2013; 35: 977–978
COMMENTARY
Maintaining empathy in medical education WIN MAY
Empathy is one of the ‘‘hot’’ topics in medical education, as most educators believe it to be a humanistic attitude that students and physicians must have (Spiro 1992). It is considered to be an essential component of professional competence (Epstein et al. 2002). Indeed, empathy has been included as one of the attributes of ‘‘professionalism’’ by Canadian residents (Brownell & Cote 2001). Kohut states: ‘‘the empathic understanding of the experience of other human beings is as basic an endowment of man as his vision, hearing, touch, taste and smell’’ (Kohut 1971). Empathy can therefore be considered as one of the most important characteristics of a physician. Most research studies have used one of the following validated self-report instruments to measure the construct of empathy – the Jefferson Scale of Physician Empathy (JSPE) (Hojat et al. 2001), the Interpersonal Reactivity Index – Empathy Concern subscale (IRI-EC) (Davis 1980), and the Balanced Emotional Empathy Scale (BEES) (Mehrabian 1996). Several studies that have examined selfperceived empathy of medical students using one of these three instruments, have reported that there is a decline in empathy during medical school, specifically as students move from pre-clinical to clinical years (Hojat et al. 2004; Austin et al. 2007; Chen et al. 2007; Newton et al. 2008; Stratton et al. 2008; Hojat et al. 2009). However, these findings have been challenged by other researchers, citing some methodological flaws (Colliver et al. 2010). Nonetheless, all agree on the importance of empathy in fostering the relationship between the patient and the doctor and the value of this relationship in providing better health care. The interest in developing interventions to increase medical students’ empathy can be traced back as early as 1989 (Kramer et al. 1989). In the current issue, two groups of researchers, one group from the United States and another from Australia reported their curricular interventions increased and maintained empathy in medical students, when measured with the JSE/JSPE-S. The article from Hojat and his colleagues focused on enhancing and sustaining empathy of medical students through the use of video-clips and movies. These authors designed a two-stage study where they first implemented a pre-post intervention to explore whether medical students’ self-perceived empathy could be increased by the intervention. They then implemented as second study ten weeks later, where students from the experimental group (from the first
study) were randomly divided into two groups, with one of the groups receiving another intervention. The authors concluded that the interventions worked, as the group exposed to both these interventions had a higher score on the JSE than those students who were not. The authors acknowledged the need for a longer-term follow-up study as the interval between the two interventions was only ten weeks. The students in this study were pre-clinical medical students, and since most declines in empathy occurred during the clinical years, a follow-up of these students in the clinical years with a re-measure of empathy would be useful. Nevertheless, this is a valuable contribution to the literature, as the authors are asking us to think about how we can reinforce students’ empathy by the judicious placement of interventions in the curriculum by encouraging us to design empirical studies to determine where and when such interventions should occur. The second study by Hegazi and Wilson employs a crosssectional design to examine whether empathy varied in different years of medical school. The authors found that there was no significant difference in the empathy scores of the medical students in the different years of medical school. They also explored the relationship between empathy and some demographic variables including not only gender and age, (which have been examined in other studies), but also marital status, cultural beliefs, religious beliefs, and previous tertiary education. In order to promote and maintain empathy, programmes aimed at promoting personal and professional development were included in the curriculum as options for students. What I found interesting was that in their conclusions, the authors stated that empathy could be preserved in the medical school by careful student selection and the inclusion of personal and professional development programmes. The fact that they brought up student selection opens up new areas to explore. Although they did not mention the selection system that was used in their medical school, there has been a lot of discussion regarding the use of cognitive and non-cognitive characteristics of medical students for selection. It may be worthwhile to explore whether any of the assessment processes used in medical schools such as the Multiple Mini-Interview, have an association with the students’ self-reported empathy. The authors also acknowledged the limitations of a cross-sectional study, recommending that readers consider longitudinal studies.
20 13
Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14 For personal use only.
