Influences on students' empathy in medical education: an exploratory interview study with medical students in their third and last year

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.

Facilitators and barriers of empathetic behaviour in physiotherapy clinical practice: A qualitative focus group study

BACKGROUND

Empathy is an essential competence of a person-centered approach, and a recognisable ability for providing physiotherapy quality healthcare. Empathetic communication enhances the improvement of patient outcomes and their experience of treatment.

OBJECTIVE

The aim of the study was to present further insights considering facilitators and barriers of an empathetic communication between patients and physiotherapists.

METHODS

A qualitative focus group study was designed according to COREQ guidance for qualitative studies. Two focus groups were conducted. The first group included six patients and two individuals from non-governmental organizations, whereas three physiotherapists, two academic physiotherapist personnel and two undergraduate physiotherapy students participated in the second group. Both groups were audio recorded, and all data was verbatim transcribed for coding thematic analysis.

RESULTS

9 themes were revealed regarding empathetic facilitators (qualities of good communication, relationship building, interprofessional collaborative practice, positive environment, love for the healthcare profession and professionalism), while 8 themes were revealed regarding barriers (challenging situations, working conditions, burn out, depreciation of empathetic communication, lack of training, lack of professionalism, lack of personal development and health professionals' own personal problems).

CONCLUSION(S)

The enhancement of empathy can be accomplished in a trustworthy relationship between patient and clinicians where the development of proficient communication skills are prioritized. However, hindering factors associated with health professionals, patients and the health system should be surmounted.

ETHICAL APPROVAL NUMBER

339-ΣΕ8/10-1-2020.

Cultivating compassion in medicine: a toolkit for medical students to improve self-kindness and enhance clinical care

BACKGROUND

Compassionate care lies at the foundation of good patient care and is a quality that patients and providers continue to value in the fast-paced setting of contemporary medicine. Compassion is often discussed superficially in medical school curricula, but the practical aspect of learning this skill is often not taught using a formal framework. In the present work, the authors present an 8-session curriculum with a mindfulness-based approach to compassion that addresses this need. It is hypothesized that students in this curriculum will improve in their levels of compassion based on validated scales.

METHODS

The curriculum was delivered to fourth-year medical students at Renaissance School of Medicine at Stony Brook University who had just completed their clerkship year. It was developed as a customizable set of modules that could be delivered in various ways. The students were taught with evidence-based cognitive exercises followed by group discussions and written reflections based on compassion-focused thematic questions. All students completed a pre- and post-Self-Compassion Scale, Compassion Scale, and Toronto Mindfulness Scale. Students in this course were compared with students in different courses about non-clinical topics delivered at the same time. Wilcoxon Signed Rank tests and Mann Whitney U tests were used to assess potential associations between pre- and post-survey responses for the validated scales and subscales.

RESULTS

17 fourth-year medical students completed pre- and post-course tests, 11 participated in the compassion curriculum while 6 participated from the other courses. Before any of the courses began, all students performed similarly on the pre-test across all scales. The students in the compassion curriculum demonstrated a significant increase in their total Self-Compassion score by 8.7 [95% CI 4.3 to 13.2] points (p = 0.008), total Compassion score by 6.0 [95% CI 1.4 to 10.6] points (p = 0.012), and the curiosity component of the Toronto Mindfulness Scale by 4.4 [95% CI 1.0 to 7.7] points (p = 0.012). There was no statistically significant difference between pre- and post-tests among the non-compassion curriculum students in the aforementioned scales (p = 0.461, p = 0.144, p = 0.785, respectively).

CONCLUSIONS

Our results indicate that the students in our course developed an enhanced ability to engage in self-compassion, to understand the shared human experience, and to be motivated to act to alleviate suffering. Regardless of a program's existing compassion education, this customizable model allows for easy integration into a medical student's crowded curriculum. Furthermore, although teaching compassion early and often in a clinician's training is desirable, our study that targeted fourth-year medical students suggests an additional benefit of rekindling the loss of compassion well described in a medical student's clinical years.

The mediating role of work-related perceptions in the relationship between empathy and self-perceived clinical performance of residents in China: A multi-center cross-sectional study

OBJECTIVE

This study aimed to describe the association between empathy and residents' clinical performance and investigate whether work-related perception mediates this relationship.

METHODS

A multi-center cross-sectional study was conducted, including 1160 residents from 10 cities in Liaoning Province between March and October 2020. The participants completed various self-reported questionnaires regarding demographic characteristics, work-related perceptions, self-perceived clinical performance, and empathy. The relationships among empathy, work-related perception, and self-perceived clinical performance were examined using a structural equation model (SEM).

RESULTS

Of the 1160 residents, 961 (82.8 %) completed the questionnaires. The SEM path analysis showed that the direct effect of empathy on self-perceived clinical performance was significant and positive (β = 0.34, P < 0.001). There existed significant effects of empathy on work-related perception (β = 0.26, P < 0.001) and work-related perception on performance (β = 0.31, P < 0.001). The path coefficients of empathy concerning self-perceived clinical performance decreased significantly (β = 0.26, P < 0.001) when work-related perception was modeled as a mediator. The bias-corrected and accelerated bootstrap test revealed that work-related perception significantly mediated the relationship between empathy and self-perceived clinical performance (a*b = 0.08, BCa 95 % CI: 0.05-0.13). However, the correlation between the sub-scales of empathy and the items of self-perceived clinical performance was not substantial, even if most of them were statistically significant. The final SEM produced a good fit to the sample data, with CMIN/DF = 2.07 (P < 0.001), CFI = 0.99, GFI = 0.99, AGFI = 0.98, TLI = 0.98, NFI = 0.97, RMSEA (90 % CI) = 0.033 (0.017, 0.049), and SRMR = 0.024.

CONCLUSION

Empathy might significantly affect self-perceived clinical performance both directly and indirectly through the mediating role of work-related perception.

PRACTICE IMPLICATIONS

Efforts to improve clinical performance among residents might benefit from interventions for cultivating empathy and practices for improving work-related perceptions of residents.

Establishment of an Evaluation Index System of Competencies for College Senior Students in General Practice Medicine in Anhui Province, China

Background

The competencies of college senior students in general practice medicine have attracted attention. This study aimed to construct an evaluation index system of competencies for college senior students in general practice medicine and to promote the reform and optimization of training programs for general medicine talent in colleges.

Methods

The two-round Delphi method was used to determine the evaluation index system of competencies for college senior students in general practice medicine, and the analytic hierarchy process (AHP) was used to calculate the weights of all levels of elements.

Results

The evaluation index system of competencies for college senior students in general practice medicine was established with 3 primary factors, 9 secondary factors and 32 tertiary factors. The Delphi results revealed that the active coefficient of experts was 1 and the authority coefficient was 0.858. The 3 primary factors were knowledge level, job skills and professionalism with weights of 0.1532, 0.4207 and 0.4261, respectively. Among the secondary factors, the top three weight coefficients were professional ethics (0.2614), community practice (0.1526) and communication skills (0.1308). Among tertiary factors, "scientific research" exhibited the lowest value with a weight coefficient of 0.0049.

Conclusion

In this study, we constructed an evaluation index system of competencies for college senior students in general practice medicine. The consensus on the content of the competencies of college senior students in general practice medicine suggests that these elements are necessary for those who will become general practitioners. This system can be used as the basis to evaluate the ability of college senior students in general practice medicine and provide guidance for the cultivation and evaluation of general medicine talent.

[Interprofessional evaluation of "soft skills" of students in the practical year]

OBJECTIVE

The present study deals with the implementation of a questionnaire with 360° evaluation to assess the performance of students in the practical year (PJ). A special focus is put on the "soft skills" (self-competence, methodological competence, social competence), whose evaluation in medical studies has not yet taken place comprehensively.

MATERIAL & METHODS

The study was conducted prospectively with 21 PJ students of the Medical Faculty of the TU Dresden. The assessment was performed by means of a self-designed questionnaire, which was divided into 4 sub-competencies (self-competence, methodological competence, social competence, clinical skills and abilities), which could be assessed by means of a 6-point Likert scale. Four professions were involved in the assessment: Medical Service, Nursing Service, Functional Service, and Administration.

RESULTS

On average, the strongest deficits in terms of self-confidence, willingness to perform, and ability to deal with conflict were revealed by students in the PJ. Students showed a very good performance in performing a medical history and basic skills of clinical examination.

CONCLUSION

The implementation of 360° feedback is possible and useful for students in the internship year across disciplines and professions. Such personal and interprofessional feedback has not been widely available. The questionnaire represents the first comprehensive measurement tool of soft skills for medical students and provides a good basis for comprehensive feedback.

