Of 750 students of the college, 470 (243 Females and 227 males) participated in the study. Current study has participation rate of 62.7%. There were an equal number of male and female students in the first and third year. Among second year participants, females exceeded males, comprising 58%. In fourth year, females were 53%, whereas in internship 56.5% students were male. The year-wise difference in male and female students is not statistically significant (p=0.43). The possible range of JSE-S Empathy scores is 20 -140. The mean empathy score of all students was 101.4 (Range 49 -135) and median=101, with a standard deviation of 15.14 ( Table 1). The 20-item empathy scale was observed to have good internal consistency in this study group (a= 0.742). Genderwise : Female medical students had significantly higher scores of empathy than male students (Table 2). In this study particularly higher empathy in female students than in male students was present only in the first and second year students ( Figure 1). From third year to internship, there was no statistically significant difference between male and female empathy scores (See Figure 1). Year wise: Overall, there is no significant difference in mean empathy scores in medical students year wise (Table 2). When year wise analysis is done in male and female students separately, it reveals that there is decline in empathy from first year to second year and then the mean empathy remains similar in rest of years both in male and female students (See Table 3 and figure 1). This may be a result of a shift from virtual, imaginative study in first year to real-time experiences via community exposure in clinicals from the second year onwards.

There was a statistically significant difference of empathy yearwise in female students as determined by one-way ANOVA, but no such difference was found in male students (Table 3). Post Hoc tests using Bonferroni showed significantly higher mean empathy scores in first-year female students when compared to third-year female students. In other year female students' empathy, no statistically significant difference was noted. (Table 3).

In the present-study, no significant association between choice of speciality and empathy levels was found. Out of 160 students who showed interest in people-oriented specialities, 86(54%) were females. Of 152 who hadn't chosen yet/chose other specialities, 84(55%) were female students. Out of 158 students who chose technology-oriented specialities, 73(46%) were females ( Table 2). A chi-square test of independence showed that there was no significant association between gender and preference of speciality. At the same time, mean values of empathy scores did not differ significantly based on choice of speciality of students overall (See Table 2), and in male and in female students separately. Moreover, there was no statistically significant difference in empathy among groups of choices of speciality across the year of education (p>0.05).

In the present study, inferences noted were : 1. Female medical students have significantly higher empathy than male medical students. 2. Empathy levels declined from first year students to second year students, but from 3rd year it remains almost constant till internship. 3.Choosing of specialities did not had an impact on empathy level scores. All the medical students present on the day of the study had given consent and participated in our study (Table 1). This is in contrast to the poor response rate of third-year students (77.2%) in the study by Chen et. al, in which a steady decrease in empathy scores was found. 8 Chen et al 12 reported higher mean empathy scores (114.3) compared to other studies like Kataoka et al. (104.30) 13 , Rahimi et al. (104.1) 16 and Shashi Kumar et al. (102.91) 24 and in current study it was 101.41. There is a need to further explore why most Asian students have almost similar scores but lower than the American studies. 1112 The curriculum in India is different in many respects from medical schools in the US, Japan and Iran. The students are exposed to clinical rotation from second year onwards (third semester), vast syllabus, practical live case based scenarios than virtual scenarios, recent horizontal and vertical integration of clinical and non clinical subjects etc., recently the medical board is taking steps to change from syllabus based curriculum to competency based curriculum.

But there is a decline of score in second year but is statistically not significant (Tables 2). Interestingly there is an increase in empathy scores in the beginning of third year this could be explained by the fact that these students were trained in patient history taking and communicating with the patient in the preceding year, whom were actively seeing patients and were also engaged in the clinical rotation. Kataoka et al in their study highlighted the point that different entrance methods in medical schools and different cultures across various countries may account for variation in empathy. 9 . The curriculum in our college differs from western and Japanese colleges in firstly students here have no exposure to humanities subjects such as economy, literature, philosophy and other sciences as found in Japanese medical curriculum and undergraduate curriculum in USA. Secondly students in this college are exposed to clinical rotation right from the beginning of second year in contrast to beginning of third year in USA, and in Japan. 89 Also, an interview to seek out the motivations of a student is not an integral part of the recruitment process into medical school in India as it is in the USA.

