Creating a Medical School Curriculum to Teach Empathy

Abstract

INTRODUCTION The importance of empathy lies in the fact that increased levels have been shown to improve multiple patient-related outcomes.1,2 Empathy expands a physician’s ability to diagnose and treat patients and can be understood as knowing the worries and anxieties of patients without joining in the sentiment of their emotional pain.3 Through this understanding, the physician understands their patients more completely.4 In this article, we review the importance of physician empathy while caring for patients and we highlight the fact that empathy decreases during medical education. There, however, exists no standard curriculum to teach empathy to medical students. While individual interventions to increase empathy have been piloted, an extensive literature search shows no comprehensive curriculum for empathy. In this piece, we seek to define a hypothetical curriculum to teach empathy to medical students by combining individual tools already proven to augment empathy. Measuring Empathy and Its Impact on Patient Care Many studies have demonstrated the positive impact of empathy. Greater empathy scores have translated to shorter duration of the common cold1 and improve control of hemoglobin A1c.2 Surgical patients cared for by empathic surgeons have greater postoperative satisfaction.5 There are many tools available to measure empathy. The most often used include the self-administered Jefferson Scale of Physician Empathy (JSPE) and the 3rd-person Jefferson Scale of Patient’s Perceptions of Physician Empathy (JSPPPE).6,7 This ability to quantify empathy has led to the observation that empathy decreases significantly during undergraduate medical education.8,9 Why Students Lose Empathy During Education and Training In students’ preclinical years, there is a decline in empathy9 followed by a more prominent drop once students enter their clinical work.9,10 Data show a significant drop from 115.7 to 108.5 (P < 0.001) for students who completed the JSPE at the end of their final preclinical year and again after their first year of clinicals.8 Furthermore, 73% of all students in this study exhibited a drop in empathy highlighting the prominence of this decline.8 A similar decline in JSPE score of 5.46 points (P = 0.001) is seen in students as they complete their first clinical year.10 With no intervention, this decline often remains until graduation.8 Finally, medical students in the United States are more likely than their peers studying in portions of Asia to have declines in empathy.11 The perseverance of medical student empathy in several countries around the world suggests that a decline in empathy for American medical students is not simply a rite of passage but may represent a failure in medical school curriculum. The decline in medical student empathy has been attributed to many sources including the belief that medicine is only advanced via controlled trials. In the clinical setting, students are learning medicine without empathy by observing physicians who lack the quality. This absence of the empathic role model has been posited to greatly influence the decline in empathy.8,9 Importance of Educational Climate Medical schools should provide more than just knowledge of patient disease; they should also highlight the moral and ethical culture of the medical community to help learners develop an empathic skillset.12 Consequences of decreased empathy are a difficulty speaking to patients with serious illnesses.13 Without formal teaching of empathy, students learn by observation and absorption of institutional culture which may celebrate efficiency over understanding. This unspoken learning has the ability to negatively influence empathy, compassion, confidence, and maturity.14 Tools for Developing Empathy Empathy can be affected by many internal and external influences. There are interventions which have shown to not only stop the decline but even increase empathy. Promising tools include standardized patients (SP) and role-play activities.9,15 SP’s as a stand-alone intervention have proven beneficial as they are able to provide professional feedback while effectively simulating many different patient situations.15 Among the most straightforward interventions are didactic empathy courses which have proven beneficial to learners.16 Creating the Optimal Curriculum to Teach Empathy We recommend empathy be taught to medical students in a similar manner to other essential skills such as physical examination. The importance of physical examination instruction is evident by the learning opportunities present in each year of medical school. Physical examination is taught by didactic lecture, SPs, observation of expert physician teachers at the bedside and through student examination on real-life patients observed by physician proctors. Individual curricula implementations for empathy have been implemented in the past. For a skill with such importance, a comprehensive curriculum like that of physical examination is proposed. The manner in which physical examination is taught is multifaceted yet well incorporated into medical curriculums. It includes explicit instruction in the form of teaching days and SPs. It also includes implicit clinical teaching which is blended in a longitudinal manner throughout a student’s years in school. On the wards students see attendings and residents use different techniques with varying levels of depth and personalization. The final aspect to learning physical examination is repetition. Students