University of Southern California, USA
Correspondence: Dr Win May, 1975 Zonal Avenue, Los Angeles, California, CA 90089, USA. Tel: 323-442-2381; fax: 323-442-2051; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/13/120977–2 ß 2013 Informa UK Ltd. DOI: 10.3109/0142159X.2013.852657
977
Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14 For personal use only.
W. May
Both these papers have used self-report instruments, which measure the perceived empathy of medical students. There have been other studies, which examined the correlations between physicians’ self-perceived empathy and clinical outcomes (Hojat et al. 2011; Del Canale et al. 2012), as well as the correlations between students’ self-perceived empathy and clinical competence as assessed by standardized patients (Chen et al. 2009; Berg et al. 2011; Ogle at al. 2013). Such studies move us along the path of the value of self-reported empathy in predicting empathy as observed by patients, as well as the link with clinical outcomes. The value of both these papers is not only in their findings but also in the questions that they bring up. I believe that since empathy is such an important characteristic of humanistic physicians and other health professionals, it is incumbent on researchers to conduct scholarly studies that provide valid answers as to how we as medical educators, can preserve, encourage and maintain the empathy of our students.
Note on Contributor WIN MAY, MD, PhD, is a Professor in the Division of Medical Education, Department of Pediatrics, at the Keck School of Medicine of the University of Southern California, and the Director of the Clinical Skills Education and Evaluation Center at the Keck School of Medicine of the University of Southern California.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References Austin EJ, Evans P, Magnus B, O’Hanlon K. 2007. A preliminary study of empathy, emotional intelligence and examination performance in MBChB students. Med Educ 41:684–689. Berg K, Majdan JF, Berg D, Veloski J, Hojat M. 2011. Medical students’ selfreported empathy and simulated patients’ assessments of student empathy: An analysis by gender and ethnicity. Acad Med 86:984–988. Brownell AK, Cote L. 2001. Senior residents’ views on the meaning of professionalism and how they learn about it. Acad Med 76:734–737.
978
Chen DCR, Lew R, Hershman W, Orlander J. 2007. A cross-sectional measurement of medical student empathy. J Gen Intern Med 22:1434–1438. Chen DCR, Pahilan ME, Orlander JD. 2009. Comparing a self-administered measure of empathy with observed behaviour among medical students. J Gen Intern Med 25:200–202. Colliver JA, Conlee MJ, Verhulst SJ, Dorsey JK. 2010. Reports of the decline of empathy during medical education are greatly exaggerated: A reexamination of the research. Acad Med 85:588–593. Davis M. 1980. A multidimensional approach to individual differences in empathy. JSAS Catalog Selected Documents Psychol 10:85. Del Canale S, Louis DZ, Maio V, Wang X, Hojat M, Gonnella JS. 2012. The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med 87:1243–1249. Epstein RM, Hundert EM. 2002. Defining and assessing professional competence. JAMA 287:226–235. Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonnella JS, Erdmann JB, Veloski JJ, Magee M. 2001. The Jefferson Scale of Physician Empathy: Development and preliminary psychometric data. Educ Psychol Meas 61:349–365. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, Magee M. 2004. An empirical study of decline in empathy in medical school. Med Educ 38:934–941. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. 2009. The devil is in the third year: A longitudinal study of the erosion of empathy in medical school. Acad Med 84:1182–1191. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. 2011. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med 86:359–364. Kramer D, Ber R, Moore M. 1989. Increasing empathy among medical students. Med Educ 23:168–173. Kohut H. 1971. The Analysis of Self. New York: International Universities Press. Mehrabian A. 1996. Manual for the BalancedEmotional Empathy Scale (BEES). Unpublished; available from Albert Mehrabian, 1130 Alta Mesa Road, Monterey, CA 93940. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. 2008. Is there hardening of the heart during medical school? Acad Med 83:244–249. Ogle J, Bushnell JA, Caputi P. 2013. Empathy is related to clinical competence in medical care. Med Educ 47:824–831. Spiro H. 1992. What is empathy and can it be taught? Ann Intern Med 116:843–846. Stratton TD, Saunders JA, Elam CL. 2008. Changes in medical students’ emotional intelligence: An exploratory study. Teach Learn Med 20:279–284.