Medical student attitudes to patient involvement in healthcare decision-making and research

OBJECTIVE

Patient involvement is used to describe the inclusion of patients as active participants in healthcare decision-making and research. This study aimed to investigate incoming year 1 medical (MBChB) students' attitudes and opinions regarding patient involvement in this context.

METHODS

We established a staff-student partnership to formulate the design of an online research survey, which included Likert scale questions and three short vignette scenarios designed to probe student attitudes towards patient involvement linked to existing legal precedent. Incoming year 1 medical students (n=333) were invited to participate in the survey before formal teaching commenced.

RESULTS

Survey data (49 participants) indicate that students were broadly familiar with, and supportive of, patient involvement in medical treatment. There was least support for patient involvement in conducting (23.9%), contributing to (37.0%) or communicating research (32.6%), whereas there was unanimous support for patients choosing treatment from a selection of options (100%).

CONCLUSION

Incoming members of the medical profession demonstrate awareness of the need to actively involve patients in healthcare decision-making but are unfamiliar with the utility and value of such involvement in research. Further empirical studies are required to examine attitudes to patient involvement in healthcare.

Exploring clinical learning experiences of novice physiotherapy students in a hospital setting

BACKGROUND

Exposure to clinical practice experiences ensures undergraduate physiotherapy students meet the clinical competencies required to graduate as autonomous practitioners. Much of the research literature has investigated the clinical experiences of medical students. While recent studies have explored physiotherapy students' experiences with simulation, few have explored their perspectives of a clinical placement in a hospital setting at the early learning stage of a four-year programme.

OBJECTIVE

To explore the perspectives of novice undergraduate physiotherapy students on a clinical placement in a real hospital setting.

METHODS

Fifteen Year 3 undergraduate physiotherapy students participated in semi-structured interviews midway through a three-week tertiary care clinical placement. Interviews were transcribed, coded and analyzed using thematic analysis.

RESULTS

Three main themes emerged: 1) student attributes affecting placement experience; 2) impact of the educator on student experience; and 3) effects of the clinical environment on student experiences.

CONCLUSION

The real clinical environment promotes a rich learning experience for students, while the clinical educator is pivotal to guiding student learning through provision of resources and feedback. Provision of early orientation and timely clarification of expectations is important to alleviate anxiety and allow students to prepare themselves.

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.

[Planetary Health in the mandatory undergraduate medical curriculum - A qualitative study to evaluate a teaching/learning intervention]

INTRODUCTION

Climate change is the greatest threat to human health and therefore has a direct impact on the work of physicians. At the same time, the health sector is also an originator of pollutants that burden the climate. The concept of Planetary Health describes, among other things, ways in which the health sector can counter the effects of climate change. Nevertheless, the inclusion of contents on sustainable action in the education of health professionals has not been made mandatory to date. The aim of this study is to answer the question of how an intervention has to be designed so that medical students specifically develop an interest in dealing with the topic on their own.

METHODS

The intervention consisted ofFor evaluation purposes, a qualitative study with guided focus group interviews of attendees was conducted. The fully transcribed focus group transcripts were analysed using Mayring's structuring qualitative content analysis. Additionally, we checked the semester evaluation for feedback on the intervention.

RESULTS

Four focus groups comprising n = 14 medical students (11 female, 3 male) were conducted. Dealing with Planetary Health as a topic during medical education was considered relevant. The partially restrained to negative reaction of the teaching practice staff involved to the checklist had a demotivating impact. A lack of time was given as a further reason for not dealing with the topic independently. Participants suggested integrating specific Planetary Health content in mandatory courses and considered environmental medicine to be especially suited. As a didactic method, case-based working in small groups seemed to be particularly appropriate. In the semester evaluation, we found both approving and critical commentaries.

DISCUSSION

Participants considered Planetary Health a relevant topic in the context of medical education. The intervention proved to be of limited use in motivating students to deal with the topic independently. A longitudinal integration of the topic in the medical curriculum seems to be appropriate.

CONCLUSIONS

From the students' perspective, it is important to teach and acquire knowledge and skills regarding to Planetary Health in the future. Despite a high level of interest, additional offers are not being utilised due to a lack of time and should therefore be made part of the mandatory curriculum, where possible.

Experience-based learning during the final year - quantitative content analyses of students' self-reports

PURPOSE

The final year offers students the opportunity to explore their future role as a physician in different environments. Learning success depends in large part on how students experience these assignments. The aim of this study is to analyze students' self-reported experiences to derive factors that promote experience-based learning in the transition phase during the final year of medical school in order to optimally prepare students for professional practice.

METHOD

Data were collected from 2013 to 2019 via written survey after each assignment in the final year. Students were asked to report their pleasant and unpleasant experiences in free-text fields. The text material was analyzed using quantitative content analysis.

RESULTS

The authors included 1762 questionnaires for analysis. They formed 12 main categories from the text material, equally covering pleasant and unpleasant experiences. Supervisors and teamwork played a central role in both questions, responsibility and working areas frequently led to positive experiences, and working conditions to negative ones.

CONCLUSION

This study confirms the great importance of supervision. Above all, successful collaboration serves as a door opener into a feeling of security which students need to take on responsibility. The authors adapted Dornan's model of experience-based learning to the transition phase to help medical schools establish tailored conditions for students' successful entry into professional practice.

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).

Trends of Change in Empathy Among Indian Medical Students: A Two-Year Follow-Up Study

Background

The development of an empathic approach is essential for doctor-patient relationships. Medical training is a challenging time that may affect empathy. This study aimed to assess the change in empathy in students during medical education.

Methods

One hundred and fifty MBBS students were recruited at admission and assessed for empathy, interpersonal reactivity, and general health. They were followed for two years and assessed at three intervals.

Results

A significant decline was seen in empathy for both male and female students. The decline was correlated with psychological stress. Gender, family structure, having siblings, and increasing General Health Questionnaire score predicted change in empathy.

Conclusion

Empathy declines with advancing training, varying with constitutional and situational factors. The medical curriculum should include skills like empathic communication as well.

Relationship of mental health and burnout with empathy among medical students in Thailand: A multicenter cross-sectional study

OBJECTIVES

To explore mental health, burnout, and the factors associated with the level of empathy among Thai medical students.

BACKGROUND

Empathy is an important component of a satisfactory physician-patient relationship. However, distress, including burnout and lack of personal well-being, are recognized to affect a lower level of empathy.

MATERIAL AND METHODS

A cross-sectional study surveyed sixth-year medical students at three faculties of medicine in Thailand at the end of the 2020 academic year. The questionnaires utilized were: 1) Personal and demographic information questionnaire, 2) Thai Mental Health Indicator-15, 3) The Maslach Burnout Inventory-Thai version, and 4) The Toronto Empathy Questionnaire. All data were analyzed using descriptive statistics, and factors associated with empathy level were analyzed via the Chi-square test or Fisher's exact test, logistic regression., and linear regression.

RESULTS

There were 336 respondents with a response rate of 70.3%. The majority were female (61.9%). Most participants reported a below-average level of empathy (61%) with a median score (IQR) of 43 (39-40). Assessment of emotion comprehension in others and altruism had the highest median empathy subgroup scores, whereas behaviors engaging higher-order empathic responses had the lowest median empathy subgroup score. One-third of participants (32.1%) had poor mental health, and two-thirds (62.8%) reported a high level of emotional exhaustion even though most of them perceived having a high level of personal accomplishment (97%). The multivariate analysis indicated that mental health was statistically significantly associated with the level of empathy. The participants with higher levels of depersonalization had statistically lower scores of demonstrating appropriate sensitivity, altruism, and behaviors engaging higher-order empathic responding.

CONCLUSIONS

Most medical students had below-average empathy levels, and two-thirds of them had high emotional exhaustion levels, yet most of them reported having a high level of personal accomplishment and good mental health. There was an association between mental health and the level of empathy. Higher levels of depersonalization related to lower scores of demonstrating sensitivity, altruism, and behaviors responding. Therefore, medical educators should pay close attention to promoting good mental health among medical students.

