“We know what we are, but know not what we may be.”
- Shakespeare
Many years ago, I knew a resident whose only focus was himself. He studied alone, consistently begged off of or ignored teaching assignments, interacted poorly with faculty members, and received poor marks from those with whom he worked. Observing him examine patients was painful — he appeared to be completely unversed in basic social skills. When he finished training, memory of him quickly evaporated. It was as though he had never been part of our lives.
What had he lacked? Many things, I suppose, but even he agreed that he lacked any sense of empathy.
Some empathy (“imaginative” or “cognitive” empathy) can be learned and it allows us to assume the roles of others to predict their thoughts and feelings. Other forms of empathy (“vicarious” or “gut reaction” empathy) represent the spontaneous visceral response to another’s emotions. Vicarious empathy cannot be learned but it can be lost.
A recent article documents the disturbing association of medical education with decreases in vicarious empathy. Groups of medical students were tested yearly for four years for their emotional responses to fictional situations. Findings included:
- Students entered medical school with vicarious empathy scores similar to the general public.
- Vicarious empathy decreased over the four years of medical school, especially during the first and third years.
- Students who eventually chose to enter specialties that focus on patient continuity (family medicine, pediatrics, internal medicine, OB/Gyn, and psychiatry) scored better on the empathy scale than students who eventually chose other specialties.
- Separate research has found that idealism and empathy drop during internship.
The authors encourage medical schools to celebrate positive professional traits and focus on providing mentors who “can aid students in overcoming losses in empathy.” Not a simple task.
Consider the process by which physicians are trained: How can students not be dramatically changed by what they experience? They are locked into competitive, cloistered, expensive, and demanding curricula, often far from friends and family. During the initial clinical years, students are expected to witness and rapidly process a steady onslaught of sickness, death, suffering, injustice, loss, uncertainty and pain. Teachers, who are themselves products of the system, may not have the skills or insight to help the students understand what is happening to the patients or to themselves.
Not surprisingly, medical students are aware that the very process into which they have entered is capable of transforming naïve, altruistic, emotionally fragile college students into hardened, egocentric, cold physicians; I suspect that they all too often observe the disturbing results but do not discern the process. As they progress through the system, they declare, “That won’t happen to me!” But, of course, it can. Albert Einstein defined "insanity" as “doing the same thing over and over and expecting different results.” Something has to change.
Medical training is evolving. Work rules are in place and curricula are under constant evaluation. Our school’s Medical Humanities program brings interested students into contact with the works of poets, artists, healers, philosophers, theologians, and writers, attempting to spark new insights and to nurture coping skills. Will we create Empathy in those who possess none? Of course not. But, will we nurture Empathy in those students with the gift and the desire? Since this new cohort of physicians will be the ones caring for my generation as we approach the end of our lives, I, for one, am pinning my hopes on it.
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Ref: Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P, Is There Hardening of the Heart During Medical School? Academic Medicine (March) 2008; 83:244-249.
