Edinburgh, United Kingdom (Spring 2017)
|Medical students check blood glucose on a patient.|
On a windy corner of Drummond Street, not far from Rutherford’s pub in Edinburgh, there is a small bronze plaque with these words:
‘And when I remembered all that I hoped and feared as I pickled about Rutherford’s in the rain and the east wind; how I feared I should be a mere shipwreck, and yet timidly hoped not; how I feared I should never have a friend, far less a wife, and yet passionately hoped I might; how I hoped(if I did not take to drink) I should possibly write one little book. And then, now, what a change! I should like the incident set upon a brass plate at the corner of that dreary thoroughfare, for all students to read, poor devils, when their hearts are down. Letters from the South Seas . Robert Louis Stevenson’.1
Stevenson’s reflections on his miserable student days are a reminder that medical students need empathy just as much as patients do. Why do some doctors take such care of their patients yet fail to extend their concern to medical students? Hippocrates writing around 400BC put the student – teacher relationship at the top of his Oath; before any consideration of a doctor’s obligations to patients.2 The word doctor, derived from the Latin docere, to teach, emphasizes a responsibility for the students’ welfare.
Undergraduate medical education is unnecessarily stressful and competitive so it is perhaps unsurprising that there is evidence of a decline in students’ empathy as they progress through their course.3 Empathy involves trying to see the world from another person’s point of view. Clinical teachers have a responsibility to give students time and space to listen and to share emotional problems. Such support should be routine for all students and not reserved just for those who are struggling.
From the moment students enter medical school they are made aware that every assessment throughout the curriculum will count towards their position in the year and so affect their chance of a good hospital post after graduation. Such pressure is not conducive to training empathetic practitioners. Competition is a strong antidote to empathy.
Some medical schools, proud of their research reputation and success at securing grant funding, have less to say about their quality of teaching and nothing to say about their low student satisfaction ratings. Students may be encouraged to be empathetic, but they soon learn if their teachers are more interested in the biomedical facts about the patient. Such a positivist approach risks viewing a patient as a scientific object of interest rather than a fellow human being.
Students learn to ‘take a history’ rather than have a conversation with a patient. Exploring the patient’s view of the world, the empathy territory, is relegated to an acronym ICE; standing for Ideas, Concerns, and Expectations, which are added at the end of the history, if time permits.4 Students can learn a form of fake empathy in clinical exams and so pick up the few marks allocated to ICE.
The strong emphasis on the biomedical part of the curriculum over the psychosocial leads students to develop a form of professionalism which has been described as ‘detached concern’.5 ‘Professionalism’ is a word that sounds cold and detached and students may think , mistakenly, that expressing emotions and connecting with patients are inappropriate. Students then struggle with their feelings for patients and do not receive training on appropriate emotional regulation; on how to balance detachment and connection.
Detachment is sometimes justified by claiming that emotional involvement will affect clinical judgement or even overwhelm the student and lead to burnout. However, appropriate empathy in clinical care is neither detachment from patients nor being overwhelmed by emotions. It is instead an iterative relational process of emotional resonance exploring the meaning of an individual patient’s experience.5 This form of empathy, which includes cognitive and emotional dimensions, involves a willingness to participate deeply in the patient’s experience but at the same time appreciate the fact that it is not one’s own experience but that of another person. Connecting with a patient in this way does not lead to burnout but to increased doctor and patient satisfaction.6
Stevenson’s reflections convey his humility and vulnerability, which are both central to the process of empathy. Patients may feel vulnerable as a result of their illnesses and students because of their lack of knowledge at this early stage in their careers. Such vulnerability should be acknowledged and celebrated, not treated by humiliation at bedside teaching.