Academic Perfectionism, Psychological Well-Being, and Suicidal Ideation in College Students

High levels of perfectionism in college students can compromise their academic performance and psychological well-being. This study aims to analyze the implication of perfectionism in psychological well-being and suicidal ideation in the last year. A total of 1.287 students from different degrees reported their academic performance in the previous academic year and completed questionnaires on academic perfectionism, psychological well-being, and suicidal thoughts in the last year. In both men and women, academic perfectionism correlates positively with academic performance and negatively with the different dimensions of psychological well-being. Likewise, both the average grade in the previous year (β = 0.364) and the level of demand of the degree (β = -0.461) are mediating variables between perfectionism and psychological well-being. Furthermore, the interaction between perfectionism and academic performance is related positively to psychological well-being, but not to with suicidal ideation. So, the relation between suicidal ideation and perfectionism is positive (OR = 1.075), but this is negative with academic performance (OR = 0.900), although both variables show a mild predictive capacity. These findings suggest that the levels of perfectionism are associated differently with the mental health of students, since if perfectionism is effective (high academic performance), psychological well-being is high, although in our results, this interaction is not as important for suicidal thoughts.

Exploring student perceptions of empathy development during medical school - A phenomenological study

OBJECTIVE

Empathy is an essential attribute of a good doctor. There are multiple dimensions to empathy, yet many curricula are limited to empathy display. This study's aim was to understand the relationship between teaching, learning and development of empathy from the perspective of medical students.

METHODS

A qualitative approach was used with interpretivist methodology. Ten final year medical students from a single UK University were interviewed. Findings came from inductive thematic analysis.

RESULTS

Five major themes were identified: 'The Empathic Process'; 'Self'; 'Patient'; 'Teacher/Clinician'; 'Environment'. Sub-themes included personal qualities, patient factors, role-models and assessment. Students value authentic patient encounters, focused feedback and opportunities for debriefing. Barriers include cognitive load, time-pressures and being observed. Students can maintain empathy through self-checking and addressing biases.

CONCLUSIONS

Students are aware of their motivations and barriers towards empathy development and can describe meaningful experiences relating to this during medical school. Students acknowledge controversy surrounding assessment of empathy, but clearly value authentic patient experiences and an environment which is free from scrutiny and distractions.

PRACTICE IMPLICATIONS

In addition to teaching communication skills, undergraduate programmes should focus on students' inner growth. This may be achieved by guiding students through meaningful reflection and open dialogue with supportive mentors.

The use of peer physical examination in undergraduate health professions education: Exploring the perceptions of students and educators in a multicultural, multiracial institution

Background. Teaching clinical skills is core content of the medical and allied health curricula of the Faculty of Health Sciences (FoHS) at the University of the Free State (UFS) in South Africa. A major pedagogical tool used for this purpose across the faculty is peer physical examination (PPE). Objective. To investigate the lived experience and perceptions of students and educators on the use of PPE in undergraduate health professions education at a multicultural and multiracial institution. Suggestions on guidelines for a PPE policy for the FoHS at the UFS were also obtained from the participants. Methods. This research was designed as a qualitative study that used focus group interviews involving 26 participants (19 students and 7 educators) to obtain verbal statements that described their experience and perceptions of the use of PPE in undergraduate health professions education. Results. Participants reported that PPE was useful to create a safe learning environment and to prepare students for the clinical aspects of their training. Enhancing students’ empathy, competency and clinical confidence were among the advantages attributed to using PPE; it also encouraged peer- assisted learning. Some of the disadvantages ascribed to PPE were that it made it difficult to maintain classroom discipline, and that it could promote memorisation over understanding. Finally, participants suggested that a guideline for PPE policy should address matters of consent, confidentiality, participation and gender, cultural, religious and racial considerations. Conclusions. The findings of this study reveal that PPE is an acceptable and useful learning strategy for the majority of students and educators. Issues relating to consent, confidentiality and cultural, religious and racial considerations are some of the potential problems associated with the use of PPE at the UFS. We believe that the suggestions given by the participants of this study will inform the establishment of a PPE policy for the FoHS of the UFS.

The effect of stress coping styles on empathy level in students of medicine: A cross-sectional study

We aimed to investigate the change in the ability of clinical empathy, which has a special importance in physician-patient relationship, during medical school years, and its relationship between stress coping styles. After the preliminary interview with 292 volunteer medical school students, the students were asked to answer the Hospital Anxiety Depression Scale, the Stress Coping Scale, and the student version of the Jefferson Doctor Empathy Scale. This study shows that the lowest median of the empathy level among medical school students was in the sixth year, and the decrease in empathy in the sixth year was mostly in the perspective taking component. When the relationship between empathy and coping styles with stress was examined, it was seen that self-confident approach was positively correlated with perspective taking (R = 0.182, P = .002) and standing in the patient's shoes (R = 0.172, P = .003). It was observed that the helpless approach, which is one of the negative coping styles, was inversely correlated with standing in the patient's shoes. As a result of the study, it was determined that the styles of coping with stress were related to the components of empathy, except for compassionate care. The self-confidence approach has an impact on the ability of standing in the patient's shoes and perspective-taking. During medical education, focusing on the approaches that increase the student's self-confidence against the stress will encounter throughout their professional life will undoubtedly increase the level of empathy.

Learning from the implementation of clinical empathy training: an explorative qualitative study in search of the barriers and facilitators

BACKGROUND

Amid concerns about the decline of empathy during the clinical training of medical clerks, evidence that empathy improves patient outcomes suggests some potential for teaching empathy in ways that will affect the knowledge, attitude and behaviour of medical clerks. This potential alone cannot, however, guarantee the success of educational innovations to introduce empathy to the medical curriculum. This research aims to identify the barriers and facilitators of the implementation of a specific clinical initiative to enhance the empathy skills of clerks, namely the training of clerks to act as a 'MedGezel' or 'medical coach'.

METHOD

We conducted an explorative qualitative study based on interview data collected and analyzed using reflexive thematic analysis and the readiness for change theory. We conducted semi-structured interviews with relevant stakeholders in this particular qualitative study. Thematic analysis was based on open and axial coding using ATLAS.ti 9, which facilitated the emergence of common themes of interest and meaning for the study.

RESULTS

A total of 13 relevant stakeholders participated as interviewees in our study. The data was collected from April to June 2021. Our analysis generated 6 main themes which can provide insights into why the implementation of the MedGezel educational innovation failed so far. The following themes emerged: the case for change: why change?; practical necessity; leadership; management and resources; staff culture; and alignment with the corporate strategy.

DISCUSSION

The implementation failure can be partially explained as resulting from the personal attitudes and choices of participants, who struggled to reconcile a vision that they liked with side effects that they feared. While participants repeatedly mentioned management and leadership issues, these organizational issues seemed less important as they could be easily resolved in practice. What was more important and fatal for the initiative was its lack of alignment with staff culture, despite its alignment with corporate strategy.

CONCLUSION

This investigation into the barriers and facilitators influencing the implementation of the MedGezel program identified 6 explanatory themes, the most impactful one being staff culture.

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

INTRODUCTION

Several studies suggest that medical student empathy declines throughout medical school. However, no studies have systematically investigated why. The objective of our proposed review is to conduct a systematic review and thematic synthesis of qualitative studies investigating the reasons empathy may change throughout medical school.

METHODS AND ANALYSIS

This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We have searched MEDLINE, Scopus, CINAHL, ERIC and APA PsycINFO for relevant studies. We will also search reference lists of included studies and contact experts to identify additional studies. We will include any qualitative study investigating the reasons why empathy changes throughout medical school. We will use the Joanna Briggs Institute tool to evaluate the risk of bias in the included studies. We will use thematic analysis to synthesise our results. For all included studies, we will summarise the main characteristics including the number of participants, medical school year, country and gender. In our discussion, we will summarise the limitations of the evidence (including the risk of bias and inconsistency), and provide a general interpretation of the results and important implications.

ETHICS AND DISSEMINATION

This study will not require ethical approval since no original data will be collected. The results of this review will be published through peer-reviewed publications and conference presentations. Additionally, this review will inform changes to the enhanced empathy curriculum at the Leicester Medical School.

How do medical students learn about SDH in the community? A qualitative study with a realist approach

INTRODUCTION

The need to learn social determinants of health (SDH) is increasing in disparate societies, but educational interventions are complex and learning mechanisms are unclear. Therefore, this study used a realist approach to identify SDH learning patterns, namely context (C), mechanism (M), and outcomes (O) in communities.

METHODS

A 4-week clinical practice program was conducted for 5^th- and 6^th-year medical students in Japan. The program included SDH lectures and group activities to explore cases linked to SDH in the community. The medical students' structural reflection reports for learning SDH were thematically analyzed through CMO perspectives.

RESULTS

First, medical students anticipated the concept of SDH and participated in a community in which a social model was central. They then transformed their perspective through observational learning and explanations from role models. Second, medical students' confrontation of contradictions in the medical model triggered integrated explanations of solid facts. Third, conceptual understanding of SDH was deepened through comparison and verbalization of concrete experiences in multiple regions. Fourth, empathy for lay people was fostered by participating from a non-authoritative position, which differed from that in medical settings.