practice their physical examination both with the critical eye of their superiors and on their own when no one is watching. While multifaceted, this approach has successfully produced capable physicians for decades and can easily be translated to teaching empathy and other skills. Explicit Teaching Just as students first learning about physical examination engage in didactic lectures, empathy should be taught in the same way. While bedside teaching is critical it cannot stand alone. As seen with physical examination curricula, students who only experience bedside teaching perform worse on Objective Structured Clinical Examinations than those who also participate in a clinical skills curriculum.17 We recommend a combined lecture and case-based approach that presents students with various situations they may encounter in the hospital. There is clear evidence that simulations whether virtual or with trained persons are effective in facilitating learning among students.18 Empathy, which is often required at patient’s most vulnerable moments, is best first practiced in these simulated environments. In physical examination, this simulation allows reproducibility and standardization of learning opportunities in a student-focused setting. While both SPs and peer role play exercises can enhance empathy,19 the use of SPs may be the optimal method to provide formative feedback and give accurate assessments on empathy.15 Role playing can provide merit in the fact that students gain understanding from playing both the patient and the physician.19 The choice of SP versus role playing can ultimately be left to the institution depending on their current use of SPs and institutional resources. The combination of didactic lessons during the first year and simulations as students become more advanced (Fig. 1), whether with SPs or role play exercises, provides a uniform curriculum and foundation for students to cultivate empathy in their patient encounters.FIGURE 1.: Proposed 4-year curriculum for teaching of empathy to medical students including empathy assessment, role model observation/assessment, didactics, and standardize patients.Longitudinal and Personal Curricula Similar to the physical examination, there must be a longitudinal clinical component to teaching empathy. In the majority of schools in the United States, physical examination is introduced in the first 2 months of training.20 Empathy training should also be initiated at a similar time and continued to allow students to build on skills. As with physical examination where students observe various attendings and residents, we believe empathy should be taught in the same way, turning the bedside into a powerful source of clinical instruction (Fig. 1). While difficult to standardize, the role-model-based approach allows students to observe various methods and styles. Direct observation of student skills by the attending or resident is also essential. In addition to observation, there must be direct assessment by these role models.21 As with physical examination where high-level assessments requires real patients,21 so too is the case with skills involving emotional intelligence such as empathy. As students advance over the course of their training, they must be encouraged to move from passive observation to active participation with patients. A longitudinal approach to this curriculum should allow students to build trust with their instructors to the level where they are leading encounters requiring high emotional intelligence and empathy. Great role-model physicians are an essential component to teaching empathy and delivering the implicit curriculum that shows students the art of medicine.22 Programs should provide faculty development structures to elevate the number of empathic role models for students. Faculty who role-model empathy must be highlighted, advanced and promoted to maintain a contingent of clinical teachers who demonstrate empathic patient care to the clinical learners. Testing for Empathy Finally, to move empathy from a nebulous idea to a tangible skill, students must be evaluated like any other proficiency. We recommend students receive evaluations with both the JSPE and JSPPPE (Fig. 1). Students should not be penalized for low scores but should be identified and encouraged to work on their skills while they are still clinically malleable. We recommend assessment with these tools when first entering school and again at the end of each subsequent year. This should encourage greater focus during training sessions as well as incentivization of self-motivated improvement. CONCLUSION Not only is empathy important to patient outcomes but it is actionable, teachable, and measurable. In this article, we have compiled a comprehensive and implementable framework for teaching empathy. The hypothetical framework we propose is novel in its use of physical examination as a model. We recommend a longitudinal curriculum which includes SPs and didactic sessions that teach empathy to medical students. Clinical rotations must include exposure to physicians who model exemplary empathic behavior. Finally, concrete longitudinal measurement of empathy will give students a mark to measure themselves against and motivate improvement. These changes will create a generation of physicians that is able to better understand their patients and thereby improve clinical outcomes. Next steps include institutional implementation, quantification of empathy change, and further optimization of curriculum.

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