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Encouraging Empathy

28 Mar

Here is a policy brief I wrote on how medical training tends to erode empathy and what can be done about it.

WHAT’S THE ISSUE?

Sir William Osler described medicine’s aims as “to cure sometimes, to relieve often, to comfort always.” To fulfill this profound calling, physicians must embody empathy. They must seek to understand what their patients are experiencing and imagine what it’s like to “walk in their shoes.”

 

Why is empathy such an important component of care? First, to diagnose a patient’s ailment, the physician must understand what the patient is experiencing and the context in which the problem is occurring.  Secondly, the very act of the physician listening to a patient’s story with genuine concern can itself be tremendously healing.  Third, only by seeking to understand a patient’s perspective is a physician able to provide care that fits the patient’s goals, values, and overall situation.

 

While an empathic impulse often leads people to enter medical school, studies show that students’ empathy tends to decrease as they progress through their education. [1]

As physician and essayist Danielle Ofri writes, “something in our medical training system serves to stamp out whatever empathy students bring with them on day one.”[2]

 

WHAT’S THE BACKGROUND?

 

Multiple theories have been proposed to explain the consistently observed decrease of empathy in medical students as they progress through their training.   One overarching cause is that students and their supervising physicians are often too overwhelmed with demands on their time, energy, and attention to focus on patients. A second cause is the lack of role models who instill the value of empathy in their students.  During their clinical rotations, medical students spend most of their time with interns and residents whose empathy is strained by the large volume of work they are expected to perform.  In this way, an ethic of efficiency over empathy is modeled for medical students. A third factor undermining students’ empathy is the emphasis on technology present at tertiary care centers where medical students train.  In these settings, the results of high-tech testing often receive more of the physicians’ and students’ attention than the actual patients in hospital beds.[3]

 

 

WHAT’S BEING TRIED?

 

Several solutions have been proposed and tried to ameliorate the erosion of empathy during medical education.  An increasingly popular approach is changing how the clinical year of medical school is arranged. Traditionally, students rotate through 2-8 week rotations of different fields of medicine such as pediatrics, internal medicine, obstetrics, and general surgery.  During these rotations, students’ capacity to become quickly competent in requisite knowledge and skills is assessed by supervising physicians. Just as a student develops familiarity and confidence in one rotation, he or she is switched to another one. This system often leaves students feeling too harried, inadequate, and overwhelmed to focus on patients and their needs. Thus, a growing number of medical educators are eliminating block rotations and instead utilizing an approach based on longitudinal relationships between medical students and patients.  In this approach, each medical student is assigned a panel of patients who they accompany to clinical encounters throughout the clinical year. As students follow their patients they learn about different fields of medicine, while getting to know the patients as persons who are more than their health conditions. In a study at Harvard Medical School, students who participated in a longitudinal program were found to have had more rewarding and humanizing learning experiences than their peers on traditional block rotations. [4] Nonetheless, enthusiasm for the longitudinal approach has been tempered by the concern, expressed by some residency directors, that it does not prepare students as well for residency as the traditional block method does.  In addition, it is much more difficult and complicated for schools to organize a longitudinal clinical curriculum than one using block rotations.

 

WHAT I PROPOSE

 

Strategies for helping medical students retain their empathy can be categorized into two types.  The first approach is changing the features of the medical training system that erode students’ empathy.  The second is to equip students to maintain their empathy even when myriad factors work to undermine it.  You might call this latter approach fostering empathic resilience.

 

Changing the System

As previously stated, an increasingly popular approach for reforming the medical training system to make it less erosive of empathy is changing the clinical year from a block method to a longitudinal one. But since many medical schools do not feel comfortable making this complicated change, it is worth considering alternative or complementary strategies.  One idea is to eliminate or at least deemphasize grading and evaluations in medical education.  Right now many medical students are so focused on achieving high marks in their courses that they neglect to give full attention to their patients. If grades and evaluations must remain, a greater emphasis should be placed on the empathy medical students demonstrate in their interactions with patients and staff.  In addition, the evaluation process should focus on helping students develop into outstanding physicians, rather than being a means of punishing or shaming students who are not living up to expected standards.

 

Another approach is decreasing the volume of work residents and medical students are expected to perform on clinical rotations.  If this change were made, the expectation would be that residents and students would spend the leftover time getting to know their patients in greater depth.  Less harried and overwhelmed residents would serve as better empathic models for the students they are supervising.

 

Since empathy is a characteristic often best learned by modeling, clinical faculty who will serve as inspiring examples of empathy should be valued.  As part of their faculty development, attending physicians should receive training in how to increase their own empathy and to model it for trainees.  When selecting and promoting clinical faculty, greater weight should be placed on the empathy that attending physicians demonstrate in their interactions with patients, students, and staff. Does the physician show genuine concern for and interest in the patients in his or her care? Or is the focus merely on test results, treatments, and getting the patient discharged?

