Empathy in Medical Education: Its Nature and Nurture - a Qualitative Study of the Views of Students and Tutors

Cultivating physician empathy: a person-centered study based in self-determination theory

While physician empathy is a vital ingredient in both physician wellness and quality of patient care, consensus on its origins, and how to cultivate it, is still lacking. The present study examines this issue in a new and innovative way, through the lens of self-determination theory. Using survey methodology, we collected data from N = 177 (44%) students at a Canadian medical school. We then used a person-centered approach (cluster analysis) to identify medical student profiles of self-determination (based on trait autonomy and perceived competence in learning) and how the learning environment impacted empathy for those in each profile. When the learning environment was more autonomy-supportive, students experienced higher satisfaction and lower frustration of their basic psychological needs in medical school, as well as greater empathy towards patients. The translation into increased empathy, however, was only evident among the students with higher self-determination at baseline. Results from this study suggest that autonomy-supportive learning environments will generally support medical students' psychological needs for optimal motivation and well-being, but whether or not they lead to empathy towards patients will depend on individual differences in self-determination. Findings and their implications are discussed in terms of developing theory-driven approaches to cultivating empathy in medical education.

Empathy in Nutrition and Dietetics: A Scoping Review

BACKGROUND

Empathy is fundamental to the provision of efficacious patient-centered health care. Currently, there is no comprehensive synthesis of peer-reviewed empirical research related to empathy in the nutrition and dietetics profession. Understanding empathy in the context of nutrition and dietetics care may lead to improved teaching practices that support nutrition and dietetics students and practitioners to provide high-quality, empathic, patient-centered care.

OBJECTIVE

This scoping review aimed to understand the approaches through which empathy is conceptualized, measured, and taught in the field of nutrition and dietetics.

METHODS

Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses-Scoping Reviews Statement and Checklist, a scoping review process was undertaken. Five databases were searched in February 2023: Cumulative Index to Nursing and Allied Health, Embase, Medline, PsycInfo, and Scopus, with no date limits. Eligible studies were English language-based, peer-reviewed, empirical research exploring or measuring empathy as an outcome in primary data stratified to nutrition and dietetics. Extracted qualitative data were synthesized and analyzed thematically with an inductive, interpretivist approach applied to conceptualize the interrelationship between empathy and dietetic practice. Quantitative data were extracted and summarized in a table.

RESULTS

Twenty-six studies were included in the scoping review. Analysis identified 2 overarching themes underpinning the current literature on empathy in nutrition and dietetics that described empathy as a key skill in the application of patient-centered care, which was supported by approaches to lifelong cultivation of empathy in the nutrition and dietetics profession. A range of tools has measured empathy in nutrition and dietetics students and practitioners with no clear consensus in findings across studies.

CONCLUSIONS

This review identified the extent and nature of empathy within nutrition and dietetics, from both practitioner and patient perspectives, and the vast array of approaches used to teach and quantify empathy in students and practitioners. Insights from this review inform the need for future studies. The results of this review suggest that future research include exploring implications of empathic dietetics care on patient outcomes and identification of best practice, evidence-based curricula and strategies to support sustainable cultivation and maintenance of empathic care across the career span of nutrition and dietetics practitioners.

Motivations of undergraduate student medical interpreters: Exposure and experience

BACKGROUND

When patients do not speak the same language as their doctors, they face poorer medical outcomes, decreased doctor-patient trust, and a diminished desire to seek medical care. It has been well established that interpretation is an essential part of an accessible healthcare system, but effective use of such language services relies on both the interpreters themselves and the healthcare teams working with them. This study presents an interdisciplinary examination of the motivations of undergraduate student medical interpreters, a group which serves as a bridge between these roles. While not full-time interpreters, they receive official training and spend time serving patients in local clinics. Further, for those who aspire to careers in medicine, interpreting provides invaluable exposure to the medical field and early professional know-how.

METHODS

Semi-structured individual interviews with undergraduate student interpreters were conducted to describe this multifaceted educational experience. A thematic analysis framework was employed to understand how and why they volunteer their time to interpret.

RESULTS

Motivations of student interpreters were found to fall under three general categories: (1) personal identity, or connection to family, language, and their career aspirations; (2) community engagement, or the opportunity to make a direct impact on patients at an early stage; and (3) pre-professional experience, both in general and specifically in healthcare. Each of these contributes to the view of a student medical interpreter as a unique contributor to language equity in medicine, as they provide language services in the short-term as well as set themselves up to be linguistically and culturally competent providers in the long-term.