Another factor influencing empathy could be that students in clinical rotation are less likely to relate to the patient and regard him as a person rather than a "case" meant for study. Probable reason could be lack of constant follow up the patients for a longer period.

In a systematic review of study with medical students, Neumann et al. 25 had put forth some important issues that might explain the decline in empathy throughout their training.

One of them was that students themselves were probably overwhelmed by the mortality and morbidity that they encounter in clinical rotation and most often they do not have anybody to help them to deal with such issues. This is also a valid concern in India, where students generally do not have a facility (such as a student counsellor) available in their college to express their feelings in relation to these phenomena. Recruiting a student counsellor on a full time basis in medical colleges will address day to day stress issues of students. A significant factor found in another Indian study was distress in the form of reduced quality of life, depression, burnout, suicidal attempts and increased substance abuse arising from a variety of factors such as declining idealism, loss of enthusiasm since joining medical college, lack of knowledge in handling stress related issues and reduced contact with family. 24 The latter could be one cause of decline of empathy among our medical students as most of them stay in hostels away from home and have only 6 to 8 weeks of vacation during an academic year to be with their families. The present study does not measure any distress, quality of life or other variables. It can be taken by future researchers to improve medical education.

In this study there is significant difference (p = 0.001) in empathy scores between male and female with the latter scoring more than male students (mean female students=104.3 vs. male students=98.4, Standard deviation=15.1 & 14.7 respectively) ( Table 1), which is in consonance with studies from USA, Portugal and Japan, Iran, Brazil. 1213152627 Female students by nature are more caring and loving and probably less affected by factors that tend to diminish empathy. It was interesting to note that more female students tend to choose people-oriented specialties but due to their smaller numbers, no significant statistical difference could be arrived at (Table2). In our study, no significant difference in empathy scores was noted among those choosing different groups of specialities (p = 0.2468). Whereas Chen et al. 12 Mariana et al. 27 had found students preferring people-oriented specialities to have more empathy than those preferring technology-oriented specialities.

In the present study, there was no statistically significant difference between empathy among choices of speciality groups across the year of education (p>0.05). On the contrary, Hojat et. al found a decline in empathy scores among those choosing a technology-oriented specialization in third year. 7 Chen et. al have also reported increased empathy among those choosing people-oriented specialization and the difference is statistically significant (p=0.002). 11 They also found little difference in mean empathy scores across first to third year among those choosing other specialities. However, in our study the variance in empathy score across various years is not significant.

1) Fewer number of respondents who were doing their internship.

2) Being a cross-sectional study, the variance seen at different years of training may not be representative of actual decline from high baseline scores. Conclusion Current study concludes that female students are more empathetic than male students. In the recent years, we can see an increasing number of female students entering into medical education. There might be a difference in the type of medical care rendered to the patient and this area has a scope for further studies.

The medical curriculum should be set up in such a way that the students are educated in communication skills. This could help them to empathise with patients in better and more effective ways. The students should be taught not only to treat the physical aspect of the disease but also care about the emotional wellbeing of the patient. This helps in developing a positive patient-doctor relationship. The present curriculum and clinical training hardly contains anything that helps our students to deal with the effect of the mortality and morbidity that students encounter in clinical rotation. In campus full time student counsellor should be available to all students for the healthy, timely ventilation of stress related issues. Education in ethics and behavioural sciences may be effective in increasing the empathy levels among the medical students. This would lead to personal growth, career satisfaction, and optimal clinical outcomes. A longitudinal follow up study including a larger sample from a greater number of colleges would help to find out if a decline in empathy with progressing years in medical college truly exists. It would also help understand the effect of gender and variation in choice of speciality based on empathy score. Also, it could further ascertain what factors could be instrumental in the decline of empathy through progressive medical training. Bibliography: