Empathy in medical education

I have been busy writing some modules for clinical teachers’ CPD and just got started on one about teaching communication skills.  I moved on a bit in the literature to “empathy”- that elusive quality that I recall being reported to decrease either through medical school or once graduates land in the clinical years and the hospital system (a 2011 systematic review of studies on the decline of empathy is here https://www.ncbi.nlm.nih.gov/pubmed/21670661).  There is often debate as to whether this is to do with, among other things, lack of specific teaching, devaluing of “soft skills”, work and training stresses or the powerful influence of role models and the “hidden curriculum”.  Some of the research also overlaps with the concept of patient-centredness.

A recent article in the August 2019 edition of Medical Teacher was a little less pessimistic and not so conclusive when it described a meta-analysis of empathy studies and noted that significant negative changes were noted, but mainly with one particular tool, that studies relied on self-report and that the various tools may not even be measuring the same thing.  So, as is often the case, methodology issues and more research needed!

Over the years there have been various suggestions (and attempts) to expose medical students to humanities subjects on the assumption that this can engender empathy.  Of course, if these observations are true, it could be a chicken and egg situation.  Are potentially empathic people more drawn to the humanities?  And how often do rather unempathic staff “prescribe” such solutions, with students responding in the way they usually do to unwanted curricular requirements? 

This article in The Conversation lobbed into my email inbox earlier this year https://theconversation.com/empathy-in-healthcare-is-finally-making-a-comeback-113593 .  It comes from “The Oxford Empathy Programme.”   It’s a very readable summary and notes that studies have suggested that “empathic communication” can be taught.  The article notes the connection to Communication Skills which are mandatory in curricula now.  The author even raises the question of the cost-effectiveness of empathy.  Some of the comments on the article noted the effect of resources on empathy, the decline in GP:patient ratios, the increasing use of telephone consultations, less holistic approaches and the “avoidance techniques” used with patients to cope with time factors. 

Other articles relate decreasing empathy to concepts of burn-out as in this blog https://www.kevinmd.com/blog/2019/03/whats-happened-to-clinician-empathy.html Two years ago I attended a play at the Edinburgh Fringe which basically described GP burnout in the UK (the picture shows the blurb about it) and I discussed this in a previous post http://mededpurls.com/blog/index.php/2017/08/30/self-care-in-the-curriculum/ .

It is therefore of note that perhaps the time pressures in the UK system are now requiring consultations to be more “efficient” and with a subtle move away from the patient-centred idealism of a few decades ago.  The Consultation Hill Model described here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2894394/ summarises some of that in the registrar context.  There is a bit of cognitive dissonance here when we think of the exhortations to greater empathy inherent in much of the training.

Another Conversation article, from 2017, https://theconversation.com/are-our-busy-doctors-and-nurses-losing-empathy-for-patients-68228  also has the common caveat that “With more demand on doctors and nurses and a push for quicker consultations, clinical empathy is being dwarfed by the need for efficiency”.  This article focussed on the impact of technology lessening direct patient contact time.  Here are two recent articles on how technology may be affecting empathy in health care – although unfortunately they are behind a paywall https://journals.sagepub.com/doi/abs/10.1177/0141076818790669 and https://journals.sagepub.com/doi/abs/10.1177/0141076817714443?journalCode=jrsb

I would suggest it is good to have a look at the literature and see what evidence there might be about empathy training if you are going to try and insert it into the syllabus. There seems to be a Cochrane Review in process.  It is a complex topic and there has been interesting research on its place in general practice, including how perceptions of empathy vary according to measures of economic deprivation http://eprints.gla.ac.uk/104350/ . Of course, there is a much broader collection of opinions on how social media may be affecting empathy in society.

I would also suggest there is another influence on developing empathy which has a parallel with the effects being felt in the health system.  It is worthwhile noting the similar changes occurring in the medical education sector:  a decline in the ratio of lecturers/educators/tutors to students/registrars; more reliance on technology than interpersonal communication (do you get to know the learners?); simulation and online delivery of teaching; more emphasis on exam results and paperwork; more rigid rules and box-ticking for accountability and so forth.  Again, a type of cognitive dissonance is experienced.  We find arguments convincing that explain the behaviour of some adults because of the environment in which they grew up so perhaps it isn’t too much of a stretch to imagine that the environment and role models that learners are experiencing will have an influence on the sort of doctors they become. Ticking learning outcomes may not be quite enough.  There are various responses that can be made to the tensions in a potentially dysfunctional system and it’s good to make these in a conscious way.  It’s worth thinking about in relation to empathy and medical education.

1 thought on “Empathy in medical education

  1. John Buckley

    Thanks Cathy
    I would suggest that ‘proper’ empathy is an important tool in efficiency and not an opposing force- especially if we regard efficiency over time not on a consultation-by-consultation basis

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