Wednesday, 9 March 2011

A medical student's thoughts on empathy and #meded

Patient + Wife by polaroid667
Patient + Wife a photo by polaroid667 on Flickr.
Today during the twitter conversation Gautam went back to one of my old blog posts on empathy and left a comment that I think deserves its own post, so I have posted it below. Much of what he writes strikes me as very true and accurate. What is the solution?

"I think the crux of the problem is the practitioners that medical students train with. I'm a final year in Sheffield and even though we have 12 weeks of general practice over two separate sessions, that leaves around 2.75 YEARS of training in hospital.

My own opinion is that in-hospital practitioners are less empathic because the prevailing attitude is that patients are problems to be solved. The 'House MD' way of looking at things still prevails amongst many practitioners - particularly surgeons but equally amongst medical physicians. Students are 'taught' empathy but equally, are (not overtly) dissuaded from feeling it, talking about it and dealing with it. The pressure is to deal with the 'real' problems - the broken leg, the tweaking of medication doses - and ignore the 'BS' - the trauma of losing a child or partner (unless they can be referred for CBT).

Contrasting hospital care to general practice, the existence of a lasting relationship between doctor and patient means that these concerns have to be taken more seriously simply because the patient is a recurring figure in the doctor's professional life. In other words, it makes sense to deal with these patients as people, rather than as problems.

Now, this theory of mine (as weakly-backed by evidence as it is!) holds some water, I feel, since patients who are seen in clinic regularly are treated differently by consultants. These patients' problems are listened to, their concerns are heard and dealt with as much as is possible. Time constraints exist with patients on the ward, as well, but for some reason, (perhaps worries about confidentiality and privacy?) they are not covered as completely.

Medical students can be taught to reflect and encouraged to empathise by the medical schools as much as possible. But while they are taught as apprentices by overworked and jaded physicians and surgeons who may not have time to empathise as much as they'd like to, true empathy remains out of reach."

Thank you, Gautam.


  1. Interestingly, my experience has been GPs are far less likely to show any empathy than doctors in hospitals. Maybe I am just unlucky!

    I am intrigued about teaching empathy. As far as I can make out, a lot of our empathy is related to the natural tendency to copy others. This is probably through the action of mirror neurons and our tendency to build internal mental models of how other people behave, and because we get better results if we can establish rapport. Being able to 'get' where somebody else is 'coming from' helps us understand what they do in the appropriate context.

    It seems to me, although I can't say I have anything much other than personal observations, thought experiments and having helped a couple of lads with Aspergers develop their 'empathy', that we can learn to behave as though we are empathic even if we aren't naturally getting the signals from observing other people. That is, it seems that we are able to train ourselves to observe enough of someone else's behaviour to be able to appear to be empathic towards them. This may (or may not) be the same as actually 'learning empathy' but it is probably close enough for practical purposes.

    I would think, though, that for most medical students the main problem is learning not to empathise too much. I only have to deal with students, not patients, and I still find that quite often I 'feel' their 'problems' more than is actually beneficial to me, them or our working relationship. And I wouldn't generally consider myself as being particularly empathic (although others disagree with me).

    But I think Gautam is right; GPs *should* be empathising more, and over-worked clinicians trying to practice and train others are less likely to be able to encourage their students to empathise sufficiently well. Maybe all Med students should also train briefly as counsellors - though heaven forbid they end up like any of the ones I've known who have been extremely inauthentic!

  2. I would tend to agree with a lot of the sentiments expressed above. There is a process at work in medical education which has been studied over time, and is sometimes referred to as professional socialisation. This occurs in many professions, and in the priesthood is referred to as "formation"

    One author in the 1950's stated that"It is the function of medical schools to transmit the culture of medicine and so advance that culture" R Merton in The Student Physician 1957. Indeed, I feel that there is something which happens very early on in Medical School which colours the way that physicians of all sorts see themselves. Usually in the first week of medical school, the "medics" are picked out as just that. There is a set way of behaving, a new language to learn, and a set of values which is instilled at this very early stage. This is all part of the process. Unfortunately, this also includes losing, or a reduction in some of the qualities that made us go into medicine in the first place.

    This process continues when one specialises - students become doctors, and then have to choose to become a "surgeon" or a "GP" or a "Medic" or a "Anaesthetist" Each of these specialties has its own values, norms and behavioural expectations. One (unofficial) manual for trainee anaesthetists even contained some final words of advice - "Remember you are an anaesthetist - keep it cocky!"

    So, as we can see, professional groupings of all kinds have traditions, values and distinct cultures. Some will value empathy more than others. The work of Lave and Wenger on Legitimate Peripheral Participation (1990's) sheds some more light on this, and points out that to be an accepted member of a community of practice, it is helpful to engage in the activities of that community - Swales (1991) also highlights participatory mechanisms as a key covenant of a community of practice. If participatory mechanisms include engaging in discourse with your peers, then the culture, attitudes and values which are prevalent in that discourse are likely to become part of your own narrative.

    In this way, I believe (and I am by no means an expert on this) medical students and trainees start to be moulded into the form of those who they respect and admire within their profession.

    So how could we change medical education to encourage the maintenance of empathy? Arthur Kleinman gives an interesting perspective on this in this week's Lancet (The Lancet, Volume 377, Issue 9768, Pages 804 - 805, 5 March 2011) He divides medical education into pre-cynical and cynical phases, which happen to coincide with pre-clinical and clinical. His remedy includes studying the arts as part of medical education, to attempt to return to the concept of paideia as practiced in ancient greece.

    I guess my ideas are slightly simpler - we need to try to change the way that we socialise medics (but very difficult given the deep-rooted stereotypes of the medical student and subsequent professional practice) But it may be possible through a consistent approach to improvement of professionalism involving role modelling, exploring the ideas of personality, human factors and relationships, not least through an appreciation of the value of the humanities, to start to change the cultures and norms of the profession, starting from the bottom up.