Lorna , a fourth year student, recounted how a cardiologist made her feel stupid in front of a patient by criticizing her lack of knowledge of an electrocardiogram. Lorna felt so ashamed that she did not feel she could return to talk to the patient in the future. Such teaching by humiliation is a form of bullying that still occurs in medical education.7 Bullying undermines a student’s confidence and self- esteem.8
Students are aware of the limitations in their knowledge and commonly suffer from the ‘imposter syndrome’.9 This syndrome is characterized by a fear of being ‘found out’. Students may perceive consultants to be ‘terrifyingly competent’ and so fail to seek their support.10 Stress inhibits empathy, which requires time and effort to establish. Most medical students are reluctant to seek support as they fear the stigma of appearing weak.10 Personal tutors and mentors should be aware of this and appreciate it is not sufficient to say to a student, “Get in touch if you have a problem”.
Students can learn empathy by mirroring good role models. We can all remember clinical teachers who have enhanced our practice. I remember an inspiring physician who always put the patient first but at the same time respected students and junior doctors as equals. He took an interest in his students and staff and developed long- lasting mentoring relationships with many hundreds of young doctors. He taught me to spend time with patients, demonstrated a novel way of conducting a clinical examination by starting at the patient’s feet, and gave up many Sunday mornings to coach us through our first postgraduate exams. It was refreshing to meet a dynamic physician who had little patience for hierarchy and showed how practicing empathetic medicine could be creative and fun.
Empathy can form a bridge across power differences between the doctor and patient. Humility is part of empathy and was regarded by Iris Murdoch as the primary virtue.11 Dostoevsky addressed empathy and humility by appealing for what he describes as ‘a human voice’.
‘We are two beings, and we have come together in infinity…for the last time in the world. Abandon your tone and take a human one! At least for once in your life speak in a human voice. Not for my sake, but for your own.’12
Some medical school have formal hierarchies and value teaching hospital practice rather than primary care. While waiting before a lecture, I chatted to a fourth year student asking her what branch of medicine she was hoping to enter. She replied, “I hate to admit it, but I love general practice”. She explained that entering general practice was looked down on by the medical school.
The culture of the medical school, sometimes called the informal curriculum, can generate a ‘group empathy’ between teaching staff and students. In such a culture teaching is valued as highly as research and students are treated as colleagues, not suspects. If such an empathetic teaching environment can be created, students will learn that their empathy is valued and so will feel free to express their own innate empathy for the benefit of patients. As Stevenson wrote ‘And then, now, what a change!’
- Stevenson, R.L., Selected Letters of Robert Louis Stevenson, ed. Mehew E. 2001, London: Yale University Press.
- Miles, S.H., The Hippocratic oath and the ethics of medicine. 2005, Oxford: Oxford University Press.
- Hojat, M., et al., The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School. Academic Medicine, 2009. 84(9): p. 1182-1191.
- Tate, P., Ideas, concerns and expectations. Medicine, 2005. 33(2): p. 26-27.
- Halpern, J., From Detached Concern to Empathy:Humanizing Medical Practice 2001, New York: Oxford University Press.
- Kearney MK, W.R., Vachon MLS,Harrison RL,Mount BM., Self-care of Physicians caring for Patients at the end of Life “Being Connected….A Key to Survival”. JAMA, 2009. 301: p. 1155-1164.
- Mistry, M., J.L.M. Mistry, and J. Latoo, Bullying: a growing workplace menace Bullying: a growing workplace menace. British Journal of Medical Practitioners, 2009. 2(1).
- Paice, E. and D. Smith, Bullying of trainee doctors is a patient safety issue. The Clinical Teacher, 2009. 6(1): p. 13-17.
- Cohen, M.J., et al., Identity transformation in medical students. The American journal of psychoanalysis, 2009. 69(1): p. 43-52.
- Jeffrey, D., Medical Mentoring:Supporting Students,Doctors in Training and General Practitioners. 2014, London: Royal College of General Practitioners.
- Murdoch, I., The sovereignty of good. 2013, London: Routledge.
- Dostoevsky, F., Demons. 2010, London: Vintage.
DAVID JEFFREY, FRCPE, FRCP (London), MRCGP, is currently researching empathy in medical students for a PhD. He is an Honorary Lecturer in Palliative Medicine at the University of Edinburgh. Formerly he was the academic mentor at Dundee Medical School , a consultant palliative care physician in the 3 Counties Cancer Centre in Cheltenham UK and prior to this a general practitioner and Course Organiser.