CONCLUSIONS

A greater understanding of student motivations adds to knowledge about language mediation and validates the utility of students in this role, encouraging the development of more student interpreter programs. Particularly in communities with high proportions of non-English speakers, these students can contribute to making medical care as inclusive and accessible as possible.

Being kind in unkind spaces: a qualitative examination of how medical educators and first year medical students perceive empathy training

Introduction

It has become de rigueur for healthcare systems to tout their ability to provide compassionate medical care that addresses the emotional as well as physical needs of patients. Not surprisingly, then, there is considerable pressure on medical schools to train their students to be empathic. Existing literature on empathy training in medicine tends to focus on how to build emotional intelligence in individual trainees, largely ignoring the sociocultural factors that contribute to or thwart empathy development in medical school. Additionally, research tends to examine student perspectives, with little attention given to medical educators and their viewpoints.

Methods

In this paper, we adopt an "emotion practice" framework and utilize an inductive descriptive study design to qualitatively consider how first year medical students (N = 23) and their instructors (N = 9) perceive empathy training at a site we call Midtown Medical School.

Results and discussion

We find that both groups have an understanding of empathic capital but differ in their beliefs about the utility and legitimacy of this capital. Both educators and students also recognize the limitations of standardized empathy curriculum but do not agree on the implications of such rote learning. Finally, students and instructors alike find the hidden curriculum of medical school to be antithetical to empathy development, concurring that it is difficult to cultivate empathy in spaces where biomedical coursework is prioritized over social-emotional learning. In short, both groups find it difficult to be kind in an unkind place.

Introduction of psychological skills laboratory in medical education

Depression and anxiety are common psychological issues among university students, yet many of them hesitate to seek professional help due to stigma. Unfortunately, university curricula often lack self-help strategies to manage these challenges and provide timely support to those in need. To address this gap, we introduced the Psychological Skills Lab (PSL) component in the undergraduate medical curriculum, which emphasizes experiential learning to promote self-determination and autonomy in health promotion. The lab allows active interaction among students, lecturers, and peers through activities like presentations, peer reviews, in session practice, gratitude journals, group discussions, and role plays. PSL helps students develop skills, empathy, mindfulness, and self compassion through regular interactions. This innovative teaching approach raises mental health awareness and empowers students to assist others when required. Thus, by incorporating self-help measures into the curriculum, students are better equipped to manage their emotional well-being while supporting those around them.

Addressing Stigma by Increasing Empathy Toward Vulnerable Populations in Preprofessional Trainees: Impacts of the Generation Tomorrow Summer Health Disparities Scholars Program

BACKGROUND

Creating empathetic health care professionals is critical to addressing the health equity challenges of today, particularly because it relates to vulnerable populations.

METHODS

To assess the impact of the Johns Hopkins Center for AIDS Research Generation Tomorrow Summer Health Disparities Scholars (GTSHDS) program on students' empathy toward individuals living with substance use disorder and differential impact on empathy related to the COVID-19 pandemic, the Attitudes towards Mental Illness Questionnaire (AMIQ), an assessment of stigmatizing attitudes, was administered. Preprogram and postprogram participation AMIQ survey data were compared using paired t tests to explore changes within the program year. Unpaired t tests were used to characterize differences between the mean scores across the 2 student cohorts.

RESULTS

Both GTSHDS cohorts displayed postprogram increase in empathy. Mean 2019 cohort AMIQ scores shifting from -1.4 (SD 2.01) to -0.8 (SD 2.35) (P = 0.54), and the 2022 cohort shifting from -3.67 (SD 2.01) to -3 (SD 1.61) (P = 0.79). On average, individual scores improved by 2.2 (SD 1.65) points in the 2019 cohort and 2.4 (SD 1.86) points in the 2022 cohort (P = 0.83). Although these were not statistically significant, they suggested a trend toward more empathy.

CONCLUSIONS

Preliminary data suggest that programs such as GTSHDS that expose students to various aspects of health care principles can prepare future health care professionals in a manner that may reduce health care disparities. Future research with larger population sizes is needed to understand the impacts of the curriculum on empathy and related concepts to achieving health equity.

Kindness: Definitions and a pilot study for the development of a kindness scale in healthcare

BACKGROUND

Empathy and compassion currently receive the most attention in healthcare with respect to the medical humanities and while these skills are important for any clinician to learn, they are complex and can be daunting to healthcare trainees when first encountered. Kindness is a simple, time-sensitive behavior not yet well characterized in the healthcare setting. With this study, we aim to clearly define it as well as investigate a few common examples of kindness that might be used to create a scale for use in the healthcare setting.

