further research, specifically among dental students. These findings contribute to a better understanding of the relationship between personality traits and empathy among dental students. Empathy was measured using the IRI, which is widely used among medical and health-related student populations in China and has demonstrated acceptable psychometric properties across cultural contexts[15]. This study found that the Big Five personality traits played a predictive role in the different dimensions of empathy. This implies that personality traits of dental students influence their expression of empathy. Additionally, resilience was found to mediate the relationship between the Big Five personality traits and empathy. Thus, resilience is a possible psychological mechanism that can explain the relationship between personality traits and empathy. These findings have implications for the education and training of dental students in prosocial behaviors that are conducive to providing quality dental care to patients. Medical educators should design educational programs to enhance empathy among dental students, which is crucial for providing quality healthcare services and enhancing patient satisfaction.
In this study, agreeableness was significantly associated with fantasy and perspective-taking dimensions of empathy. Highly agreeable people are described as trustworthy, honest, generous, compliant, humble, and empathetic. Moreover, agreeableness is closely tied to prosocial behavior[26,27], encompassing the inclination to help, donate, comfort, and care for others, potentially resulting in the transfer of positive emotional states from one individual to another[28]. Therefore, agreeable individuals are more likely to directly affect others’ well-being, which is consistent with previous studies. For example, when the level of perspective-taking is high, doctors are more adept at understanding the patient’s viewpoint, reducing the impact of exposure to stress on their emotional responses, and contributing to prosocial behaviors[29]. In a cross-sectional survey, highly agreeable nurses demonstrated greater readiness to assist and trust others, along with increased empathy, kindness, and politeness toward patients. Additionally, agreeableness among nurses is associated with the ability to empathize and communicate with terminally ill patients[30] and a willingness to dedicate time and attention to their emotional well-being[31]. In studies among medical students and internists, agreeableness was associated with outstanding academic and clinical performance[32,33].
A fundamental characteristic of extraversion is positive emotions[18]. According to previous research[34], positive emotions can broaden one’s cognitive scope, establish enduring social resources, and consequently, lead to more significant interactions with the environment. Expanded mental and emotional resources may enable extraverted individuals to be attentive to others’ feelings (i.e., empathic concern) and consider others’ perspectives (i.e., perspective-taking)[35]. A previous study found a positive correlation between extraversion, perspective-taking, and empathic concern[36], which aligns with the findings of the present study. Additionally, extraverted behavior is positively associated with resilience, which further fosters the experience of positive emotions, encourages seeking and forming relationships with others, and contributes to building a strong social support network[37].
Openness is a personality trait characterized by a vivid imagination and an active fantasy life. The relevance of the fantasy subscale in medical education has been debated. People with high openness tend to experience deep emotional states and can differentiate between them. They are analytical, theoretically oriented, curious, and willing to engage in various activities. Moreover, they tend to challenge authority, conventions, and traditional beliefs. In the context of the fantasy dimension of empathy, the relationship with openness is logical, since an open attitude toward the fictitious worlds of books, dramas, and related mediums is a prerequisite for experiencing empathy in a fictional setting[38-40]. A previous study revealed that highly fantasy-prone children scored higher on cognitive and emotional empathy than their low fantasy-prone counterparts[41]. Consistent with a previous study on the relationship between empathy and personality traits in Saudi medical students, openness to experience was significantly related to perspective-taking and fantasy[42]. Openness to experience is positively associated with cognitive flexibility and empathy[20], both of which are likely to be beneficial in academic and clinical settings. Therefore, dental students who are open to new experiences may demonstrate flexibility by exhibiting a greater understanding of the patient’s perspective, actively engaging in empathy, and putting themselves in others’ shoes.
Conscientiousness is characterized by self-confidence in one’s abilities, good organizational skills, a preference for making plans, a sense of responsibility, higher levels of ambition, and diligent work to achieve goals. This trait further includes self-discipline and cautiousness. While conscientiousness is a quasi-moral trait, its characteristics include impulse control and restraint[34,43]. In numerous studies involving medical students, a consistent link has been shown between conscientiousness and academic success[28,36-38]. Conscientiousness is associated with improved psychological health and adaptive coping skills[44]. Furthermore, highly conscientious individuals tend to pay attention to others’ perspectives and feelings and are prepared to take action to maintain interpersonal harmony and reduce conflict[41]. Conscientious individuals may be considered more empathetic since they typically seek to resolve conflicts with others and proactively avoid causing trouble[45].
