Developing Empathy in Future Physicians
[Medscape Med Students, 2001. © 2001 Medscape, Inc.]Vijay Aswani, PhD
One has only to read memoirs of recent medical graduates, such as Melvin Konner's Becoming a Doctor, Shem Samuel's House of God, and Robert Marrion's Learning to Play God, to marvel at the anecdotes and stories of tired interns and residents to whom patients become nameless, faceless obstacles or interruptions of much-desired sleep.
This, coupled with patients' fear that when they are most vulnerable they will be in the hands of an albeit competent but callous physician, has led to increased focus on the issue of empathy in the medical profession.
Some of the factors that seem to drive empathy to a low point in physicians-in-training result from 2 traditional views doctors absorb during medical school. One is the "care:cure dilemma." This usually asserts that it is doctors who do the curing and nurses who do the caring. The other is the traditional format of interviewing and the social ethos of medical training and medical practice, which stress clinical detachment.Indeed, Nisker humorously refers to medical education as the Yellow Brick Road, where "from the time the medical school's acceptance letter is opened, students set off in pursuit of the attributes of the good physician: intelligence, compassion and courage."
The students already possess these traits, just as the Scarecrow, Tin Man and Lion did before they set out for Oz, but they may dissolve in education systems that still decree that the initiation to medicine involve tons of tutored words and consuming call schedules.
The rigors of medical school can take other tolls. Factors that can drain a doctor-hopeful include:
Insufficient skills to deal emotionally
Organizational demands or limitations
Lack of example or correction of behavior
Scientists who have studied the transformation in medical students during their clerkships tell us that in a psychological attempt to deal with first encounters of illness, death, pain, and suffering, students may swing from empathy to overidentification, or objectivity to avoidance.
Those who study the problem call for a vertical support structure for coping with the emotional demands and reactions to what one sees and hears in the hospital. Spiro puts it eloquently when he speaks of the need for "conversations about experiences, discussions of patients and their human stories, more leisure and unstructured contemplation of the humanities.
Physicians need rhetoric as much as knowledge, and they need stories as much as journals if they are to be more empathetic than computers."
A number of investigators have suggested that reading medical prose or good literature on death, sickness, dying, and the doctor-patient relationship can help one to sort out one's own feelings. An excellent Web site in this regard that I can recommend is http://www.medicalprose.com/.
Another useful idea is to rent a video after exams that relates to a class you took. For example, in our biochemistry class, after studying the lipid disorders, we watched the movie Lorenzo's Oil (see http://www.teachwithmovies.org/guides/lorenzos-oil.html for a summary of the film and some ideas on using it in your classes). It was heartening to see tears in the eyes of several future doctors as they watched the parents and child fight the disease. It brought new feelings to the bland text and equation descriptions of the disease in our biochemistry book.
Finally, in some residency programs, first-day residents are assigned a clinical scenario to act out and are instructed to pose as patients and approach their department. The nurses at the triage usually do not know who they are and they get treated just as any other patient would who is visiting the department. For most of them, it is an eye-opening experience.
Call to Compassion
Patients in pain, suffering, and illness seek relief from medicine and the healthcare system, but they also seek human comfort, understanding, and empathy. Most of the measures can be easily assimilated into the structure of most medical schools. In all fairness to the overworked, sleep-starved drones of the medical world -- the interns and residents -- they are there when you need them.
Their compassion is spoken with action and response to call. As Spiro has so eloquently stated, "Computed tomographic scans offer no compassion and magnetic resonance imaging has no human face. Only men and women are capable of empathy."
Factors shown to enhance empathy in medical students and future physicians include:
A liberal and humanistic education
Exposure to literature and philosophy
Training in interpersonal communication skills
Workshops on attentive listening, sensitivity, and empathy
Early and continued exposure to the hospital environment and patients
Experience as a patient -- real or simulated
Konner M. Becoming a Doctor. New York: Penguin Books; 1987.
Shem S. House of God. New York: Dell Books; 1981.
Marion R. Learning to Play God: The Coming of Age of a Young Doctor. New York: Fawcett Books; 1993.
Nisker JA. The yellow brick road of medical education. CMAJ. 1997;156:689-691.
Spiro H. What is empathy and can it be taught? Ann Intern Med. 1992;116:843-846.
Schatz IJ. Empathy and medical education. Hawaii Med J. 1995;54:495-497.
Beaudoin C, Maheux B, Cote L, Des Marchais JE, Jean P, Berkson L. Clinical teachers as humanistic caregivers and educators: perceptions of senior clerks and second-year residents. CMAJ. 1998;159:765-769.
Vijay Aswani, PhD, is Assistant Professor of Biochemistry at Medical University of the Americas, Nevis, West Indies.
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