Viewpoint: Guiding Medical Students Toward Empathetic Patient Care
AAMC Reporter: June 2012
By Mohammadreza Hojat, Ph.D., Research Professor in the Department of Psychiatry and Behavior at Thomas Jefferson University Jefferson Medical College and Director of the Jefferson Longitudinal Study at the Center for Research in Medical Education and Health Care
Empathic engagement is the pillar of the patient-physician relationship. It is beneficial not only to the patient, but also to the physician. There is a basic human need to be understood that is fulfilled through an empathic relationship. Mutual understanding leads to empathy, the bedrock of a trusting relationship that improves compliance, thus leading to optimal patient outcomes.
Are medical students prepared to empathize with their future patients? How can we determine whether students will have this important attribute? About a decade ago, our research team at Jefferson Medical College developed the Jefferson Scale of Empathy (JSE), a psychometrically sound instrument that measures empathy in the context of health care education and patient care. We have provided psychometric evidence in support of its validity and reliability. The JSE is available in three forms: one that measures empathy among physicians and other practicing health professionals, another that measures empathy among medical students, and a third that measures empathy among students in other health disciplines, such as nursing or pharmacy. The JSE is one of the most researched instruments in medical education, has received broad attention in the United States and abroad, has been translated into 42 languages, and used in 63 countries so far.
Empathy is an elusive concept. In the context of patient care, our empathy research team defines empathy as “predominantly a cognitive (as opposed to affective) attribute that involves an understanding (as opposed to a feeling) of a patient’s concerns and experiences combined with a capacity to communicate this understanding, and an intention to help.” This definition makes a distinction between empathy (predominantly a cognitive attribute) and sympathy (predominantly an effective attribute). We believe that the two concepts have different consequences in patient care. For example, empathy in abundance is always beneficial in patient care, while sympathy in excess can be detrimental, causing emotional dependency in patients and leading to emotional exhaustion, burnout, and compassion fatigue in physicians.
Through our empathy research over the past decade, we have found that empathy among physicians clearly matters. Students with high empathy scores were more likely to pursue “people-oriented” specialties, such as primary care or psychiatry. We obtained significant associations between JSE scores on the one hand, and faculty’s ratings of students’ clinical competence, simulated patients’ evaluations of students’ empathic engagement in objective structured clinical exam stations, peer nominations on professionalism attributes, and scores of attitudes toward interprofessional collaboration, on the other hand.
Our findings also have placed empathy in the realm of evidence-based medicine. We have shown that physicians’ scores on the JSE were predictive of optimal patient outcomes in diabetic patients (indicated by results of hemoglobin A1c and LDL-C tests). In another study underway in Italy, we are testing the hypothesis that patients of physicians with high empathy scores have a higher compliance rate (measured by patients’ continued use of prescribed beta-blockers after an acute myocardial infarction).
The clear link between physician empathy and improved outcomes makes it critical that we nurture empathy in future physicians. The AAMC and the American Board of Internal Medicine have recommended that medical educators assess and enhance empathetic skills during undergraduate and graduate medical education. Our findings support this recommendation. We found that JSE scores declined significantly in the third year of medical school when the curriculum shifts toward patient care activities. We also observed a similar decline in empathy scores among nursing students who had more exposure to patient care than others. Medical students reported a lack of positive role models, excessive workloads and exhaustion, disrespectful and overly demanding patients, over-reliance on computer-based diagnostic and therapeutic technology, and a market-driven health care system as factors that contribute to the erosion of empathy and the escalation of cynicism.
How can we prevent that erosion of empathy and enhance this attribute in health professions students? In one study, we found that watching a short theatrical play (depicting problems facing elderly patients), could significantly increase JSE scores in medical and pharmacy students. The increase in empathy scores, however, did not last for a long time. In another study we found that first-year emergency medicine residents who shadowed patients in the emergency room for a short period of time prevented empathy decline compared with their counterparts who followed their routine training schedules. We are exploring approaches to not only enhance but also to sustain empathy by additional reinforcement during the course of medical education.
Our research has confirmed that empathy must be considered an important component of a health care provider’s overall competence and is a significant factor in optimal patient outcomes. These findings suggest that leaders and faculty at all levels of health professions education must implement targeted educational remedies to enhance and sustain empathy in all students and trainees, and assess the educational outcomes. We are planning to continue our effort to incorporate activities such as watching and discussing video clips of patient encounters from movies in our medical school educational program, and the shadowing experiences in our emergency medicine residency program, to improve bedside manner.
We have explored some uncharted territories from the time that we embarked on a journey to the terrain of empathy in the education and practice of patient care. Some “unfinished business” remains. More research is needed to identify the relative contribution of different factors that erode empathy, such as “hidden” educational messages, intimidating educational environments, defensive medicine, dissatisfied patients, and government and health insurance rules and regulations. We need more research on the association between caregivers’ empathy and clinical outcomes in a variety of diseases and settings. We need additional research to explore more effective approaches to enhance empathy with more sustained effects. We need to explore the neurological underpinning of empathy by using advanced brain imaging technology (e.g., fMRI) to better understand mechanisms that evoke empathy. The research agenda gets longer rather than shorter with new findings that raise more questions than answers. I believe we have not yet encountered the most interesting aspects of our journey. We have a long way to travel in the uncharted world of empathy in patient care.