Neuroticism is characterized by experiencing negative thoughts and feelings, emotional instability, and a lack of a sense of security. Compared to emotionally stable individuals, individuals with high neuroticism are more susceptible to experiencing negative emotions such as anxiety and depression[46], making it difficult for them to empathize with others or care for their feelings[47]. In the present study, personal distress was the most robust empathy dimension that correlated positively with neuroticism, which is conceptually understandable. Since the measure of personal distress assesses attitudes and feelings toward stressful interpersonal situations, it has been argued that neuroticism plays a dual role in empathy. Personal distress is associated with self-centered motives rather than moral motives[43,44]. In situations where contact with suffering individuals is unavoidable, such as relationships in which the person plays the role of helping others, people experiencing personal distress may passively assist others since this is one of the quickest ways to alleviate their negative emotional states. Furthermore, some argue that an excessive degree of empathy can lead to self-centered emotional reactions driven by concern for others, hindering a doctor’s performance and influencing medical decisions[48,49]. Doctors who empathize with their patients find it challenging to maintain their emotional dominance.
Considering a medical education perspective, this pattern may represent a double-edged effect of neuroticism on empathic engagement. On the one hand, heightened emotional sensitivity may enhance vulnerability to anxiety, emotional overload, and empathic fatigue in high-stress clinical environments. On the other hand, when appropriately supported, this sensitivity may facilitate a deeper awareness of patients’ suffering. Therefore, highly neurotic students may particularly benefit from structured supervision and targeted training in emotional regulation, enabling them to transform emotional reactivity into sustainable, patient-centered empathy rather than maladaptive personal distress. Furthermore, heightened emotional sensitivity associated with neuroticism may lead individuals to report higher levels of empathic engagement across multiple dimensions during self-reported assessments, particularly in contexts involving frequent exposure to patients’ emotional distress. In medical training environments, this heightened vigilance toward emotional cues may be interpreted as empathy, even when it primarily reflects anxiety-driven emotional involvement rather than well-regulated clinical empathy.
Professionals require advanced emotional regulation skills to maximize the positive effects of empathy, which can be facilitated by neuroticism.
The mediating effect of resilience
Positive psychology focuses on the strengths and behaviors that help individuals face challenges or setbacks. Resilience is a positive psychology construct, and the Connor-Davidson Resilience Scale measures five aspects of resilience: Personal competence, trust in one’s instincts and the strengthening effects of stress, acceptance of change and secure relationships, control, and spiritual influences. Resilience is the ability to adapt well by exhibiting stable trajectories and healthy functioning after highly stressful and potentially traumatic life events[14,29,50]. Thus, resilience is a dynamic process that encompasses positive adaptation in the face of adversity[51].
Previous research has indicated significant differences in all personality trait dimensions related to resilience. In one study, resilient individuals scored significantly higher on extraversion, openness to experience, conscientiousness, and agreeableness than non-resilient individuals[52]. These findings support an association between personality traits and resilience. Extraverted individuals may have the ability to think more flexibly in stressful situations owing to their possession of positive emotions and may have more personal resources to use when facing challenges and difficulties, which may further enhance their resilience. People who have an attitude of openness to experience may have the ability to adopt a critical stance when facing challenging life events, the ability to try different choices, the courage to propose their solutions, and a creative power, which may explain why they may be more resilient than others. People who are highly agreeable may experience reduced conflicts in interpersonal relationships, be more positively accepted by their social environment, and obtain more emotional support, which may make them more resilient. The critical qualities possessed by conscientious individuals may help them overcome adverse situations when facing challenging life events. Therefore, conscientiousness can be seen as a quality that contributes to their recovery capability[53]. Individuals with higher levels of neuroticism are more vulnerable to the effects of emotional stress and have a higher risk of emotional disorders. Conversely, those with lower levels of neuroticism tend to cope more effectively with stress and possess the capacity to maintain emotional equilibrium[54]. Therefore, neuroticism would be negatively associated with resilience.
