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January 14, 2013

Maintaining Empathy While Mastering Medicine

Medical students are selected as much for their character as for their knowledge. The trait most valued (or that should be the most valued) is empathy. Ironically, studies show an erosion of empathy during medical school. Why does this happen, and what can we do about it?

We all know what empathy is, or think we do, but medical educators have struggled to define it in the context of medical care. Empathy facilitates understanding of another person's concerns, and many ascribe to empathy the emotional characteristic of feeling another's pain and suffering. But in recent years, researchers and psychometricians have come to view empathy as a primarily cognitive attribute that can be role-modeled, taught, and assessed. (1)

Regardless of whether empathy is a thought, an emotion, or a combination of the two, progress has been made in developing psychometrically sound research instruments to measure empathy. In the field of medical education and patient care, the most highly regarded and widely used instrument is the Jefferson [Medical College] Scale of Physician Empathy (JSPE). The Jefferson Scale has been used since 2007, and extensive evidence now exists in the literature to support its validity and reliability. The designers of the JSPE (2) believe that it measures three factors (although some critics have reservations regarding this):

  1. the "physicians understanding of the emotional status of their patients," and the capacity to communicate this understanding
  2. the " 'compassionate care' component of the patient-physician relationship"
  3. the "ability to stand in the patient's shoes."

The JSPE demonstrates that a significant decline in empathy occurs during the third year of medical school and continues beyond graduation through residency training.

Why do many idealistic students who start medical school with a cargo of genuine enthusiasm to serve those in need of help undergo a significant reduction in as-measured empathy? Multiple and complex answers exist, but there is a consensus that the medical school curriculum "focuses the students' attention on diseases, not on the patients who have them." (3) The reliance on computer-based diagnostic and therapeutic technology overshadows the importance of human interactions. Also, referring to patients on rounds according to their diseases rather than their names (which does happen) reflects the lack of a human connection.

Medical educators also point to the emphasis a market-driven health care system places on controlled clinical trials and evidence-based medicine without a corresponding emphasis on empathy. In addition, there is a growing trend in medicine for physicians to behave with "clinical neutrality"--that is emotional detachment and professional distance--with avoidance of interpersonal interaction with patients. (2)

Add to this the "usual suspects" that medical students must contend with, including time pressure, sleep loss, high volume of material to learn, overly demanding patients, and fear of making mistakes, and it's understandable that empathy is crowded out.

Is the loss of empathy inevitable? I believe the answer is an emphatic "no." Not all students show a loss or decline in empathy. Moreover, the September 2009 issue of Academic Medicine that carried the report of declining empathy in the U.S. also carried a similar study (4) showing that in Japan, empathy grows during the medical school years. (Interestingly, in both reports, women showed more empathy than men.)

What are the ways medical students and residents can maintain and enhance empathy? Here are ten suggestions derived from the scholarly literature that I have personally found helpful:

  1. Select a medical school where empathy is valued. How can you tell? See if it promotes the approaches discussed below.
  2. For a role model, particularly during the clinical years, adopt an experienced clinician who is gifted in patient care and enjoys working with medical students. He or she will be flattered to be available to mentor you in that role.
  3. Make a personal commitment to talk to and listen to your patients. Take the necessary time to converse in a meaningful manner, and keep the relationship central while you participate in their care.
  4. Don't skimp on taking medical histories. In addition to getting the pertinent medical facts, use this as an entrée to building a relationship.
  5. Take every opportunity to maintain longitudinal follow-up with your patients; it will be rewarding to both you and your patients. This is often possible--and encouraged--when patients return for their follow-up visits. Otherwise maintain e-mail communication with the patient or access the patient's medical records, confirming first that this is consistent with hospital's policies.
  6. When a patient dies or treatment fails, don't respond by avoiding interpersonal engagement with other and future patients. Talk through your feelings with mentors and peers.
  7. Remember that affect and emotion are important components of the doctor-patient relationship. Don't try to conceal them.
  8. Work to improve your interpersonal communication skills. For example, be aware of the mood, attitude, and body language you present to your patients, make eye contact, and be a good listener.
  9. Take advantage of role-playing opportunities; analyze audio or video encounters with patients. Look into the Balint Society, a supportive and collaborative medical organization present at many medical schools and consisting of clinicians and teachers who emphasize the importance of emotion and personal understanding in the doctor-patient relationship.
  10. Maintain your humanist interests in literature and the arts. There is a strong impression stated in the academic literature that this reinforces empathy (2-4).
The rewards of building and maintaining empathy in one's medical career are manifold and real. Physician empathy almost certainly results in better health outcomes for patients (1) while ensuring personal growth and career satisfaction for the physician. So, as you train for a lifetime practicing medicine, remember to treat the person, not just the disease.

References

1. Hojat, Mohammadreza. 2007. Empathy in patient care antecedents,development, measurement, and outcomes. New York: Springer. http://dx.doi.org/10.1007/0-387-33608-7.

2. Hojat M., Vergare M.J., Maxwell K., et al. 2009. "The devil is in the third year: A longitudinal study of erosion of empathy in medical school". Academic Medicine. 84 (9): 1182-1191.

3. Spiro H. 2009. "Commentary: The practice of empathy". Academic Medicine. 84 (9): 1177-1179.

4. Kataoka H.U., Ochi K., Koide N., Hojat M., and Gonnella J.S. 2009. "Measurement of empathy among Japanese medical students: Psychometrics and score differences by gender and level of medical education". Academic Medicine. 84 (9): 1192-1197.

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