Saturday, April 24, 2010


If you ask people what they want in a physician, most people will list a few key characteristics.  Usually, these will include knowledge and competence, availability, and empathy and compassion.

It's distressing, then, to read that medical students start to lose empathy as early as their first year of medical school.  Empathy scores fall off after the first year, and then take another step down at the end of the third year after completing clinical rotations.  In the first case, this is apparently due to the stress and hardship of med school.  In the second case, the researchers think that this is related to the fact that hospitalized patients are sick, that the work can be hard, and that teaching physicians are rushed and may not provide the mentorship and teaching students were hoping for.  The drop after 3rd year might also be impacted by the fact that students care for patients whose illnesses can result at least in part from choices they have made: smoking, substance abuse, obesity, etc.

It is difficult to put in 2 long and hard years of classroom learning to prepare yourself for clinical rotations.  It is even harder to adjust to the fact that some of the patients you care for on the wards are there in part because of what they did to themselves.  I suspect it is easier to be empathic when caring for a child with cancer or an older patient who broke a hip in a fall then someone shot by a rival gang member or a lifelong smoker with end-stage emphysema.

This is a shame, because most students enter medical school with a strong desire to help others and a wish to make a difference for the better in peoples' lives.  Reading medical school applicants' essays reveals a group with great hope, energy and passion to enter a healing profession.  To see this energy start to lag within a year is troubling.

Some students fare better than others.  Women sustain empathy better than men, and students entering primary care and generalist specialties do better than those who enter Radiology and Surgery.  But it is evident that our medical education system has to do better.

There are ways to address these concerns.  At VCU School of Medicine, Project Heart matches students with mentors who help work through these issues during the pre-clinical years.  The Foundations of Clinical Medicine teaches clinical skills in the M1 and M2 years, but also teaches how to work with patients and how to handle difficult situations.  I don't know how VCU School of Medicine compares to other schools, but I am glad that this problem is recognized and is being addressed.

There are other ways to address this, including matching students with mentors who embody the desired qualities, asking students about their emotional or personal reactions to patients being cared for, and addressing non-empathic behaviors that might be demonstrated during patient care (whether student, resident, attending, nurse, colleague, etc).

Medical education has changed a lot in the last 10 years.  Gone are the days of 36- or 48-hour on-call shifts, and the system has shifted toward a more humanistic perspective.  Addressing medical student burnout and empathy are important next steps.

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