Does Medical School Erode Student Empathy?

August 10, 2011

By Nandini Govil

Faculty Peer Reviewed

Empathy is an elusive concept, espoused by many as an integral component of effective doctoring. In the medical literature, empathy is defined as a physician’s ability to recognize and validate a patient’s experiences and perspectives,  and to convey this understanding back to the patient.[1] A firm distinction is drawn between sympathy (an emotional attribute) and empathy (a cognitive skill that can be modeled, taught, and assessed).[2]

Research indicates that physician empathy results in better patient compliance and  outcomes, and even reduces medical malpractice suits.[3] A recent study demonstrates that physicians with higher empathy scores have more diabetic patients who reach target hemoglobin A1C levels (<7%) and low-density lipoprotein levels (<100 mg/dL) compared to physicians with lower empathy scores.[4] Hoping to provide students with a holistic education, American medical schools have embraced a didactic focus on empathy.

The results are recognized by physicians-in-training across the country. During the traditional white coat ceremony, starry-eyed medical students pledge their devotion to relieving pain and suffering. Reminders of this commitment continue throughout school, with classes focused on the physician-patient relationship, and a variety of objective structured clinical examinations (OSCEs) grading students on their empathy skills.

So how is it possible that studies examining medical student empathy indicate that empathy scores decrease, rather than increase, during medical school?

Yes, that is correct. Despite the solemn oaths and noble aspirations, empathy diminishes during medical school. And, apparently, the decline is significant.

Researching this phenomenon was difficult without an empathy scale designed specifically for medical professionals.[5] Then, Dr. Mohammadreza Hojat developed the Jefferson Scale of Physician Empathy (JSPE), a 20-item questionnaire measuring components of empathy among physicians in patient-care settings. In this survey, respondents indicate their level of agreement with each item on a 7-point scale. The total score ranges from 20-140, with higher scores indicating a higher degree of empathy. There is also a student version of the scale (JSPE-S). Both scales have been validated in multiple settings; self-reported resident scores are consistent with both patient and residency-director assessment of clinical empathy.[6,7]

In 2007, the Jefferson scale was used to assess the empathy of students at the Boston University School of Medicine. Students in all four years received the JSPE-S at end-of-year student events. The results were staggering. A significant decrease in empathy score was noted, from 118.5 at the end of first year to 106.6 at the end of fourth year. As in previous studies, women outperformed men. Also, students interested in “people-oriented fields” (family medicine, internal medicine, pediatrics, obstetrics/gynecology, emergency medicine, and psychiatry) outperformed students interested in “technology-oriented fields” (anesthesiology, radiology, pathology, surgery, and surgical subspecialties). Most troubling was that the biggest decrease in empathy occurred after the third year of medical school, the first full year of clinical experience for students.[1] Similar trends were observed among students at the Jefferson School of Medicine. Here, empathy scores did not change during the first two years, but a striking decline occurred at the end of the third year and persisted until graduation.[8,9]

There was also an observed relationship between decreased empathy and student career choice. In the Jefferson School of Medicine study, students with the greatest drop in empathy often switched their preferences from people-oriented specialties to technology-oriented specialties. This trend was especially pronounced for female students; women choosing technology-based careers upon graduation were the ones with the most pronounced empathy declines of the entire female cohort.[9]

These results imply an important but uncomfortable question. Is working closely with patients in the third year actually making medical students less empathetic?

This is a disturbing thought for many of us.

No study directly explores this question, perhaps because of its disconcerting nature. Some respond by questioning the validity of the previous studies, claiming that the results are grossly exaggerated and that a subjective value such as empathy cannot be quantitatively measured.[10] Others acknowledge the problem, but blame external sources. One study at UMDNJ-New Jersey Medical School finds a correlation with high medical student burnout scores and low empathy. Another blames increasing time pressure, overreliance on technology, negative clinical experiences, and lack of role models.[2] It has been difficult to find a culprit, but this does not change that fact that something is amiss. The focus on empathy in the medical school curriculum is not translating into practice. Ironically, a JSPE-S study in Japan, a country that traditionally does not emphasize empathy in medical school, found that medical student empathy scores actually increase throughout medical education.[11]

So, let us address the next question we type-A personalities are dying to ask. How do we fix it? It seems that communication may be the key. A Spanish study looking at medical student empathy scores after participation in a 25-hour communication workshop noted a 5.25 empathy point increase, with increases in 68.9% of participants.[12] A unique project involving doctors who became patients stated that small changes such as “communicating directly about taboo topics and being more sensitive in discussing ‘bad news,’ adherence, and nonmedical concerns” can make a difference.[13] A study at the Robert Wood Johnson Medical School found that a longitudinal experience involving “blogging about clerkship experiences, debriefing after significant events, and discussing journal articles, fiction, and film” raised empathy scores.[14]

These studies imply that students do not lack empathy or lose it during medical school. Instead, what students struggle with most is the last part of the definition of empathy: the ability to communicate it to patients. This struggle seems to surface during the third year of medical school. Perhaps it is the fractured nature of clinical experience, or the competitive drive to appear impervious that is to blame. However, since empathy affects clinical outcomes just as much as prescribing the right medication, it is worth treating.  Research suggests the remedy may be for students to talk to each other about struggles with empathy. Only by improving communication skills can we really improve our clinical acumen.

