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Goodbye Dr. Welby…Hello Dr. House

Created August 3, 2011 by Helena Bachmann
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You’d think that compassionate doctors are a given but, unfortunately, that is not always the case. TV’s anti-social and arrogant Dr. House may only be a fictional character, but research shows that decline in physician empathy happens in the real world as well, and it starts to take root during medical school.

Numerous studies have reiterated these findings over the years, including one conducted in 2006 by the Mayo Clinic. That particular research found that among the 10 most common items on patients’ “wish-lists” was their physicians’ ability to be caring and compassionate.

In fact, the level of empathy can actually impact – both positively and negatively – the patients’ health. In March of this year, Academic Medicine, thejournal of the Association of American Medical Colleges (AAMC), reported a study involving 891 diabetics and 29 family physicians treating them. The doctors were asked to rate their empathy as “high,” “moderate,” or “low.”  Patients whose physicians had a high empathy score were much more likely to better control their diabetes than their counterparts with low-empathy doctors.

What Studies Show

In the past years, several studies have documented this troubling trend.

The most recent research, published in the August 2011 issue of Academic Medicine, found that“empathy declines significantly during the course of medical school and residency.”

An earlier study that appeared in the same publication in 2008 showed a similar trend:  Student empathy scores dropped after the first year of medical school, further decreasing during the third year.

An article in the March 31, 2011 issue of New England Journal of Medicine confirms the existence of documented evidence showing “the high level of compassion with which students enter medical school and the sharp decline that occurs during the ensuing four years.”

The article notes that most of this decline occurs in the third year, just as students shift from an academic environment to a hands-on patient care in a pressure-filled hospital setting. “It is ironic that precisely when students can finally begin the work they believe they came to medical school to do — taking care of patients — they begin to lose empathy,” it says.

Multiple Reasons

While the study published in the August 2011 Academic Medicine does not give specific reasons for this phenomenon, the researchers of the 2008 study – which followed 419 medical students at the University of Arkansas for Medical Sciences from 1997 to 2004 – offered several possible explanations.

Stress and anxiety caused by the students’ competitiveness and desire to overachieve on exams could contribute to the empathy drain, researchers said. Later on, while doing clinical rotations, residents mentored by rushed and overworked hospital physicians may not have received as much guidance on proper “bedside manner” as they needed.

And, the study points out, other health professionals are not immune to this phenomenon either. In a comparison of 130 U.S. dental students, self-assessed compassion toward patients declined considerably during clinical training.

Rx for Compassion

The erosion of empathy among medical students is, justifiably so, an important issue to educators.

“We are aware of this important literature on the loss of empathy and altruism among medical students and post-graduate medical trainees as they go through school and training,” Henry M. Sondheimer, M.D., AAMC’s Senior Director of Student Affairs and Student Programs tells SDN.  “This is an area of great concern for the student affairs deans I work with.”

In order to train future doctors to be more compassionate and sensitive in their relationships with patients, many of the 135 U.S medical schools the AAMC represents “have introduced or are in the process of introducing extensive wellness programs for their students, which they hope will counter this disturbing trend,” Dr. Sondheimer says.

The newest such program, called SELECT (an acronym for Scholarly Excellence. Leadership Experiences. Collaborative Training) has just started at University of South Florida College of Medicine (USF COM), with the arrival, on July 25, of the inaugural class of 19 students. Those numbers will increase to 48 students next year, and 56 in 2013 and thereafter.

“Students will be immersed in leadership training and grounded in empathy and other core principles of patient-centered care,” Alicia D.H. Monroe, MD, USF COM’ Vice Dean of Educational Affairs tells SDN. She adds that students in this program will take regular “core MD” classes in addition to their SELECT-specific curriculum.

She explains that this new track, developed in collaboration with the Lehigh Valley Health Network (LVHN) in Allentown PA, will provide “outstanding education in the biomedical and clinical sciences, unique training in leadership development, intense coaching, and the scholarly tools students need to become empathetic, passionate leaders who will be catalysts for change.”

Students can apply to the traditional MD Program, the SELECT MD program, or both. However, those wishing to participate in the SELECT program are expected to show evidence of compassion and a caring attitude before they are admitted. As Dr. Monroe explains it, “Faculty trained in the interview technique evaluate the prospective students’ responses – studying not just the events they described, but how they reacted to those events – to look for key characteristics of emotional intelligence, such as collaboration, adaptability, or emotional self-control.”

After completing their first two years on USF COM’s Tampa FL campus, SELECT students will undergo two years of clinical training at LVHN. “Faculty based in both Florida and Pennsylvania will actively collaborate to teach, coach and mentor SELECT program students throughout the four- year curriculum,” Dr. Monroe adds.

A Creative Approach

Some medical schools are taking innovative approaches to instilling principles of sensitive patient care in a new generation of doctors.

Instead of focusing merely on the scientific subjects required for a MD (or DO) degree, many schools are increasingly emphasizing courses in the arts and humanities, which allow med students to develop the ability to observe and express their own feelings in a context not usually available in the medical setting.

The following two examples – culled from various reports – demonstrate some of the more creative ways in which medical colleges across the United States attempt to foster empathy among their students:

  • Brown University’s medical school has a reflective-writing program that assesses their students’ ability to express feelings about difficult experiences, such as witnessing their first death.
  • Students at Weill Cornell Medical College can sharpen their observational skills – certainly a key quality for a physician – by visiting the Metropolitan Museum of Art and hearing a commentary by an art historian. Or, they can choose to join the Music and Medicine Initiative, a program Weill Cornell runs together with The Juilliard School of Music.

Positive Results

Research suggests that programs like these are effective in fostering compassionate patient care.

The March 2011 issue of Academic Medicine reported an experiment that involved 209 Robert Wood Johnson Medical School students in the classes of 2009 and 2010. They followed a mandatory “Humanism and Professionalism” course, which included blogging about their clerkship experiences, talking about important events they had witnessed, and discussing articles, books, and films.

The “before-and-after” findings showed that third-year students who participated in this program did not show a significant decline in empathy. “A curriculum that includes safe, protected time for third-year students to discuss their reactions to patient care situations during clerkships may have contributed to the preservation of empathy,” the report summed up, adding that “programs designed to validate humanism in medicine may reverse the decline in empathy.”

That is the goal empathy-based programs at various medical schools are trying to achieve.

“We fully expect to see physicians who exude compassion and confidence, who have a clear sense of vision, mission and purpose, and who can demonstrate flexibility and adaptability in responding to both crisis situations and clinical dilemmas,” SELECT’s Dr. Monroe points out.  This new generation of physicians “will be able to balance the values, hopes and dreams of patients with the best scientific and clinical evidence, while demonstrating the highest degree of professional integrity.”

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