BMC Medical Education Review – November, 2015

The manuscript deals with an important issue in Medical Education: the validation of the Spanish Jefferson Scale of Empathy (JSE) for the assessment of empathic skills of Spanish medical students. Authors present an innovative approach for such assessment, with the second order confirmatory analysis for the total score of the JSE. Nevertheless, the manuscript presents some methodological flaws, which I will mention as follows:

Major Compulsory Revisions

1. In the Introduction of the manuscript, authors should state the importance of validation studies in medical education research. The historical rescue of the importance of empathy in the context of clinical care seems of minor importance to the BMC Medical Education readership, since there is a solid ground of evidence pointing to the association of empathy and clinician-patient relationship.

2. Although innovative, the analysis of the JSE through a second order latent factor model to consider the global score should be ground on a theoretical framework stated by the authors in the Introduction. The fact that is has not been tested yet does not justify such analysis. Should empathy be considered a one-dimensional construct? Or is it a multidimensional construct that encompasses cognitive, emotional and behavioural characteristics?

3. Table 1 should be excluded, as a narrative review of the existing evidence on JSE psychometric properties is not the scope of the manuscript (it is neither in the aim nor in the methods of the manuscript).

4. Authors should explicit the response rate considering the total of medical students eligible for the study. Does the sample represent the population of Spanish medical students? Is the proportion of female and male medical students similar to the general population of medical students in Spain? Unless this is clearly stated in the Methods section, conclusions are limited due to selection bias and generalization of results is impaired. How many students were excluded from analysis? This information is closely related to data quality (percentage of students with 5 or more items left in blank).

5. Table 2 should be reviewed: sums do not represent totals and information is rather confusing. The title of the table also does not reflect the data presented.

6. All references that refer to unpublished material should be excluded from the manuscript: references 21 and 25.

7. How were students protected from feeling constrained to participate in the study? It is common knowledge that all studies involving human participants should undergo ethical approval, even if the study does not involve clinical questions or procedures.

Minor Essential Revisions

1. Some abbreviations throughout the manuscript are in Spanish: “TP” for “Perspective Taking” (page 10, line 18; Table 4), “H vs M” for “Male vs Female” (Table 1). Authors should review all other abbreviations carefully.

2. In the “Measures” section, authors mentioned that students completed the adapted Spanish version or the JSE-S. Which alterations were made to the original Spanish version? How was this adaptation achieved? How was consensus on the adapted version achieved by the panel of experts?

Discretionary Revisions English editing is necessary.

Reviewer Confidential Comments to Editor I am particularly concerned with the statement that the study was exempted from the Review Board’s Research Ethics Committee: how were students protected from feeling constrained to participate in the study? Such constraints, if existed, would definitely undermine study results. It is common knowledge that all studies involving human participants should undergo ethical approval, even if the study does not involve clinical questions or procedures.