Nandini Govil is a 4th year medical student at NYU School of Medicine

Peer reviewed by Antonella Surbone, MD, section editor, ethics, Clinical Correlations

Image courtesy of Wikimedia Commons

References

1. Chen D, Lew R, Hershman W, Orlander J. A cross-sectional measurement of medical student empathy. J Gen Intern Med. 2007;22(10):1434-1438.  http://www.ncbi.nlm.nih.gov/pubmed/17653807

2. Crandall SJ, Marion GS. Commentary: Identifying attitudes towards empathy: an essential feature of professionalism. Acad Med. 2009;84(9):1174-1176.

3. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004;27(3):237-251.  http://ehp.sagepub.com/content/27/3/237.abstract

4. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86(3):359-364.  http://www.ncbi.nlm.nih.gov/pubmed/21248604

5. Diseker RA, Michielutte R. An analysis of empathy in medical students before and following clinical experience. J Med Educ. 1981;56(12):1004-1010.

6. Hojat M, Mangione S, Nasca TJ, Gonnella JS, Magee M. Empathy scores in medical school and ratings of empathic behavior in residency training 3 years later. J Soc Psychol. 2005;145(6):663-672.

7. Glaser KM, Markham FW, Adler HM, McManus PR, Hojat M. Relationships between scores on the Jefferson Scale of physician empathy, patient perceptions of physician empathy, and humanistic approaches to patient care: a validity study. Med Sci Monit. 2007;13(7):CR291-294.  http://www.ncbi.nlm.nih.gov/pubmed/17599021

8. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ. 2004;38(9):934-941.

9. Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-1191.

10. Colliver JA, Conlee MJ, Verhulst SJ, Dorsey JK. Reports of the decline of empathy during medical education are greatly exaggerated: a reexamination of the research. Acad Med. 2010;85(4):588-593.

11. Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS. Measurement of empathy among Japanese medical students: psychometrics and score differences by gender and level of medical education. Acad Med. 2009;84(9):1192-1197.

12. Fernández-Olano C, Montoya-Fernández J, Salinas-Sánchez AS. Impact of clinical interview training on the empathy level of medical students and medical residents. Med Teach. 2008;30(3):322-324.

13. Klitzman R. Improving education on doctor-patient relationships and communication: lessons from doctors who become patients. Acad Med. May 2006;81(5):447-453.  http://journals.lww.com/academicmedicine/fulltext/2006/05000/improving_education_on_doctor_patient.8.aspx

14. Rosenthal S, Howard B, Schlussel YR, et al. Humanism at heart: preserving empathy in third-year medical students. Acad Med. Mar 2011;86(3):350-358.

3 Responses to Does Medical School Erode Student Empathy?

  1. Adina Kalet on August 11, 2011 at 11:54 am

    As Nandini points out the fall off in empathy during the 3rd year has been a persistent finding in the literature for a long time. In addition to what is already so beautifully reviewed in this article, I would like to propose another possible explanation for this change in student’s self assessed empathy- Professional Identity Formation– this is the developmental process students go through to “try on” their own identity as they begin to differentiate into generalist fields and “technology based” fields. It may be that as students recognize their own desires to practice in certain specialty domains they begin to emulate those already in those fields– in the generalist fields faculty and the content domain demand that they have excellent communication skills and are particularly patient centered and in the technology oriented fields students may perceive that they need to be “technology” oriented.. and role models in those fields may not emphasize the patient centered domains (although there may well be individuals who are very skillful in these areas)… Of course this loss of empathy is a serious issue for all physicians– and there is literature to suggest that many students who lose empathy- bounce bad later.. so it may also be a matter of being personally challenged by the emotional overwhelm of the 3rd year… if there are good role models to demonstrate that dealing with challenging patient situations is a creative and wonderful part of doctoring students fair better than if those role models do not present themselves at the appropriate moments. ….

  2. Felice Aull on August 11, 2011 at 4:59 pm

    Nandini Govil writes a thoughtful essay about the important topic of empathy in medical practice. But rather than rule out the role of emotion in development and practice of empathy, the model of empathy that physician-scholar Jodi Halpern promotes may be more effective. In her book, From Detached Concern to Empathy: Humanizing Medical Practice. (New York: Oxford University Press) 2001, Halpern proposes a model of clinical empathy as emotional reasoning. She argues that empathy requires the “ability to resonate emotionally so that the physician can imagine how it feels to experience something (85) and that “experiencing emotion guides what one imagines about another’s experience, and thus provides a direction and context for learning” (91). Empathy, Halpern says, is critical for both diagnosis and effective treatment. Nandini Govil notes that discussion of difficult and often taboo topics among students or with patients may increase overall “empathy scores” – suggesting that acknowledgment of emotion and incorporation of emotion into clinical education is important. Further, as Adina Kalet points out, role models may make all the difference in student attitudes toward their experiences, and it may be that mentors who demonstrate motivation and enthusiasm are also more inclined to display and use emotion in their interactions with patients.

  3. Edwin Rutsch on August 14, 2011 at 1:25 pm

    May I suggest a further resource to learn more about empathy and compassion.
    The Center for Building a Culture of Empathy
    The Culture of Empathy website is the largest internet portal for resources and information about the values of empathy and compassion. It contains articles, conferences, definitions, experts, history, interviews,  videos, science and much more about empathy and compassion.
    http://CultureOfEmpathy.com

    Also, we invite you to post a link to your article about empathy to our Empathy Center Facebook page.
    http://Facebook.com/EmpathyCenter

    I posted a link to your article in our
    Empathy and Health Care Magazine
    The latest news about empathy and compassion from around the world
    http://bit.ly/dSXjfF

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