METHODS

A literature search was performed to rigorously define kindness. A kindness scale based on this definition was then compiled and administered to 45 patients across three outpatient clinical settings to evaluate the association between several actions and the patient's perception of kindness.

RESULTS

Kind actions are small, take little effort, and are short in duration to their intended effect. We define kindness as an action that benefits another, as perceived by the recipient of the kind action. The results from our clinical study indicate several actions such as greeting the patient with a smile, asking questions about the patient's daily life, listening carefully, and appearing interested in the patient have a moderate strength correlation to a perception of kindness. The physician being perceived as kind also had a weak-moderate strength correlation to the patient subjectively reporting improvement after their visit.

CONCLUSIONS

Definitions in the medical humanities are important as they guide the scales used to measure them. This article defines kindness and describes some examples of its manifestation in the healthcare setting. Our study indicates that performing kind actions may improve a patient's subjective perception of their care, however, future studies are needed to evaluate whether this benefit extends to health outcomes as has been demonstrated for skills such as empathy and good communication. "Constant kindness can accomplish much. As the sun makes ice melt, kindness causes misunderstanding, mistrust, and hostility to evaporate." ~Albert Schweitzer.

Why might medical student empathy change throughout medical school? a systematic review and thematic synthesis of qualitative studies

BACKGROUND

Several studies suggest that medical student empathy declines throughout medical school. However, no studies have synthesised the evidence regarding why empathy declines.

OBJECTIVE

To conduct a systematic review and thematic synthesis of qualitative studies investigating why student empathy may change throughout medical school.

METHODS

We included any qualitative study that investigated why empathy might change during medical school. We searched the Medline, Scopus, CINAHL, ERIC, and APA PsycInfo databases for relevant studies. All databases were searched from their inception to 18 July 2022. We also searched the reference lists of the included studies and contacted experts to identify additional studies. We used the Joanna Briggs Institute tool to evaluate the risk of bias in the included studies. Overall confidence in our results was assessed using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach. We used thematic methods to synthesise our findings.

RESULTS

Our searches yielded 2523 records, and 16 studies involving a total of 771 students were eligible for analysis. Most studies (n = 11) were from Europe or North America. The descriptive themes and sub-themes were identified for each study. Increased complexity in patients and their diseases, together with the 'hidden curriculum' (including a stressful workload, prioritisation of biomedical knowledge, and (sometimes) poor role models), led to student adaptations, such as cynicism and desensitisation. Students' prior lives and professional experiences appeared to exacerbate the decline in empathy. However, there were bias concerns for most of the included studies.

DISCUSSION

Many of the included studies included were small, and some did not include demographic participant data. Given the likely benefits of providing empathic care for patients and practitioners, medical education interventions should focus on developing an 'empathic hidden curriculum' that mitigates the decline in medical student empathy.

TRIAL REGISTRATION

A protocol for this systematic review was submitted for registration with the International Prospective Register of Systematic Reviews (PROSPERO) on 28 July 2022 (registration number CRD42022347856).

Weak inclusion of the medical humanities in medical education: a qualitative study among Danish medical students

BACKGROUND

The modern medical education is predominantly grounded in the biomedical sciences. In recent years, medical humanities have been included into the medical curricula in many countries around the world one of the objectives being to promote patient-centred, empathic care by future physicians. Studies have been made of the impact of inclusion of medical humanities components within the medical curriculum. Although some results suggest increased empathy, others remain inconclusive. To gain insight into the depth, context, and impact of inclusion of the medical humanities for future physicians, this study aimed to explore Danish medical students' understanding of and reflections on how the medical humanities relate to the medical education, including the clinic.

METHODS

We conducted a qualitative research study, involving semi-structured interviews with twenty-three Danish medical students across years of curriculum and medical schools. Interviews were recorded, transcribed verbatim and analyzed using Braun and Clarke's thematic analysis.

RESULTS

The findings demonstrate the subordinate role of the medical humanities in the medical educational system. Students prioritize biomedical knowledge building in the preclinical curriculum, partly as a reaction to an unbalanced institutional inclusion of the medical humanities. Observing how structural empathy incentives are lacking in the clinical curriculum, the values inherent in the medical humanities are undermined.

CONCLUSION

Danish medical students become part of an educational environment with lacking institutional conditions and structures to promote the strong inclusion of the medical humanities. A focus is therefore needed on the values, norms and structures of the medical educational systems that undermine a strong inclusion of the medical humanities into medical education.