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Wednesday, October 23rd 2013

Empathy In Medical Training

I think I lost some empathy during medical school when I started my clinical rotations. There’s some evidence I’m not alone in the literature. Danielle Ofri has written a book on physician empathy and what it means for patients. And she’s commented on the loss of empathy during the third year of medical school over at Slate,

Students are not just learning medicine during the third year of medical school; they are learning how to be doctors. Despite the carefully crafted official medical curriculum, it is the “hidden curriculum” that drives the take-home messages. The students astutely note how their superiors comport themselves, how they interact with patients, how they treat other staff members. The students are keen observers of how their supervisors dress—and how they may dress down those around them. They figure out which groups of patients can be the object of sarcasm or humor, and which cannot.

On a daily basis, the students witness fear, anger, grief, humiliation—in patients and doctors alike—all of which are largely unacknowledged. They see egos rubbing up against each other, hierarchies at play, bureaucracies in action. They observe that many of the niceties of patient care fall prey to the demands of efficiency and high patient turnover. Much of what they learned about doctor-patient communication, bedside manner, and empathy turns out to be mere lip service when it comes to the actualities of patient care.

It’s no wonder that the third year of medical school figures prominently in studies that document the decline of empathy and moral reasoning in medical trainees.

Very true. A first year medical student is something more optimistic and bright eyed than most attending physicians and these initial years of clinical training seem to play a lot into that change.

While it seems to level off in the evidence as physicians go through training, I personally have found empathy a difficult thing to preserve. I imagine much of that has to do with the patient populations I’ve worked with, especially early in my training.

Like many interns and residents my early training has dealt with individuals often times with significant social stresses, poor socioeconomic factors, poor medical compliance and poor health literacy. There are many self inflicted health problems. These can be frustrating interactions for any physician, especially new ones.

But what perhaps is more unique to my training and has perhaps dealt my empathy a larger blow is the trauma population I’ve cared for. I spent the vast majority of my early years of training a the large trauma center for a sizable encatchment. It is one thing to see patients do harm to themselves by refusing to comply with medical advice or by daredevil stunts that end in injury. That is trying enough. It is, at least for me, considerably more stress on my optimism and faith in humanity to see people injure others either intentionally or even by negligent stupidity.

And while it must not be the case, it always seems those at fault get the easy end of it and the innocents take the brunt of the injury. That drunk driver has some contusion he’s going to be fine from it always seems; it’s that nine year old in the car he hit who is struggling.

Empathy is tough to preserve during the early years of training; especially really early in that third year of medical school. But it’s important and schools are starting to pay more attention to such and trying strategies to try to preserve it in their students and trainees. I know those programs are going to grow and I think they’re worthwhile.