The decline of empathy

It’s probably safe to say that most medical students start their training with a high desire to be empathetic toward their patients.

But these ideals often don’t survive the grueling process of becoming a doctor, a recent study published in the American Journal of Pharmaceutical Education has found.

Researchers at Midwestern University in Chicago and Thomas Jefferson University in Philadelphia wanted to know whether exposing first-year medical and pharmacy students to a theatrical exercise depicting the challenges of aging would improve their ability to empathize.

It did. The study involved 370 students at the Chicago College of Pharmacy and the Chicago College of Osteopathic Medicine at Midwestern University. They were asked to complete a test measuring their empathy levels before and immediately after the skit, and they scored significantly better afterwards. Unfortunately, though, the effects weren’t long-lasting. When the empathy test was administered again (one week later for the pharmacy students, 26 days later for the medical students), most of the scores had returned to their original baseline.

This doesn’t necessarily mean these students were completely lacking in empathy. But it points to the difficulty of instilling and maintaining this quality in the future health care workforce as they progress through their training.

Previous studies have reinforced this. The one that’s probably cited the most often appeared in 2008 in the Academic Medicine journal and examines what the authors describe as “hardening of the heart” during medical training. It tracked four classes of students at the University of Arkansas for Medical Sciences and documented notable declines in empathy scores, especially after the first and third years of medical school.

Similar findings have been reported among students in dental school and in postgraduate medical education.

Given the intensity of medical training, it seems inevitable that students would undergo some hardening of the heart, if for no other reason than to cope with the sheer burden. The academic demands are rigorous. The reality of providing care for actual patients, which starts in their third year, can be overwhelming and disillusioning for many students, especially when patients die or don’t fare well. Training environments that place medical students at rock-bottom in the pecking order are exhausting at best and abusive at worst. Add in the ever-present anxiety about grades and educational loans, and it’s no wonder that empathy begins to take a back seat.

Here’s a peek at the emotional state of a second-year medical student at Johns Hopkins who is about to transition into hospital training:

Suddenly the theoretical becomes practical, the “nice-to-knows” become “must-knows,” and simple clinical scenarios become ethical dilemmas. The vicissitudes become quite intense: one moment you feel ready to save a life as you stand triumphant over a mannequin, then suddenly you’re hovering in the pediatrics emergency department hearing the gurgle of a seizing child and feel completely helpless to handle such situations.

But it all begs the question: Is empathy something you can teach to medical students, or is it innate? If it’s teachable, can the curriculum be strengthened to foster and develop empathy? If it’s innate, should the admission process put more emphasis on selecting students who have this quality?

The 2008 study in Academic Medicine uncovered some interesting nuances. Overall, students who chose specialties in fields with a high amount of patient contact and continuity of care – family medicine, internal medicine, pediatrics, obstetrics-gynecology, psychiatry – had higher scores on the empathy scale than those in other specialties such as surgery or radiology. Male students in the core specialties actually scored higher than the population norm at the beginning of their training. On the other hand, the largest decline in empathy scores took place among male students in non-core specialties. Meanwhile, female medical students started at the norm and scores then declined for females choosing non-core specialties.

Of note, few if any of these students entered medical school with a deficiency in their empathetic abilities. But something about the training process may have diminished their capacity to feel empathy for others. To date there haven’t been many studies to determine whether this is temporary or whether it persists throughout their career. The study in the pharmacy education journal suggests that even when students are exposed to academic exercises specifically designed to increase their empathy, the effects may be short-lived.

Despite a lot of study, especially in the past decade or so, there remain many questions about how best to foster empathy in students who will be spending the rest of their working years in patient care. It matters because patients are more likely to comply, more likely to receive an accurate diagnosis and more likely to be satisfied with the clinician-patient relationship when empathy is present, the pharmacy journal authors wrote. “Empathy is an important component of the healthcare provider-patient relationship that has been linked to optimal patient outcomes.”