This study investigated the mediating role of resilience in the relationship between the Big Five personality traits and empathy. The findings indicated that resilience fully mediated the relationships between empathy and the traits of agreeableness, conscientiousness, and openness, whereas it partially mediated the links between empathy and extraversion and between empathy and neuroticism. Research has suggested a significant correlation between resilience and empathy, indicating that they both may influence the cognitive form of clinical empathy. Highly resilient individuals, who recognize their difficulties and develop appropriate coping strategies, may also be capable of empathetic responses[55]. In addition, an increasing number of researchers agree that despite correctly controlling and testing intermediate variables, most research results involve partial mediation. Although full mediation does not preclude other variables from explaining the relationship between two variables, partial mediation clearly indicates that the mediating variable is not sufficient to explain the relationship between two variables but partially explains it. Indeed, the identification of other potential mediating variables such as work relationships and social support may explain the additional factors that may influence the pathways through which extraversion and neuroticism are related to empathy. Exploring these variables could provide valuable insights into the complex interplay between personality, resilience, and empathy[56,57].
Implications for the education of dental students
Considering an educational perspective, the findings of the present study highlight the need of a multilevel and developmentally-informed approach to empathy training in dental education.
First, students with low empathy can be identified early through the non-stigmatizing use of brief screening tools, such as shortened versions of the Big Five Inventory or the IRI, which can be integrated into academic advising or student psychological support systems. These assessments should be framed as developmental feedback rather than evaluative judgments to guide personalized educational support rather than labeling students[58].
Second, resilience-oriented interventions should be systematically incorporated into clinical skills training. Engaging in structured reflective practices encompassing cognitive reappraisal, stress management, and emotional regulation after simulated clinical encounters or real-patient consultations may help students process challenging interactions while maintaining empathic engagement. Evidence indicates that targeted educational workshops and skill-based interventions can effectively enhance resilience and adaptive coping among medical trainees.
Third, empathy cultivation should be incorporated throughout the dental curriculum. Educational approaches such as narrative medicine, reflective writing, and supervised clinical reflection can help students attend to patients’ experiences, emotions, and concerns, thereby fostering empathy while enhancing self-awareness and psychological resilience[59,60]. Furthermore, paying greater attention to non-verbal communication and perceptual interactions during clinical encounters may strengthen their empathic engagement and doctor-patient relationships[61].
Strengths and limitations
This study has several strengths. First, previous research has repeatedly demonstrated that empathy promotes resilience. However, this study postulated that resilience positively enhances empathy. This novel perspective provides another avenue of investigation for future research and has implications for the education of dental students. Second, the results have implications for the psychological development of dental students in their current healthcare environment. These findings provide valuable information for nations, societies, and schools to cultivate empathy and resilience among dental students. This contributes to enhancing the social responsibility of dental students, improving doctor-patient relationships, increasing patients’ trust, satisfaction, and treatment compliance, and improving clinical outcomes.
This study has several limitations. First, using self-report questionnaires to evaluate personality dimensions may contribute to social desirability bias in which individuals may respond in socially acceptable ways, potentially leading to biased or inaccurate data. For example, some male participants may respond to items on the IRI that have feminine characteristics (tenderness, concern, and fear) in a way that does not admit to having feminine thoughts, feelings, or behaviors[62,63]; or they may admit to having such characteristics when they do not have them because it is expected that they should. Second, causal relationships between the study variables could not be determined owing to the cross-sectional nature of the study. Future cohort studies are required to validate the findings of the present study. Additionally, the use of common method variance may have influenced the observed associations because all the variables were assessed using self-report measures administered at a single timepoint. Although anonymity was ensured to reduce response bias, future studies could incorporate multisource data, such as behavioral assessments using standardized patients, peer evaluations, or faculty ratings. Moreover, the present study did not explicitly examine cultural factors. The expression and interpretation of empathy in Chinese collectivist culture may differ from those in Western individualistic contexts, which may impact the applicability of the IRI and the localization of educational interventions. Finally, the generalizability of the results is limited. Therefore, it is advisable to validate the research results using different samples across medical specialties.