CONCLUSION

Medical students can learn about the connections between society and medicine through four types of SDH learning patterns.

Empathy as a learning objective in medical education: using phenomenology of learning theory to explore medical students' learning processes

BACKGROUND

Clinical empathy has been associated with a range of positive patient- and clinician outcomes. Educating medical students to become empathic physicians has in recent years become a clearly pronounced learning objective in medical education in many countries worldwide. Research knowledge about how medical students experience the learning processes conveyed by empathy-enhancing educational interventions is lacking. Our study aimed to explore Danish medical students' perspectives on which experiences allowed learning processes to take place in relation to empathy and empathic communication with patients.

METHODS

We conducted a qualitative research study, involving semi-structured interviews with twenty-three Danish medical students across years of curriculum and universities. Braun and Clarke's reflexive thematic analysis (RTA) guided the analytical process, moving on a continuum from inductive to deductive, theoretical approaches. Key concepts in regard to learning processes deriving from Amadeo Giorgi's learning theory were applied to analyse the data.

RESULTS

Learning processes in relation to clinical empathy occured: 1. when theoretical knowledge about empathy became embodied and contextualied within a clinical context 2. through interpersonal interactions, e.g., with peers, faculty members and clinicians, that conveyed behavior-mobilizing positive and negative affect and 3. when new learning discoveries in 2. and 3. were appropriated as a personalized and adequate behavior that transcends the situational level.

CONCLUSION

Rather than being an immediate product of knowledge transmission, skill acquisition or training, learning clinical empathy is experienced as a dynamic, temporal process embedded in a daily clinical lifeworld of becoming an increasingly human professional.

Perception of Medical Students on the Need for End-of-Life Care: A Q-Methodology Study

End-of-life care and the limitation of therapeutic effort are among the most controversial aspects of medical practice. Many subjective factors can influence decision-making regarding these issues. The Q methodology provides a scientific basis for the systematic study of subjectivity by identifying different thought patterns. This methodology was performed to find student profiles in 143 students at Cantabria University (Spain), who will soon deal with difficult situations related to this topic. A chi-square test was used to compare proportions. We obtained three profiles: the first seeks to ensure quality of life and attaches great importance to the patient’s wishes; the second prioritizes life extension above anything else; the third incorporates the economic perspective into medical decision-making. Those who had religious beliefs were mostly included in profile 2 (48.8% vs. 7.3% in profile 1 and 43.9% in profile 3), and those who considered that their beliefs did not influence their ethical principles, were mainly included in profile 3 (48.5% vs. 24.7% in profile 1 and 26.8% in profile 2). The different profiles on end-of-life care amongst medical students are influenced by personal factors. Increasing the clinical experience of students with terminally ill patients would contribute to the development of knowledge-based opinion profiles and would avoid reliance on personal experiences.

Factors associated with the improvement of the empathy levels among clinical-year medical students in Southern Thailand: a university-based cross-sectional study

BACKGROUND

Empathy is one of the core medical professionalisms that distress, burnout, and lack of personal well-being is also recognized as an important influencer on lower empathy levels. Therefore, this study aimed to explore the mental health, burnout, and factors associated with the empathy levels among Thai, clinical-year medical students.

METHODS

This cross-sectional study surveyed all fourth-to sixth-year medical students at the Faculty of Medicine, Prince of Songkla University, in Thailand; at the end of the 2020 academic year. The questionnaires utilized were: (1) The personal and demographic information questionnaire, (2) The Toronto Empathy Questionnaire, (3) Thai Mental Health Indicator-15, and (4) The Maslach Burnout Inventory; Thai version. All data were analyzed using descriptive statistics, and factors associated with empathy levels were analyzed via the chi-square test and logistic regressions.

RESULTS

There were 466 participants, with a response rate of 91.5%. The majority were female (56.2%), and reported a below-average level of empathy (57.1%); with a median score (IQR) of 44 (40-48). The gender proportion of a below-average empathy level among male and female participants was 66.3% and 50.4%, respectively. Of the participants, 29.6% had poor mental health, 63.5% and 39.7% reported a high level of emotional exhaustion and depersonalization scores; even though most of them (96.6%) perceived having a high level of personal accomplishment. Multivariate analysis indicated that females, higher mental health, and a low level of depersonalization were statistically significant protective factors, which improved the empathy levels.

CONCLUSIONS

More than half of the clinical-year medical students reported below-average empathy levels. Female gender, better mental health, and a low level of depersonalization were related to the improvement of the empathy levels. Therefore, medical educators should emphasize the importance of focusing supporting students, of all genders and in regards to all stages of medical education, to increase their levels of empathy, to promote individual well-being, and to effectively prevent the phenomenon of student 'burnout'.

The development of empathy in the healthcare setting: a qualitative approach

BACKGROUND

Healthcare professionals' empathetic behaviors have been known to lead to higher satisfaction levels and produce better health outcomes for patients. However, empathy could decrease over time especially during training and clinical practice. This study explored factors that contributed to the development of empathy in the healthcare setting. Findings could be used to improve the effectiveness and sustainability of empathy training.

METHOD

A qualitative approach, informed by aspects of grounded theory, was utilized to identify factors that enabled the development of empathy from the perspectives of doctors, nurses, allied healthcare workers and students. Twelve sessions of focus group discussions were conducted with 60 participants from two hospitals, a medical school, and a nursing school. Data was analyzed independently by three investigators who later corroborated to refine the codes, subthemes, and themes. Factors which influence the development of empathy were identified and categorized. This formed the basis of the creation of a tentative theory of empathy development for the healthcare setting.

RESULTS

The authors identified various personal (e.g. inherent characteristics, physiological and mental states, professional identity) and external (e.g. work environment, life experience, situational stressors) factors that affected the development of empathy. These could be further categorized into three groups based on the stability of their impact on the individuals' empathy state, contributed by high, medium, or low stability factors. Findings suggest empathy is more trait-like and stable in nature but is also susceptible to fluctuation depending on the circumstances faced by healthcare professionals. Interventions targeting medium and low stability factors could potentially promote the development of empathy in the clinical setting.

CONCLUSIONS

Understanding factors that impact the development of empathy allows us to develop measures that could be implemented during training or at the workplace leading to improve the quality of care and higher clinical work satisfaction.

Residents as Research Subjects: Balancing Resident Education and Contribution to Advancing Educational Innovations

BACKGROUND

Research in education advances knowledge and improves learning, but the literature does not define how to protect residents' rights as subjects in studies or how to limit the impact of their participation on their clinical training.

OBJECTIVE

We aimed to develop a consensual framework on how to include residents as participants in education research, with the dual goal of protecting their rights and promoting their contributions to research.

METHODS

A nominal group technique approach was used to structure 3 iterative meetings held with the pre-existing residency training program committee and 7 invited experts between September 2018 and April 2019. Thematic text analysis was conducted to prepare a final report, including recommendations.

RESULTS

Five themes, each with recommendations, were identified: (1) Freedom of participation: participation, non-participation, or withdrawal from a study should not interfere with teacher-learner relationship (recommendation: improve recruitment and consent forms); (2) Avoidance of over-solicitation (recommendation: limit the number of ongoing studies); (3) Management of time dedicated to participation in research (recommendations: schedule and proportion of time for study participation); (4) Emotional safety (recommendation: requirement for debriefing and confidential counseling); and (5) Educational safety: data collected during a study should not influence clinical assessment of the resident (recommendation: principal investigator should not be involved in the evaluation process of learners in clinical rotation).

CONCLUSIONS

Our nominal group technique approach resulted in raising 5 specific issues about freedom of participation of residents in research in medical education, over-solicitation, time dedicated to research, emotional safety, and educational safety.

A quantitative evaluation of empathy using JSE-S Tool, before and after a Medical Humanities Module, amongst first-year medical students in Nepal

BACKGROUND

Doctors' empathy: the understanding of patients' experiences, concerns and perspectives, is highly valued by patients yet often lacking in patient care. Medical Humanities has been introduced within undergraduate curriculum to address this lack in empathy. There is a paucity of research on the impact of a course on medical humanities on the empathy of medical students, particularly in South Asia. Here we report on the impact of such an intervention in first-year medical students and aim to help outcome-based medical education and the evaluation and promotion of humanities within medical courses.

METHODS

This study is a quantitative evaluation of student empathy before and after a Medical Humanities Module. The study employs the Jefferson Scale of Empathy-Student version (JSE-S). Participants were first-year medical students at Patan Academy of Health Sciences, Nepal. All cohort students were invited to participate and written consent was obtained. Data were collected both prior-to and on-completion-of, a six-week Medical Humanities Module. Pre- and post-module data were analyzed and the resulting empathy scores compared using the paired t-test or Wilcoxon signed-rank test. Subgroup analysis was undertaken to determine the association of the score with gender and preferred future speciality.

RESULTS

Sixty-two student responses were analyzed, 32 (52%) of whom were male. In the pre-module scores females had a slightly higher mean score than males:108 and 103 respectively. Participants who preferred people-oriented specialities also scored higher than those preferring procedure and technology-oriented specialities: 107 and 103 respectively. There was a significant increase in mean score for the entire class from pre-module to post-module: 105 to 116, p-value of < 0.001. Mean scores rose from 103 to 116 in males, and from 108 to 116 in females. Participants preferring procedure and technology-oriented specialities showed a significant increase in mean scores:103 to 117, and participants preferring people-oriented specialities demonstrated a smaller increase:107 to 111.

CONCLUSIONS

This study provides evidence of the impact of a Medical Humanities course for increasing medical student empathy scores at an institution in Nepal. Teaching of Medical Humanities is an important contributor to the development of empathy in medical students and its widespread expansion in the whole of South Asia should be considered.

Development of student empathy during medical education: changes and the influence of context and training

PURPOSE

Empathy levels have been observed to often decrease when medical undergraduates move to the clinical years, particularly in the Western countries. However, empathy either remains similar or increases in many Asian medical schools. This study investigated the longitudinal empathy profile of medical students in Singapore.

METHODS

Two cohorts of medical students who enrolled in 2013 and 2014 to the National University of Singapore were tracked for 5 years. The Jefferson Scale of Empathy-student version was used. Analyses on the mean of the empathy level and individual factors, year-wise and gender comparison were conducted.

RESULTS

Average response rates for cohort 1 and 2 were 68.1% (n=181-263) and 55.4% (n=81-265), respectively. For both cohorts, there was no significant change across year of study in the mean empathy score. Average scores for both cohorts were 113.94 and 115.66. Though not significant, we observed mean empathy to be lowest at the end of year 5 (112.74) and highest in year 2 (114.72) for cohort 1 while for cohort 2, the lowest level of empathy was observed in year 5 (114.20) and highest in year 4 (118.42). Analysis of subcomponents of empathy only showed a significant difference for cohort one factor 1 (perspective taking) and factor 3 (standing in patients' shoes) across the study years.

CONCLUSION

No significant change in empathy score was observed during the transition from pre-clinical to clinical years, unlike many Western and Far-Eastern studies. This might be due to the curriculum and influence of the Asian values.

Importance of communication in medical practice and medical education: An emphasis on empathy and attitudes and their possible influences

BACKGROUND

Healthcare professionals need to be prepared to promote healthy lifestyles and care for patients. By focusing on what students should be able to perform one day as clinicians, we can bridge the gap between mere theoretical knowledge and its practical application. Gender aspects in clinical medicine also have to be considered when speaking of personalized medicine and learning curricula.

AIM

To determine sets of intellectual, personal, social, and emotional abilities that comprise core qualifications in medicine for performing well in anamnesis-taking, in order to identify training needs.

METHODS

An analysis of training clinicians’ conceptions with respect to optimal medical history taking was performed. The chosen study design also aimed to assess gender effects. Structured interviews with supervising clinicians were carried out in a descriptive study at the Medical University of Vienna. Results were analyzed by conducting a qualitative computer-assisted content analysis of the interviews. Inductive category formation was applied. The main questions posed to the supervisors dealt with (1) Observed competencies of students in medical history taking; and (2) The supervisor’s own conceptions of "ideal medical history taking".

RESULTS

A total of 33 training clinicians (n = 33), engaged in supervising medical students according to the MedUni Vienna’s curriculum standards, agreed to be enrolled in the study and met inclusion criteria. The qualitative content analysis revealed the following themes relevant to taking an anamnesis: (1) Knowledge; (2) Soft skills (relationship-building abilities, trust, and attitude); (3) Methodical skills (structuring, precision, and completeness of information gathering); and (4) Environmental/contextual factors (language barrier, time pressure, interruptions). Overall, health care professionals consider empathy and attitude as critical features concerning the quality of medical history taking. When looking at physicians’ theoretical conceptions, more general practitioners and psychiatrists mentioned attitude and empathy in the context of "ideal medical history taking", with a higher percentage of females. With respect to observations of students’ history taking, a positive impact from attitude and empathy was mainly described by male health care professionals, whereas no predominance of specialty was found. Representatives of general medicine and internal medicine, when observing medical students, more often emphasized a negative impact on history taking when students lacked attitude or showed non-empathetic behavior; no gender-specific difference was detected for this finding.

CONCLUSION

The analysis reveals that for clinicians engaged in medical student education, only a combination of skills, including adequate knowledge and methodical implementations, is supposed to guarantee acceptable performance. This study’s findings support the importance of concepts like relationship building, attitude, and empathy. However, there may be contextual factors in play as well, and transference of theoretical concepts into the clinical setting might prove challenging.

Medical Students' Perspectives on the Factors Affecting Empathy Development During Their Undergraduate Training

INTRODUCTION

This study investigated the perspectives of medical students on the factors influencing empathy development during their undergraduate training.

METHODOLOGY

A descriptive phenomenological approach was used to generate illustrations of empathy development and decline that had educational significance and applicability. Individual online semi-structured interviews were conducted to elicit experiential details from twelve final-year medical students. The interview recordings were transcribed verbatim, and data were analysed employing Braun and Clarke's thematic analysis method.

RESULTS

The self-reported empathic behavior of medical students seemed to have improved with time in medical school. Students attributed their empathy development to real patient encounters, positive role-modelling by teachers, and attainment of confidence and personal maturity. They identified exams, academic overload, time constraints, personal stresses, negative role models, unconducive learning environments, and lack of formal empathy training as barriers to empathy development.

CONCLUSION

Medical institutes should identify and address the barriers to empathy development and encourage the holistic development of medical students. Furthermore, medical educators should model their behavior accurately for their increasing roles and responsibilities and support the students in their empathic expressions with patients.

Validation of the Romanian Version of the Toronto Empathy Questionnaire (TEQ) among Undergraduate Medical Students

Medical professionals require adequate abilities to identify others’ emotions and express personal emotions. We aimed to determine the validity and reliability of an empathy measuring tool in medical students for this study. We employed Spreng’s Toronto Empathy Questionnaire (TEQ) as a starting point for this validation. The process was performed in several steps, including an English-Romanian-English translation and a focus group meeting to establish each question’s degree of understandability and usability, with minor improvements of wording in each step. We checked internal and external consistency in a pilot group (n = 67). For construct and convergent validity, we used a sample of 649 students. The overall internal and external reliability performed well, with Cronbach’s alpha = 0.727 and respective ICC = 0.776. The principal component analysis resulted in 3 components: prosocial helping behavior, inappropriate sensitivity, dismissive attitude. Component 1 includes positively worded questions, and components 2 and 3 include negatively worded questions. Women had significantly higher scores than men in convergent validity, but we did not highlight any differences for other demographic factors. The Romanian version of the TEQ is a reliable and valid tool to measure empathy among undergraduate medical students that may be further used in subsequent research.

Depression, anxiety, burnout and empathy among Spanish medical students

Medical Education studies suggest that medical students experience mental distress in a proportion higher than in the rest of the population In the present study, we aimed to conduct a nationwide analysis of the prevalence of mental health problems among medical students. The study was carried out in 2020 in all 43 medical schools in Spain, and analyzes the prevalence of depression, anxiety, empathy and burnout among medical students (n = 5216). To measure these variables we used the Beck Depression Inventory Test for assessing depression, the Maslach Burnout Inventory Survey for Students was used for burnout, the State-Trait Anxiety Inventory (STAI) was used to assess anxiety state and trait and the Jefferson Empathy Scale 12 to obtain empathy scores. In relation to depression, the data indicate an overall prevalence of 41%, with 23.4% of participants having moderate to severe levels, and 10% experiencing suicidal ideation. Burnout prevalence was 37%, significantly higher among 6^th year than among 1^st year students. Anxiety levels were consistent with those reported previously among medical students (25%), and were higher than in the general population for both trait and state anxiety. The prevalence of trait anxiety was higher among women. Empathy scores were at the top end of the scale, with the highest-scoring group (>130) containing a greater percentage of women. Similarly to those published previously for other countries, these results provide a clear picture of the mental disorders affecting Spanish medical students. Medicine is an extremely demanding degree and it is important that universities and medical schools view this study as an opportunity to ensure conditions that help minimize mental health problems among their students. Some of the factors underlying these problems can be prevented by, among other things, creating an environment in which mental health is openly discussed and guidance is provided. Other factors need to be treated medically, and medical schools and universities should therefore provide support to students in need through the medical services available within their institutions.