 

Bolstering Empathic Resilience

In the culture of many hospitals and clinics, the supreme, overarching value is getting the day’s work done. The implicit idea is that once doctors plough through the workday’s demands, they can then start really living their lives.  Little effort is made to pay attention to and be mindful of the meaning of the work at hand. To combat this culture of efficiency students should be offered training in mindfulness.[5] Just as mindful eating means savoring the food you eat, so students could be trained to be attentive to the meaning of the work they are doing.

 

Mindfulness should also be encouraged through students writing about their clinical experiences in ordinary language. In this way, a coherent narrative can be formed out of the blur of the day’s clinical activity. In the Humanism and Professionalism Program at the Robert Wood Johnson Center Medical School, students meet regularly in small groups with mentors to discuss journal entries they write about their clinical experiences. In this way, they explore topics such as tribulations of patient care, positive and negative role models they are exposed to, and the specific challenges of maintaining humanism and professionalism in situations that often seem expressly designed to chip away at these values.  Students are also assigned readings that promoted reflection on the meaning and purpose of the practice of medicine.  To determine if this program was effective in helping students retain their empathy, two consecutive classes of medical students took a validated test of empathy before they started this program in their clinical year and then again at the end of the year. On average, researchers found no decline in empathy scores for both classes. The students in other studies using the same measure of empathy showed a decline after they finished their clinical rotations.[6]

 

Another means of enhancing students’ empathy is improving their communications skills.  One model for doing so emphasized the development of three basic communication skills namely, “recognition” of patient’s negative emotions, concerns, and inner experiences; “exploration” of these emotions, concerns, and experiences; and “acknowledging” them to generate a feeling in the patient of being understood.[7] Along these lines, students should be taught how to respond when patients try their ability to empathize. To accomplish this, facilitators and students could watch and discuss videos of physicians responding in a professional, healing manner to patients who are angry, worried, loquacious, not adherent to recommendations, and challenging historians. Students could also be videotaped responding to standardized patients presenting with similar scenarios. They could then receive feedback from the patients and faculty-members about how they might communicate more empathically.

 

WHAT’S NEXT?

 

Medical schools should consider taking the following steps to make their training system less erosive of students’ empathy.

 

1)   Change the methods of student assessment.  Place less emphasis on students’ grades and evaluations. The purpose of assessing students’ performance should be enabling them to be the best physicians possible. Student evaluations should not be a means of sorting out who will qualify for the most sought-after residency programs. This creates a competitive, cut-throat culture that is not conducive to empathy.

2)   Decrease the volume of work residents and medical students are expected to perform on clinical rotations.  Expect and ensure that trainees use the leftover time to get to know patients in greater depth.

3)   Promote empathy is clinical faculty.  Provide faculty development that teaches supervising physicians how to increase their own empathy and model it for trainees.  Select and promote clinical faculty who exemplify empathy in their interactions with patients, students, and staff.

4)   Provide training in mindfulness for students and their supervising physicians.

5)   Encourage students to write about their clinical experiences, creating narratives that reveal the meaning of their work.

6)   Equip students with communication skills that will enable them to better empathize with patients.

 

 

[1] B.W. Newton et al.  “Is There a Hardening of the Heart During Medical School?” Academic Medicine 83 (2008): 244-49; M. Hojat et al., “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” Academic Medicine 84 (2009): 1182-91; M. Neumann et al., “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents,” Academic Medicine 86 (2011): 996-1009

[2] Ofri, Danielle. What Doctors Feel: How Emotions Affect the Practice of Medicine. p. 30 Beacon Press, 2013.

[3] Verghese, Abraham. Culture Shock—Patient as Icon, Icon as Patient. New England Journal of Medicine. December 25, 2008. 359;26

[4] Chen, Paulene.  Reinventing the Third-Year Medical Student, New York Times, April 19, 2012.  http://mobile.nytimes.com/blogs/well/2012/04/19/reinventing-the-third-year-medical-student/

[5] Dobkin, Patricia & Tom A Hutchinson.Teaching mindfulness in medical school: where are we now and where are we going? Medical Education, 2013; 47: 768–779

[6] Rosenthal, S. Humanism at heart: preserving empathy in third-year medical students. Acad Med. 2011 Mar;86(3):350-8.

[7] Suchman, A.L. Markakis, K., Beckman, H.C. & Frankel, R. (1997). A model of empathic communication in the medical interview. JAMA, 277, 678-682.

 

 
2 Comments

Posted by on March 28, 2014 in Uncategorized

 

2 responses to “Encouraging Empathy

  1. Christa broderick

    April 6, 2014 at 12:16 am

    Dear Dr. M, I love reading your website. I should be encouraging you to become a professor at the UT med school soon to be and you would be great. You really could have a wonderful impact on students and fellow doctors. Over the years I have gone from physicians who had time to listen to physicians who are completely exhausted by the schedule. From the first time I went to see you, I was amazed at how much time you took to listen and question.
    The only problem with encouraging you to become a prof at the med school is what would I do if you were no longer at the med clinic? Guess I would have to hope you would still see your former patients if only to show your students who they will be treating!
    Hope you and your family are doing well,
    Christa Broderick

     

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