COMMENTARY
Maintaining empathy in medical education WIN MAY
Empathy is one of the ‘‘hot’’ topics in medical education, as most educators believe it to be a humanistic attitude that students and physicians must have (Spiro 1992). It is considered to be an essential component of professional competence (Epstein et al. 2002). Indeed, empathy has been included as one of the attributes of ‘‘professionalism’’ by Canadian residents (Brownell & Cote 2001). Kohut states: ‘‘the empathic understanding of the experience of other human beings is as basic an endowment of man as his vision, hearing, touch, taste and smell’’ (Kohut 1971). Empathy can therefore be considered as one of the most important characteristics of a physician. Most research studies have used one of the following validated self-report instruments to measure the construct of empathy – the Jefferson Scale of Physician Empathy (JSPE) (Hojat et al. 2001), the Interpersonal Reactivity Index – Empathy Concern subscale (IRI-EC) (Davis 1980), and the Balanced Emotional Empathy Scale (BEES) (Mehrabian 1996). Several studies that have examined selfperceived empathy of medical students using one of these three instruments, have reported that there is a decline in empathy during medical school, specifically as students move from pre-clinical to clinical years (Hojat et al. 2004; Austin et al. 2007; Chen et al. 2007; Newton et al. 2008; Stratton et al. 2008; Hojat et al. 2009). However, these findings have been challenged by other researchers, citing some methodological flaws (Colliver et al. 2010). Nonetheless, all agree on the importance of empathy in fostering the relationship between the patient and the doctor and the value of this relationship in providing better health care. The interest in developing interventions to increase medical students’ empathy can be traced back as early as 1989 (Kramer et al. 1989). In the current issue, two groups of researchers, one group from the United States and another from Australia reported their curricular interventions increased and maintained empathy in medical students, when measured with the JSE/JSPE-S. The article from Hojat and his colleagues focused on enhancing and sustaining empathy of medical students through the use of video-clips and movies. These authors designed a two-stage study where they first implemented a pre-post intervention to explore whether medical students’ self-perceived empathy could be increased by the intervention. They then implemented as second study ten weeks later, where students from the experimental group (from the first
study) were randomly divided into two groups, with one of the groups receiving another intervention. The authors concluded that the interventions worked, as the group exposed to both these interventions had a higher score on the JSE than those students who were not. The authors acknowledged the need for a longer-term follow-up study as the interval between the two interventions was only ten weeks. The students in this study were pre-clinical medical students, and since most declines in empathy occurred during the clinical years, a follow-up of these students in the clinical years with a re-measure of empathy would be useful. Nevertheless, this is a valuable contribution to the literature, as the authors are asking us to think about how we can reinforce students’ empathy by the judicious placement of interventions in the curriculum by encouraging us to design empirical studies to determine where and when such interventions should occur. The second study by Hegazi and Wilson employs a crosssectional design to examine whether empathy varied in different years of medical school. The authors found that there was no significant difference in the empathy scores of the medical students in the different years of medical school. They also explored the relationship between empathy and some demographic variables including not only gender and age, (which have been examined in other studies), but also marital status, cultural beliefs, religious beliefs, and previous tertiary education. In order to promote and maintain empathy, programmes aimed at promoting personal and professional development were included in the curriculum as options for students. What I found interesting was that in their conclusions, the authors stated that empathy could be preserved in the medical school by careful student selection and the inclusion of personal and professional development programmes. The fact that they brought up student selection opens up new areas to explore. Although they did not mention the selection system that was used in their medical school, there has been a lot of discussion regarding the use of cognitive and non-cognitive characteristics of medical students for selection. It may be worthwhile to explore whether any of the assessment processes used in medical schools such as the Multiple Mini-Interview, have an association with the students’ self-reported empathy. The authors also acknowledged the limitations of a cross-sectional study, recommending that readers consider longitudinal studies.
20 13
Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14 For personal use only.