Reflective Writing about Near-Peer Blogs: A Novel Method for Introducing the Medical Humanities in Premedical Education

Narrative analysis, creative writing, and interactive reflective writing have been identified as valuable for professional identity formation and resilience among medical and premedical students alike. This study proposes that medical student blogs are novel pedagogical tools for fostering peer-to-peer learning in academic medicine and are currently underutilized as a near-peer resource for premedical students to learn about the medical profession. To evaluate the pedagogical utility of medical student blogs for introducing core themes in the medical humanities, the authors conducted qualitative analysis of one hundred seventy-six reflective essays by baccalaureate premedical students written in response to medical student-authored narrative blog posts. Using an iterative thematic approach, the authors identified common patterns in the reflective essays, distilled major themes, coded the essays, and conducted narrative analysis through close reading. Qualitative analysis identified three core themes (empathic conflict, bias in healthcare, and the humanity of medicine) and one overarching theme (near-peer affinities). The premedical students' essays demonstrated significant self-reflection in response to near-peer works, discussed their perceptions of medical professionalism, and expressed concerns about their future progress through the medical education system. The essays consistently attributed the impact of the medical student narratives to the authors' status as near-peers. The authors conclude that reading and engaging in reflective writing about near-peer blog posts encourages premedical students to develop an understanding of core concepts in the medical humanities and promotes their reflection on the profession of medicine. Thus, incorporating online blogs written by medical trainees as narrative works in medical humanities classrooms is a novel pedagogical method for fostering peer-to-peer learning in academic medicine.

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

CONTEXT

Medical education is committed to teaching patient centred communication and empathy. However, quantitative research suggests empathy scores tend to decline as students progress through medical school. In qualitative terms, there is a need to better understand how students and tutors view the practice and teaching of clinical empathy and the phenomenon of empathic erosion.

METHODS

Working within a constructivist paradigm, researchers thematically analysed the individual interview data from a purposive sample of 13 senior students and 9 tutors.

RESULTS

The four major themes were as follows: (1) 'the nature of empathy', including the concept of the innate empathy that students already possess at the beginning of medical school; (2) 'beyond the formal curriculum' and the central importance of role modelling; (3) 'the formal curriculum and the tick-box influence of assessments'; and (4) the 'durability of empathy', including ethical erosion and resilience. A garden model of empathy development is proposed - beginning with the innate seeds of empathy that students bring to medical school, the flowering of empathy is a fragile process, subject to both enablers and barriers in the formal, informal, and hidden curricula.

CONCLUSION

This study provides insights into empathic erosion in medical school, including the problems of negative role modelling and the limitations of an assessment system that rewards 'tick-box' representations of empathy, rather than true acts of compassion. It also identifies factors that should enable the flowering of empathy, such as new pedagogical approaches to resilience and a role for the arts and humanities.

Awareness, Knowledge, Attitude and Empathy Levels of Dental Postgraduates Towards Their Patients During Practice and Research-A Questionnaire Based Survey

Empathy is vital in ensuring the quality of the patient-clinician relationship. Empathy in the health care setting is the ability to understand a patient's experiences and feelings and communicate this understanding for better clinical outcomes in dental treatments. The study aimed to compare levels of empathy in post-graduate dental students across the different years of the master's degree course. Questionnaire forms distributed among post graduate students and awareness, knowledge, attitude, and empathy levels towards their patients were assessed. Responses of all the post-graduate students of all specialties in a dental institute were subjected to statistical analysis to know and compare their empathy towards the patients during their clinical practice and research throughout their three-year master's degree. The mean empathy score was 52.01 (maximum of 100), with a standard deviation of 6.69. The empathy scores decreased slightly from the first to the third year of the master's degree. The participant's age, marital status, place of residence, and specialties of dental post-graduation showed much significant difference in empathy levels. The study found slight significant gender differences in empathy among the participants. The empathy scores declined gradually very slightly as they were promoted to the next level in the course. The increase in empathy levels found in this study is more significant than those reported in similar studies due to the inclusion of educational and orientation programs at the time of admission into post-graduate studies.

Effects of a 2-Week Remote Learning Program on Empathy and Clinical and Communication Skills in Premedical Students: Mixed Methods Evaluation Study

BACKGROUND

Expressing empathy builds trust with patients, increases patient satisfaction, and is associated with better health outcomes. Research shows that expressing empathy to patients improves patient adherence to medications and decreases patient anxiety and the number of malpractice lawsuits. However, there is a dearth of research on teaching empathy to premedical students. The Clinical Science, Technology, and Medicine Summer Internship of Stanford Medicine (also called the Stanford Anesthesia Summer Institute) is a 2-week collaborative medical internship for high school and undergraduate students to inspire learners to be compassionate health care providers. The summer 2020 program was adapted to accomplish these objectives in a fully remote environment because of the COVID-19 global pandemic.

OBJECTIVE

This study aims to measure the change in empathy and competencies of participants in clinical and communication skills before and after program participation.

METHODS

A total of 41 participants completed only the core track of this program, and 39 participants completed the core + research track of this program. Participants in both tracks received instructions in selected clinical skills and interacted directly with patients to improve their interviewing skills. Research track participants received additional instructions in research methodology. All participants completed web-based pre- and postsurveys containing Knowledge and Skills Assessment (KSA) questions. Participant empathy was assessed using the validated Consultation and Relational Empathy measure. A subset of participants completed optional focus groups to discuss empathy. The pre- and post-KSA and Consultation and Relational Empathy measure scores were compared using paired 2-tailed t tests and a linear regression model. Open-ended focus group answers were then analyzed thematically.

RESULTS

Participants in both tracks demonstrated significant improvement in empathy after the 2-week remote learning course (P=.007 in core track; P<.001 in research track). These results remained significant when controlling for gender and age. A lower pretest score was associated with a greater change in empathy. Participants in both tracks demonstrated significant improvement in KSA questions related to surgical skills (P<.001 in core track; P<.001 in research track), epinephrine pen use (P<.001 in core track; P<.001 in research track), x-ray image interpretation (P<.001 in core track; P<.001 in research track), and synthesizing information to solve problems (P<.001 in core track; P=.05 in research track). The core track participants also showed significant improvements in health communication skills (P=.001). Qualitative analysis yielded 3 themes: empathy as action, empathy as a mindset, and empathy in designing health care systems.

CONCLUSIONS

Summer internships that introduce high school and undergraduate students to the field of health care through hands-on interaction and patient involvement may be an effective way to develop measurable empathy skills when combined with clinical skills training and mentorship. Notably, increases in empathy were observed in a program administered via a remote learning environment.

Deterioration in hygiene behavior among fifth-year medical students during the placement of intravenous catheters: a prospective cohort comparison of practical skills

BACKGROUND

The American Association of Medical Colleges has defined peripheral intravenous cannulation as one of the eight practical skills that a medical student should possess upon graduation. Since following a standard hygiene protocol can reduce the rate of complications such as bloodstream infections, the medical student's compliance to hygienic standards is highly relevant.

METHODS

This unicentric longitudinal cohort study included 177 medical students undergoing OSCE 1 in the winter semesters 2016/2017 and 2017/2018 as well as OSCE 2 during the winter semesters 2018/2019 and 2019/2020 at the University of Cologne. Their performance in peripheral intravenous cannulation was rated by trained student supervisors using a scaled 13-item questionnaire and compared between OSCE 1 and OSCE 2.

RESULTS

Overall, a decline in the correct placement of peripheral intravenous catheters was observed among advanced medical students during OSCE 2 (mean total score: 6.27 ± 1.84) in comparison to their results in OSCE 1 (mean total score: 7.67 ± 1.7). During OSCE 2, the students were more negligent in regard to hygienic behavior, such as disinfection of the puncture site as well as hand disinfection before and after venipuncture. Their patients were also less likely to be informed about the procedure as compared to OSCE 1.

CONCLUSIONS

An unsatisfying performance in regard to peripheral intravenous cannulation was observed in medical students with hygiene compliance deteriorating between the third and fifth year of their study. Thus, we promote an extension of practical hygiene and stress management training in medical school to reduce complications associated with intravenous catheters, such as bloodstream infections.