    There has been an approach to this - reported in Academic Medicine
    (Acad Med. 2006 Oct;81(10):871-6) which I confess to only having just discovered, but it is something which has held my interest for a long time, as I believe in this field we will unlock some of the reasons why physicians can sometimes be such resistors to change in the workplace over subjects like patient safety, and quality improvement.

  3. Toby,

    Very interesting - I am jealous of you ability to blog.

    It is certainly a fact (in simpler terms) that medical students tend to be a bundle of enthusiasm, and this gets massively dampened by the end of their first year as a doctor. The same thing is seen with graduate management trainees.
    What I am very interested in is that this does not seem to be happening in the hospitals where we are getting the F1s to run QI projects. As they learn that they can make a difference this enthusiasm stays (and even grows). A coincidence maybe, but I think not.

    Rob Bethune

  4. Thanks to all for your comments so far.

    I guess that Gautam raises the issue that as a student he sees empathy demonstrated less often in acute hospital medicine. I think that is true, but also it is may be appropriate. I was hoping that someone might chip in and explain more about what working in acute hospital medicine is like. My experience of it is more than 10 years ago now.

    Gautam shows a very clear understanding of how the patient-doctor relationship varies not just between primary and secondary care, but also between inpatient (short-term and acute) and outpatient (long-term and relational).

    Is the danger that we are not explicit enough when teaching about what the different priorities in each situation are? When we teach communication skills we try to address some of these differences.

    Next, Toby raises with great clarity the issue of socialisation. Your points certainly address much wider organisational culture issues than just demonstration of empathy. Last week we have a curriculum review day. In a sessions the post-graduate dean said that one of the most important things for an F1 doctor to know was that they worked for an organisation and that they could do something to improve it. We're putting a lot of work in to harmonising the final year or medical school and the first year working in Wales, and hopefully this awareness will be one of the main outcomes. I should point out that he also joked that some consultants didn't seem to be aware that they worked for an organisation that they could improve either.

    Changing organisational cultures? This will be a long conversation. But thanks for having some of it here.

  5. I'm very pleasantly surprised that my original rambling thoughts have provoked such insightful discussion! If I may respond to each of them in turn...

    Pat, my own opinion is that some students probably do empathise with patients. I suppose that 'teaching' empathy is perhaps, beyond what we can strive for because if the culture of the student's chosen speciality (as I shall touch on later) doesn't encourage this sort of 'woolly thinking' then it's difficult to perpetuate. The most undesirable way of ensuring it's done is also the way to make it valued the least - mandating empathic training and reflection. By formalising a process such as this one, you devalue it. I think that training medical students as counsellors might be less beneficial than encouraging them to be counsellors - working for Night Line or Samaritans, etc. for one day could drive home the point that people have other problems besides medical ones and that these can be the real issue at hand. If the medical student is to become an empathic doctor (and that's what we're seeking here) then it needs to be a long term behaviour which the person actively seeks him- or herself.

    Toby - your breadth of reading on this subject is astonishing! I strongly agree with the observations you make - effectively that each branch of medicine is its own cult with specific behaviours and traits that you probably wouldn't find outside of medicine (and sometimes, wouldn't find acceptable outside of that speciality). You have to drink the Kool Aid to be one of the accepted few.

    I concur completely about studying non-medical (particularly humanity and arts subjects) topics as part of medical education. To incorporate that into medical education is absolutely key to actually garnering some empathy amongst peers. Understanding how a character feels or how a case study feels is, perhaps, the easiest form of empathy - the details are laid out in front of you, unlike with a patient where you need to establish trust and almost extract these details, AFTER (or perhaps during) which you can begin to empathise.

    I also take your point re: socialising - I myself tried to socialise with as many non-medics as possible in the first few years but I ran into the same problem everyone else did - they'd all left by the time I'd finished my intercalated year! Staying completely free of medics when socialising is probably undesirable, but mixing just with your coworkers-to-be is also going to give a very narrow understanding of the world. Enforced socialisation with lawyers during ethics and law teaching could be a good way for both groups to learn where the other is coming from - again, the beginning of an empathic understanding could brew about not only patients but also about the much-maligned 'other' professionals.

    Rob - that's a really interesting observation, I'll have to read up on that! Also, I'll have to become involved in a quality improvement project when I start F1...

    Anne Marie, I think that the real problem is the concern that orthodox educators have regarding the hidden curriculum. Once you start exploring it, it's very easy to see that there is plenty more than first appears - empathy being one of the topics that could be added to ethics, law, history of medicine, communication skills, medical (and non-medical) humanities, psychology, medical education (which should, in my opinion, be given more emphasis at undergraduate level - we are going to have to teach as F1s!) and plenty more. I think that there's a real danger that everything gets shoved into one afternoon a week for 6 weeks and that people will attend 4 of these (to not fail) and won't pay attention for any of them.

    Finally, I must say that I have to applaud the attitude of your postgraduate dean, as well! I fully intend to improve our NHS as an soon as I've passed these finals!

  6. In other professions (I'm thinking here of Psychotherapy and Psychology), it is necessary as part of the training process to undergo personal therapy so that the student can learn what it is like to be 'on the other side' of the desk (or chair formation!)

    Trainees in these professions also have regular supervision where they are encouraged to explore the emotions that arise when dealing with their work/patients.

    I think that these training strategies would help medical students and qualified doctors to become more emotionally articulate and more at ease with the emotional side of their work.

    Isn't there such a thing as Balint groups? Perhaps these should become a formal part of training for all doctors and attendance could be made compulsory as part of the revalidation process.


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