University of Southern California, USA
Correspondence: Dr Win May, 1975 Zonal Avenue, Los Angeles, California, CA 90089, USA. Tel: 323-442-2381; fax: 323-442-2051; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/13/120977–2 ß 2013 Informa UK Ltd. DOI: 10.3109/0142159X.2013.852657
977
Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/27/14 For personal use only.
W. May
Both these papers have used self-report instruments, which measure the perceived empathy of medical students. There have been other studies, which examined the correlations between physicians’ self-perceived empathy and clinical outcomes (Hojat et al. 2011; Del Canale et al. 2012), as well as the correlations between students’ self-perceived empathy and clinical competence as assessed by standardized patients (Chen et al. 2009; Berg et al. 2011; Ogle at al. 2013). Such studies move us along the path of the value of self-reported empathy in predicting empathy as observed by patients, as well as the link with clinical outcomes. The value of both these papers is not only in their findings but also in the questions that they bring up. I believe that since empathy is such an important characteristic of humanistic physicians and other health professionals, it is incumbent on researchers to conduct scholarly studies that provide valid answers as to how we as medical educators, can preserve, encourage and maintain the empathy of our students.
Note on Contributor WIN MAY, MD, PhD, is a Professor in the Division of Medical Education, Department of Pediatrics, at the Keck School of Medicine of the University of Southern California, and the Director of the Clinical Skills Education and Evaluation Center at the Keck School of Medicine of the University of Southern California.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
References Austin EJ, Evans P, Magnus B, O’Hanlon K. 2007. A preliminary study of empathy, emotional intelligence and examination performance in MBChB students. Med Educ 41:684–689. Berg K, Majdan JF, Berg D, Veloski J, Hojat M. 2011. Medical students’ selfreported empathy and simulated patients’ assessments of student empathy: An analysis by gender and ethnicity. Acad Med 86:984–988. Brownell AK, Cote L. 2001. Senior residents’ views on the meaning of professionalism and how they learn about it. Acad Med 76:734–737.
978
Chen DCR, Lew R, Hershman W, Orlander J. 2007. A cross-sectional measurement of medical student empathy. J Gen Intern Med 22:1434–1438. Chen DCR, Pahilan ME, Orlander JD. 2009. Comparing a self-administered measure of empathy with observed behaviour among medical students. J Gen Intern Med 25:200–202. Colliver JA, Conlee MJ, Verhulst SJ, Dorsey JK. 2010. Reports of the decline of empathy during medical education are greatly exaggerated: A reexamination of the research. Acad Med 85:588–593. Davis M. 1980. A multidimensional approach to individual differences in empathy. JSAS Catalog Selected Documents Psychol 10:85. Del Canale S, Louis DZ, Maio V, Wang X, Hojat M, Gonnella JS. 2012. The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med 87:1243–1249. Epstein RM, Hundert EM. 2002. Defining and assessing professional competence. JAMA 287:226–235. Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonnella JS, Erdmann JB, Veloski JJ, Magee M. 2001. The Jefferson Scale of Physician Empathy: Development and preliminary psychometric data. Educ Psychol Meas 61:349–365. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, Magee M. 2004. An empirical study of decline in empathy in medical school. Med Educ 38:934–941. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. 2009. The devil is in the third year: A longitudinal study of the erosion of empathy in medical school. Acad Med 84:1182–1191. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. 2011. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med 86:359–364. Kramer D, Ber R, Moore M. 1989. Increasing empathy among medical students. Med Educ 23:168–173. Kohut H. 1971. The Analysis of Self. New York: International Universities Press. Mehrabian A. 1996. Manual for the BalancedEmotional Empathy Scale (BEES). Unpublished; available from Albert Mehrabian, 1130 Alta Mesa Road, Monterey, CA 93940. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. 2008. Is there hardening of the heart during medical school? Acad Med 83:244–249. Ogle J, Bushnell JA, Caputi P. 2013. Empathy is related to clinical competence in medical care. Med Educ 47:824–831. Spiro H. 1992. What is empathy and can it be taught? Ann Intern Med 116:843–846. Stratton TD, Saunders JA, Elam CL. 2008. Changes in medical students’ emotional intelligence: An exploratory study. Teach Learn Med 20:279–284.