Perceived Injustice Helps Explain the Association Between Chronic Pain Stigma and Movement-Evoked Pain in Adults with Nonspecific Chronic Low Back Pain

OBJECTIVE

For most patients with chronic low back pain (cLBP), the cause is "nonspecific," meaning there is no clear association between pain and identifiable pathology of the spine or associated tissues. Laypersons and providers alike are less inclined to help, feel less sympathy, dislike patients more, suspect deception, and attribute lower pain severity to patients whose pain does not have an objective basis in tissue pathology. Because of these stigmatizing responses from others, patients with cLBP may feel that their pain is particularly unjust and unfair. These pain-related injustice perceptions may subsequently contribute to greater cLBP severity. The purpose of this study was to examine whether perceived injustice helps explain the relationship between chronic pain stigma and movement-evoked pain severity among individuals with cLBP.

METHODS

Participants included 105 patients with cLBP who completed questionnaires assessing chronic pain stigma and pain-related injustice perception, as well as a short physical performance battery for the assessment of movement-evoked pain and physical function.

RESULTS

Findings revealed that perceived injustice significantly mediated the association between chronic pain stigma and cLBP severity (indirect effect = 6.64, 95% confidence interval [CI] = 2.041 to 14.913) and physical function (indirect effect = -0.401, 95% CI = -1.029 to -0.052). Greater chronic pain stigma was associated with greater perceived injustice (P = 0.001), which in turn was associated with greater movement-evoked pain severity (P = 0.003).

CONCLUSIONS

These results suggest that perceived injustice may be a means through which chronic pain stigma impacts nonspecific cLBP severity and physical function.

Exploring relational and moral features in medical students

OBJECTIVES

We aimed to explore empathy, moral competencies, callous traits, and temperament in a sample of medical students. Furthermore, we aimed to investigate differences in our variables across the 1st and 5th years of medical education and possible correlations between them.

METHODS

This was a cross-sectional study with 138 medical students. We resorted to self-reported instruments that were given at the end of classes: Barrett-Lennard Relational Inventory, Temperament Evaluation of Memphis, Pisa and San Diego Auto-questionnaire, Inventory of Callous-Unemotional Traits, and Moral Competence Test. For the statistical analysis, we resorted to descriptive and inferential statistics, using non-parametric tests when data didn't follow a normal distribution.

RESULTS

We found no statistical difference between empathy scores in 1st (N=104, Mean=41.42, SD=22.48) and 5th year students (N=34, Mean=37.35, SD=23.35), t₍₁₃₆₎=0.908, p=0.366. Callous traits were negatively correlated with empathy (r₍₁₃₆₎=-0.444, p=0.000) and no correlation between moral competences and empathy (r₍₉₆₎=0.029, p=0.779) was observed. We found a negative correlation between empathy and cyclothymic, anxious and irritable temperaments (r₍₁₃₆₎=-0.334, p=0.000, r₍₁₃₆₎=-0.281, p=0.001, r₍₁₃₆₎=-0.400, p=0.000).

CONCLUSIONS

Our scores corroborate previous evidence that medical students are empathic, have good moral standards and low callous traits. We saw no differences in empathy scores between the two years and future studies could explore the particulars of medical curriculums impacting this variable. In our study, empathy was negatively correlated with callous traits and linked with specific temperaments. Considering these variables at admission to medical school as well as preserving and improving them in medical education might offer better standards of care.

How medical school alters empathy: Student love and break up letters to empathy for patients

INTRODUCTION

Medical education is committed to promoting empathic communication. Despite this, much research indicates that empathy actually decreases as students progress through medical school. In qualitative terms, relatively little is known about this changing student relationship with the concept of empathy for patients and how teaching affects it. This study explores that knowledge gap.

METHODS

Adopting a constructivist paradigm, we utilised a research approach new to medical education: Love and Breakup Letter Methodology. A purposive sample of 20 medical students were asked to write love and break up letters to 'empathy for patients'. The letters were prompts for the focus group discussions that followed. Forty letters and three focus group discussions were thematically analysed.

RESULTS

The three major themes were: art and artifice; empathic burden; and empathy as a virtue. Students were uncomfortable with the common practice of faking empathic statements, a problem exacerbated by the need to 'tick the empathy box' during examinations. Students evolved their own empathic style, progressing from rote empathic statements towards phrases which suited their individual communication practice. They also learned non-verbal empathy from positive clinician role-modelling. Students reported considerable empathic burden. Significant barriers to empathy were reported within the hidden curriculum, including negative role-modelling that socialises students into having less compassion for difficult patients. Students strongly associated empathy with virtue.

CONCLUSIONS

Medical education should address the problem of inauthentic empathy, including faking empathic s in assessments. Educators should remember the value of non-verbal compassionate communication. The problems of empathic burden, negative role modelling and of finding empathy difficult for challenging patients may account for some of the empathy decline reported in quantitative research. Framing empathy as a virtue may help students utilise empathy more readily when faced with patients they perceive as challenging and may promote a more authentic empathic practice.

Applying empathic communication skills in clinical practice: Medical students' experiences

Background

Studies have demonstrated that empathic communication improves patient outcomes and helps doctors to deliver accurate symptom reports and diagnoses. These benefits emphasise the need for medical students to apply empathic communication skills during their interactions with patients. Focussed empathic communication skill workshops were introduced into the undergraduate medical students’ training at the Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa. This study aimed to explore students’ perceptions of applying these empathic communication skills during their clinical practice. We were interested in determining the factors that might influence the development of empathic communication skills. The findings could help curriculum developers to optimise these workshops for inclusion in a formal medical curriculum.

Methods

This study followed a qualitative, descriptive enquiry, exploring the perceptions of medical students through focus-group discussions. The students (N = 18) were selected using convenience sampling techniques. Recordings were transcribed, and the data were thematically analysed.

Results

The two main themes identified relate to the students and the clinical learning environment. The students valued the knowledge and skills they acquired. However, feelings of emotional vulnerability, a lack of language proficiency and inadequate role modelling were highlighted as challenges when applying empathic communication during clinical practice.

Conclusion

The students reported positively on the workshops as these improved both their patient and personal interactions. However, for students to develop these skills further for clinical practice, they need more intentional and supervised opportunities to practise, reflect and receive constructive feedback. These learning opportunities could help medical schools deliver graduates who can competently communicate with their patients in an empathic manner.

Matriculating Students' Opinions on Cadaveric Dissection: Maintaining Tradition in Changing Times

As medical education advances, cadaveric dissection is no longer the sole modality to teach anatomy. In light of this, there is limited data regarding how incoming medical students perceive the importance of cadaveric dissection and whether they continue to desire the experience as they consider matriculating to medical school. Surveys were sent to incoming first-year medical students concerning their views of death and dissection. Our data show a strong and temporally reproducible opinion that cadaveric dissection is important among incoming medical students. This survey also reviews the predominant emotional reactions generated in anticipation of the cadaveric dissection experience.

Medical Students' Perspectives on Empathy: A Systematic Review and Metasynthesis

PURPOSE

Some evidence indicates that physician empathy declines during medical training, which has made it the subject of much research. Qualitative studies are relevant in this context, focusing as they do on how students themselves conceive and understand empathy during medical school. The aim of this study was to explore medical students' perspectives on empathy by conducting a metasynthesis, including a systematic review of the literature and analysis of included studies.

METHOD

The authors systematically searched 4 databases through June 17, 2019, for qualitative studies reporting medical students' perspectives on empathy in medical school. They assessed article quality using the Critical Appraisal Skills Program, and they applied thematic analysis to identify key themes and synthesize them.

RESULTS

The authors included 35 articles from 18 countries in their analysis. Four main themes emerged: (1) Defining empathy, with a lack of understanding of the concept; (2) Teaching empathy, with a focus on the hidden curriculum and clinical supervisors; (3) Willingness to be an empathetic doctor, with ambivalence expressed by some study participants; and (4) Evolution of empathy during medical school, specifically its decline.

CONCLUSIONS

Medical students are beset by theoretical confusion regarding the concept of empathy, and they express doubts about its utility and relevance. Instruction should focus on simpler concepts such as listening, and schools should leverage clinical supervisors' strong influence on students' empathy. Prioritizing certain types of knowledge (clinical facts) during medical education has a globally negative effect on medical students' empathy.

Empathy amongst dental students: An institutional cross-sectional survey in Poland and Croatia

AIM

To determine and compare levels of empathy and its dimensions in Polish and Croatian dental students.

METHODS

Fourth- and fifth-year dental students (N = 193) at the University of Rijeka and University of Silesia completed questionnaires to determine levels of overall empathy and its dimensions: compassionate care (CC), perspective taking (PT) and ability to stand in someone else's shoes (ASSES). Total empathy and its dimensions were analysed depending on the country of origin, year of study and gender of the participants. The HPS version of the Jefferson Scale of Physician Empathy was used to conduct the research. Statistical analysis was performed using the Mann-Whitney U test.

