Maintaining empathy in medical education

Empathy is one of the ‘‘hot’’ topics in medical education, as most educators believe it to be a humanistic attitude that students and physicians must have (Spiro 1992). It is considered to be an essential component of professional competence (Epstein et al. 2002). Indeed, empathy has been included as one of the attributes of ‘‘professionalism’’ by Canadian residents (Brownell & Cote 2001). Kohut states: ‘‘the empathic understanding of the experience of other human beings is as basic an endowment of man as his vision, hearing, touch, taste and smell’’ (Kohut 1971). Empathy can therefore be considered as one of the most important characteristics of a physician. Most research studies have used one of the following validated self-report instruments to measure the construct of empathy – the Jefferson Scale of Physician Empathy (JSPE) (Hojat et al. 2001), the Interpersonal Reactivity Index – Empathy Concern subscale (IRI-EC (Davis 1980), and the Balanced Emotional Empathy Scale (BEES) (Mehrabian 1996). Several studies that have examined selfperceived empathy of medical students using one of these three instruments, have reported that there is a decline in empathy during medical school, specifically as students move from pre-clinical to clinical years (Hojat et al. 2004; Austin et al. 2007; Chen et al. 2007; Newton et al. 2008; Stratton et al. 2008; Hojat et al. 2009). However, these findings have been challenged by other researchers, citing some methodological flaws (Colliver et al. 2010). Nonetheless, all agree on the importance of empathy in fostering the relationship between the patient and the doctor and the value of this relationship in providing better health care. The interest in developing interventions to increase medical students’ empathy can be traced back as early as 1989 (Kramer et al. 1989). In the current issue, two groups of researchers, one group from the United States and another from Australia reported their curricular interventions increased and maintained empathy in medical students, when measured with the JSE/JSPE-S. The article from Hojat and his colleagues focused on enhancing and sustaining empathy of medical students through the use of video-clips and movies. These authors designed a two-stage study where they first implemented a pre-post intervention to explore whether medical students’ self-perceived empathy could be increased by the intervention. They then implemented as second study ten weeks later, where students from the experimental group (from the first study) were randomly divided into two groups, with one of the groups receiving another intervention. The authors concluded that the interventions worked, as the group exposed to both these interventions had a higher score on the JSE than those students who were not. The authors acknowledged the need for a longer-term follow-up study as the interval between the two interventions was only ten weeks. The students in this study were pre-clinical medical students, and since most declines in empathy occurred during the clinical years, a follow-up of these students in the clinical years with a re-measure of empathy would be useful. Nevertheless, this is a valuable contribution to the literature, as the authors are asking us to think about how we can reinforce students’ empathy by the judicious placement of interventions in the curriculum by encouraging us to design empirical studies to determine where and when such interventions should occur. The second study by Hegazi and Wilson employs a crosssectional design to examine whether empathy varied in different years of medical school. The authors found that there was no significant difference in the empathy scores of the medical students in the different years of medical school. They also explored the relationship between empathy and some demographic variables including not only gender and age, (which have been examined in other studies), but also marital status, cultural beliefs, religious beliefs, and previous tertiary education. In order to promote and maintain empathy, programmes aimed at promoting personal and professional development were included in the curriculum as options for students. What I found interesting was that in their conclusions, the authors stated that empathy could be preserved in the medical school by careful student selection and the inclusion of personal and professional development programmes. The fact that they brought up student selection opens up new areas to explore. Although they did not mention the selection system that was used in their medical school, there has been a lot of discussion regarding the use of cognitive and non-cognitive characteristics of medical students for selection. It may be worthwhile to explore whether any of the assessment processes used in medical schools such as the Multiple Mini-Interview, have an association with the students’ self-reported empathy. The authors also acknowledged the limitations of a cross-sectional study, recommending that readers consider longitudinal studies.