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“Is There Hardening of the Heart During Medical School?” asks a new study appearing in March’s Academic Medicine.
Seems so.
The longitudinal study finds significant decreases in “vicarious,” or emotionally driven, empathy, during the course of medical education. Significant drops happen after the first year and after the third, clinical year when “students,” the article notes, “were seeing patients they had, presumably, looked forward to helping.” (The drop at that point of first patient contact in the third year is particularly concerning, the lead author, Bruce W. Newton, said in an interview Thursday).
“The significant decrease in vicarious empathy is of concern, because empathy is crucial for a successful physician-patient relationship,” says the study, authored by Newton, Laurie Barber, James Clardy, Elton Cleveland, and Patricia O'Sullivan. All are from the University of Arkansas for Medical Sciences, except O'Sullivan, of the University of California at San Francisco.
“Empathy is one of the most highly desirable professional traits that medical education should promote, because empathic communication skills promote patient satisfaction and adherence to treatment plans while decreasing the likelihood of malpractice suits. Patients view physicians who possess the quality of emotional empathy as being better caregivers.”
The article analyzes changes in the scores of 419 students at the University of Arkansas for Medical Sciences on the Balanced Emotional Empathy Scale over the course of medical school. Students from four classes completed the survey measuring emotional empathy at the beginning of each of four years (the authors do not track them into residency and beyond). Other studies on empathy in medical school -- which have yielded conflicting results, the study states -- have focused on so-called "imaginative empathy." That’s described as a cognitive ability to “role play” or imagine another person’s thoughts and feelings, as opposed to the emotional, or innate, reaction studied here.
“The way I like to explain it is, if both of your parents are living and one of your colleagues has a parent that dies, you can use the role-playing empathy to feel sad and empathic for that person. But if you yourself have experienced a death of a parent, then you can really put yourself in those shoes. You feel it inside the gut,” said Newton, an associate professor of neurobiology and developmental sciences and associate dean for undergraduate medical education at the Arkansas institution.
The survey instrument used is gender-sensitive, with women’s baseline scores in year one significantly higher than those of men (a mean of 61.75 versus 37.87). The study tracks changes in emotional empathy by gender and specialty choice. The authors find, for instance, that students who choose the “core” specialties, where they see many of the same patients (i.e. internal medicine, family medicine, pediatrics, obstetrics-gynecology and psychiatry), manage to better maintain their empathy throughout medical school compared to those who choose “noncore” specialties (like radiology or surgery), where continuous contact with specific patients is limited.
Especially dramatic is the decline in vicarious empathy among women who pursue noncore specialties, Newton said. The authors suggest that, “Because noncore specialties … are still predominantly chosen by men, the noncore women we studied were adjusting in the same way that the less empathetic noncore males did."
More generally speaking, the study points out that earlier research has "shown that medical school can often have a detrimental effect on certain aspects of students' professional growth. Negative characteristics such as cynicism may increase, and ethical and moral development can be stunted."
The authors suggest, for instance, that the significant drop in empathy after the first year of medical school could result, in part, from high stress and anxiety in a competitive atmosphere (as well as disillusionment as students discover that their idea of being a doctor doesn't match up to the reality).
Levels of empathy then stay relatively stable after the second year, which, like the first, is built around basic science courses, before declining following the first clinical year. The fact that treatment is often tied to a focus on technology and the large cultural differences between medical students and patients both could complicate developing empathy, the article says. It also notes "a chronic lack of clinical role models" that other studies have described.
Asked if vicarious (as opposed to imaginative or cognitive) empathy can be taught, Newton paused. “Probably not. It is what you have.” He stressed the need, however, for more emphasis on teaching and role modeling. He proposed, for instance, the formation of "teaching academies" within medical schools, where some faculty would be freed from the pressure of securing external research grants to focus on students instead.
"Med school's tough. It's hard; students get cynical," Newton said. What's needed, he said, "is just more human contact." Whether or not empathy can actually be taught, more personalized instruction is one strategy, he argued, to help students maintain the higher levels of empathy they generally bring to medical school the first day, and not the last.