RESULTS

The analysis showed no significant differences in total empathy level between Polish and Croatian students (P = .838). However, separate analysis of empathy items showed significant differences between the two groups. Croatian students obtained significantly higher average PT values (P = .021), whilst Polish students had significantly higher CC scores (P < .001). Analysis of Croatian respondents revealed significantly higher ASSES scores in the fourth- and fifth-year students (P = .047). Analysis in the Polish group demonstrated an increase in PT scores from the fourth to the fifth year of study (P = .008).

CONCLUSION

Croatian students scored higher on items associated with cognitive empathy, whilst Polish students displayed higher values in the aspect of emotional empathy. The present results demonstrated an increase in cognitive empathy level in Polish students, whilst in their Croatian colleagues, the level of cognitive empathy decreased with the progression of the academic programme.

Empathy variation of undergraduate medical students after early clinical contact: a cross-sectional study in China

OBJECTIVES

Empathy education is very important for medical students. There is little research on the influence of early clinical practice on the development of empathy and other aspects of professionalism in medical students. The aim of this study was to compare the self-reported empathy levels of first-year and second-year undergraduate medical students before and after their early clinical contact curriculum.

SETTING

The study was conducted at the Shanghai University of Medicine & Health Sciences, Shanghai, China.

PARTICIPANTS

A total of 257 undergraduate medical students participated in the study. The 154 first-year students were studying in 10 community-based teaching hospitals, and the 103 second-year students were studying in 3 university-affiliated hospitals.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary measures: the Jefferson Scale of Empathy-Student version (JSE-S) was compared between students of different sexes and in different academic years before their early clinical contact course. Secondary measures: comparisons were made after they finished the curriculum 3 weeks later.

RESULTS

A total of 219 of 257 students responded (85.21% response rate), and 214 answers could be analysed (135 first-year and 79 second-year students; 120 female and 94 male individuals). No significant differences in the empathy scores before early clinical contact were observed between students of different sexes and in different academic years. After early clinical contact, the mean JSE-S score of the participants was significantly higher than the mean score at the beginning of the curriculum.

CONCLUSIONS

Empathy-focused training during early clinical contact can improve the empathetic capacity of undergraduate medical students. Fostering empathetic attitudes among undergraduate medical students is necessary for the early stage of their medical education. Further research is needed on the long-term effects of empathy-focused education in entry-level medical students.

Effect of a Single-Session Communication Skills Training on Empathy in Medical Students

OBJECTIVE

Empathy scores have been found to decline over the years spent in medical school. The authors aimed to evaluate the change in empathy levels in medical students following a single-session communication skills training.

METHODS

Eighty-two second-year medical students were randomized into intervention and control groups. The intervention comprised of a single-session empathetic communication skills training using PowerPoint, video clips, and roleplay. Empathy was assessed using the Jefferson Scale of Empathy-Student version (JSE) at baseline, post-intervention (for the intervention group), and at follow up after 3 weeks.

RESULTS

The mean JSE score of the intervention group was 109.7 ± 11.8 at baseline, with significant improvement post-intervention (114.2 ± 10.6, p = 0.014). However, the score declined at the 3-week follow-up (106.8 ± 11.8). The mean baseline JSE score of the control group was 107.5 ± 12.4, with a decline at follow-up (101.8 ± 16.0). Though both groups showed a decline in the JSE score at follow-up, the decline was significant only for the control group (p = 0.020), which did not receive the training.

CONCLUSIONS

The study showed significant improvement immediately, and lower decline at follow-up, in empathy levels following a communication skills training. The findings suggest a need to incorporate a regular training program into the existing medical curriculum, to enhance empathy and prevent its decline over the years.

Validation of the Toronto Empathy Questionnaire (TEQ) Among Medical Students in China: Analyses Using Three Psychometric Methods

This study aimed to validate the simplified Chinese version of the Toronto Empathy Questionnaire (cTEQ) for use with the Chinese population. The original English version of the TEQ was translated into simplified Chinese based on international criteria. Psychometric analyses were performed based on three psychometric methods: classical test theory (CTT), item response theory (IRT), and Rasch model theory (RMT). Differential item functioning analysis was adopted to check possible item bias caused by responses from different subgroups based on sex and ethnicity. A total of 1296 medical students successfully completed the TEQ through an online survey; 75.2% of respondents were female and the average age was 19 years old. Forty students completed the questionnaire 2 weeks later to assess the test–retest reliability of the questionnaire. Confirmatory factor analysis supported a 3-factor structure of the cTEQ. The CTT analyses confirmed that the cTEQ has sound psychometric properties. However, IRT and RMT analyses suggested some items might need further modifications and revisions.

Can empathy be preserved in medical education?

OBJECTIVES

The aim of this study was to investigate changes in empathy during medical education, as well as to identify promoters and inhibitors of empathy and analyse their roles.

METHODS

We used qualitative content analysis to examine 69 critically reflective essays written by medical students as a part of their final examination at the end of the medical program. The essays were based on previous self-evaluations performed each term and represented retrospective reflections on their professional development.

RESULTS

A majority of the students felt that their empathy did not decrease during medical education. On the contrary, many felt that their empathy had increased, especially the cognitive part of empathy, without loss of affective empathy. Many of them described a professionalisation process resulting in an ability to meet patients with preserved empathy but without being overwhelmed by emotions. They identified several factors that promoted the development of empathy: a multiplicity of patients, positive role models, and educational activities focusing on reflection and self-awareness. They also identified inhibitors of empathy: lack of professional competence and a stressful and empathy-hostile medical culture.

CONCLUSIONS

Our analysis of these retrospective reflections by students suggests that empathy can be preserved during medical education, despite the presence of important inhibitors of empathy. This finding might be due to the presence of more potent promoters and/or to the fact that educational activities might result in a decreased susceptibility to empathy-decreasing circumstances.

Recommendations of behavioural facilitators for success in a physiotherapy clinical practice module: Successful students' perspectives

Background

Students struggle to bridge the gap between theory and application thereof in clinical settings. Exploring the behaviours of students who have been shown to be successful in the clinical practice module of physiotherapy could provide an insight into what facilitated their success. Sharing this information with other students could assist with decreasing anxiety and improving student success.

Objectives

The objective of this study was to explore behaviours that facilitate student success in a physiotherapy clinical practice module from the perspective of high-achieving students.

Method

Data were collected at the University of the Western Cape's physiotherapy department in South Africa. Ten students with the highest marks in clinical practice from the 2016 and 2017 final-year cohorts were purposively selected and invited to participate in two different Nominal Group Technique (NGT) discussions. In total, 14 students consented to participate in the study. A demographic and socio-economic status questionnaire and an NGT discussion were used to collect data. Participants analysed the NGT discussion data themselves by ranking facilitators in order of priority.

Results

Doing pre-block preparation, self-reflection and having a good rapport with patients as well as personal motivation and coping strategies were identified as the most important behavioural facilitators for physiotherapy students' success in a clinical practice module.

Conclusion

Clinical practice is considered to be the most stressful module for undergraduate physiotherapy students. Considering this, recommendations from previously successful students could contribute towards the success of present and future students and in decreasing the stress associated with clinical practice.

Clinical implications

Recommendations from students on behavioural facilitators that enabled them to be successful in a physiotherapy clinical practice module can assist future students entering clinical practice to be successful in this stressful module. This information is also useful for clinical educators to assist students who struggle, and to recommend potential changes or improvements to the current physiotherapy clinical practice module.

The Role of Empathy in Health and Social Care Professionals

The current article is an integrative and analytical literature review on the concept and meaning of empathy in health and social care professionals. Empathy, i.e., the ability to understand the personal experience of the patient without bonding with them, constitutes an important communication skill for a health professional, one that includes three dimensions: the emotional, cognitive, and behavioral. It has been proven that health professionals with high levels of empathy operate more efficiently as to the fulfillment of their role in eliciting therapeutic change. The empathetic professional comprehends the needs of the health care users, as the latter feel safe to express the thoughts and problems that concern them. Although the importance of empathy is undeniable, a significantly high percentage of health professionals seem to find it difficult to adopt a model of empathetic communication in their everyday practice. Some of the factors that negatively influence the development of empathy are the high number of patients that professionals have to manage, the lack of adequate time, the focus on therapy within the existing academic culture, but also the lack of education in empathy. Developing empathetic skills should not only be the underlying objective in the teaching process of health and social care undergraduate students, but also the subject of the lifelong and continuous education of professionals.