Saturday, September 12, 2009

Are we training physicians to be empathic? Apparently not.

Three articles in the September issue of Academic Medicine, the journal of the Association of American Medical Colleges (AAMC) address the issue of development – or more concerning, the erosion -- of empathy among medical students and doctors. All three used the Jefferson Scale of Physician Empathy (JSPE), developed at the Jefferson Medical College in Philadelphia, and all included Jefferson faculty who developed the JSPE as authors. Two were done in collaboration with authors from other countries, one examining doctors in Italy and the other medical students in Japan. However, the most important one for us looked at US medical students, at Jefferson Medical College.[1] The authors administered the JSPE to students entering medical school in 2002 and 2004, and then administered it again to each of them 4 more times, at the end of each of their years of medical school. The results, while unfortunately not surprising to those of us who teach in medical schools, should be very concerning for everyone else in the country. The empathy scores were pretty much unchanged from entry to the end of the second year, but dropped significantly by the end of the third year for both classes. They stayed down, picking up slightly, by graduation at the end of the fourth year.

For those of you who don’t know, the third year of medical school in the US is when the main “clinical” portion of the education of students begins. In most schools, the first two years are largely dedicated to learning “basic science”, although increasing amounts of clinical material have been added in more recent years. But in the third year, students do their “core” clinical rotations (usually internal medicine, surgery, pediatrics, psychiatry, family medicine, obstetrics/gynecology, sometimes neurology and geriatrics). They spend this time largely working in the hospital, on hospital services with faculty members and residents, who are medical school graduates training in the particular specialty. This is the main time of “clinician formation”, when the student, who has been spending the bulk of his/her time in a classroom, works, under close supervision, in the actual care of actual people. One would hope (at least this one would hope) that working with actual people (called “patients” in the medical jargon) would provide students an opportunity to become more empathic, seeing the pain and suffering and hopes and expectations and fears and prayers of the people with whom they work. That it has the opposite effect is scary.

Students were given the opportunity to identify themselves so that data could be analyzed over time for individuals or groups of individuals as well as the whole group. Unfortunately, only 25% did so, so looking at trends among sub-groups, which could only be done on this smaller group, provides less robust data. However, within this “matched” group, women started with higher empathy scores than did men and dropped less, although still significantly. In addition, students who planned to enter “technology-oriented” specialties (anesthesiology pathology, radiology, surgery, orthopedics, etc.) not only had greater drops in their empathy scores than those entering “people oriented” specialties (family medicine, internal medicine, pediatrics, emergency medicine, psychiatry, obstetrics and gynecology), but had lower scores to begin with. This means that (at least among the 25% who allowed themselves to be tracked, among these two classes at Jefferson) there is a difference in empathy levels even at baseline, at entry, between those entering the different types of specialties (when taken as a group). It may also be worth noting that Japanese students did not demonstrate this decline; the reasons are presumably cultural.[2]

Why? All medical educators have their theories, but this research only can contribute information gleaned from the elective, open-ended comments students were invited to make. Themes that arose included exhaustion (working so hard and so many hours makes it difficult to care so much about others), victim blaming (it is hard to feel for someone whose behaviors brought their illness on themselves), and negative role models (the residents and teaching physicians were not empathic):

Reflecting on the nature of the training environment, one student stated ‘I was constantly reminded of the hierarchy of medicine and how it was not the student’s job to speak up even in defense of the patient’s best interest. The bureaucratic side of medicine overshadowed the human, empathic side.’ When students perceive from their training experiences that the ‘’humanistic side of medicine is too soft and a waste of time…I worry that over time I will be “molded by the system” into this idea””, they are correct. The study shows that they are.

The authors spend a fair amount of time distinguishing between empathy, which they are trying to measure, which they feel more of is always good for the practice of medicine, and sympathy, a less cognitive (thinking) and more affective (feeling) characteristic which they feels helps at some level but at too high a level can impede the practice of high-quality medicine. Empathy is less innate, more subject to learning and thinking, requires more effort, and is more likely to be accurate. The behavioral motivation is altruistic, while sympathy is egoistic; that is “I feel your pain” (sympathy) is instinctive but also is about the “feeler” (the student or doctor) rather than the patient. It is different from “I understand your suffering”. This latter not only is more likely to lead to helping, but is more likely to be “energy conserving” and lead to growth; the former to burnout.

This suggests a few things to me. The first is, obviously, that we need to change our medical education system, and the way patient care is role modeled. This may seem easy, but it is not; societies (and medicine is a micro-society) do not change easily, because new apprentices are taught by those in power. However, they do change, and the difference between medical education today and twenty or forty or sixty years ago is enormous. There is, for starters, teaching about these issues. Small group discussions, reflection papers, support networks exist where they never existed in the past. And students come from much more varied backgrounds – there are more women, and people from different class and geographic backgrounds and even pre-medical majors (music and English as well as biology and chemistry). And student are increasingly often older, second career – with prior life experiences in other professions, in business, in the workplace, and have had more experiences with healthcare as consumers either first-hand or in their families. But old traditions die hard; when biochemistry is valued more than ethics (and of course it is, because this is what you are tested on and your grades are based on both in school and your National Board exams); when being knowledgeable about the lab tests and x-rays is valued more than knowing the patient (and it often is by clinical teachers); when getting the work done is more important than understanding what work the patient wants done (and it very frequently is), it is hard to change.

What about experiences in medical school? The NY Times, September 9, 2009, “Summer of work exposes medical students to system’s ills” ( describes the experiences of medical students at the University of Washington working with rural, therefore mostly primary care, doctors in the 5 states the school serves (Alaska, Idaho, Montana, Washington, Wyoming). Many schools do similar programs, either required like Washington’s (e.g., New Mexico) or elective, like at the University of Kansas. The feedback seems to be similar – many students really like it and learn a lot and find it incredibly valuable pointing them to a future of service, and others find it frustrating to see inefficient systems, poor reimbursement to primary care, overwork of physicians, and thus plan (or are reinforced in their original plan) to be urban-based subspecialists. Like the Jefferson work on empathy, exposure to actual people and actual practice can reinforce either positive or negative attitudes; the sad part is when it introduces negatives to those who came in thinking more positively.

Thus, as I have written before, input variables matter. If we want more empathic physicians, the best strategy is to recruit more empathic students to medical school, and to provide them with role models who demonstrate empathy and learning settings in which having greater empathy is more valued and is considered a core quality. Medical educators are working hard on this; the public needs to demand it.

[1] 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”, Academic Medicine, Sept 2009;84(2):1182-91.
[2] 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,” Academic Medicine Sept09;84(9):1192-7.

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