Teaching Medical Students Empathy Qualitative Analysis of 1st and 4th Year Perspectives : Teaching Medical Students Empathy Qualitative Analysis of 1 st and 4 th Year Perspectives Funded by a grant from the College of Medicine Chapman Education Center Patrick Lynn, MS4, Susan Horky , LCSW Melanie Hagen, MD FACP University of Florida College of Medicine Focus Groups: Focus Groups 10 first year medical students 7 males 3 females 7 fourth year medical students 5 males 2 females Five primary questions: Five primary questions What is empathy? What are the benefits of empathy? What are the disadvantages of empathy? What helps develop empathy in medical school? What hinders the development of empathy in medical school? Coding: Coding First year group 53 female comments 46 male comments Second year group 32 female comments 57 male comments What is empathy?: What is empathy? Most frequent definitions, by gender What is empathy?: What is empathy? Students struggled with whether having had the same experience was necessary for empathy Individual observations: You must help the patient help you understand him/her Empathy means different things to different patients – must tailor one’s approach Benefits of empathy: Benefits of empathy Benefits of empathy by medical school year Disadvantages of empathy: Disadvantages of empathy Themes by coding frequency Risk of being fake Loss of clinical judgment Emotionally draining, painful Balance is important Becoming immune, distancing Skill is more important than empathy Some patients dislike show of empathy May favor Some patients Disadvantages of empathy: Disadvantages of empathy Students sometimes conflated empathy with being emotional Gradually each group concluded that empathy is responding in the way that will be most helpful to patients Disadvantages : Disadvantages Students appeared to believe that empathy was a positive value, but volunteered more disadvantages (35 references) than advantages (25). What helps develop empathy: What helps develop empathy What helps vs. what hinders empathy development: What helps vs. what hinders empathy development There was general consensus that hearing from patients about their experiences is valuable Students placed significant emphasis on the learning environment – faculty attitudes can either help or hinder development of empathy Students held differing opinions on the value of reading about patients and reflective writing Learning from patients: Learning from patients “We had this sickle cell patient, I mean you can read about it all you want, but, I never knew how it was portrayed, how a patient lived it .” “And I think that's where genetics did a really great job in the case presentations because you learned about some obscure receptor mutation but then you brought in this person who has it and how huge it has been in their life. And I think that's a great way to do that . I learned way more hearing a person talk about the disease than just actually reading it .” Learning from patients: Learning from patients “I think, one, when you start to become more responsible for [patient care], then you realize that decisions that are being made, that no one else is going to step in and make the right decisions. You start to be the person that all the family comes to and asks questions. You start to be the one that's feeling it ...When you start to be the one who people are asking to or coming to with questions, where people are breaking down to, that's when you have no choice but to feel empathy or just completely disconnect .” Learning from patients: Learning from patients “It (empathy) just comes with interacting with people over and over again .” “Maybe it doesn't happen the first patient you see, but the more you see patients and the more you get a full history and social history and talking about what is going on with them, the more you'll learn. And you'll learn more from hearing that from multiple patients than you'll learn from a few classes. What about instead of taking those classes that person volunteered at a hospital and talked to patients every day ?” Role Modeling: Role Modeling “The physician-leaders that we had in our small group were very well-picked. I think that was some great teaching for us, to see and to hear them discuss how they treated patients and why. So, the more good role models that can be hand picked and then shown to us, the better .” Role modeling-with patients: Role modeling-with patients “I think that [empathy] is one of the things that you don't teach like a course, but it's more of something you do by example.” “You learn it from watching your attendings and residents do it when you're on the wards during third and fourth year. And both are important .” The other thing is..I think models and role models are very important and can teach you something” Role modeling-supportive faculty: Role modeling-supportive faculty “If the professor just shows that they care about students, you know, and you're like ‘Oh , that's what people are supposed to do .’” “But I do think you can foster an environment, just watching people interact with other people. Some of our mentors are role models, some don't .” Role modeling-supportive faculty : Role modeling-supportive faculty “Dr . R. is a really good example of this. Someone who has absolute respect for his students that's very clear to everyone who takes the course. I got that sense from him that he respected us as individuals and that he cared about us as whole people not just as medical students there to recite the knowledge that he was feeding to us. And so I agree there are ways it can be modeled and emphasized, not necessarily made explicit, but certainly in any implicit or unwritten curriculum .” What works against empathy: What works against empathy Biomedical focus works against empathy: Biomedical focus works against empathy “My wife pointed it out to me, actually, that since we've been in medical school and have met people outside of school that have health issues, I immediately have been asking questions that are not related to their lives at all. But, like, "Hi, your kid had his shoulder broken when he was delivered, can I feel it? Is it broke? Does it hurt when I do this?" [group laughter] She just looks at me like I'm an alien, you know, “What are you doing? That kid has a broken arm, jerk, it hurts !" So, definitely, whether it's just a random curiosity or stage that we are going through as students, I don't know, or maybe just me, but in the end it's kind of concerning. It used to be when someone said “ Ihad a stroke," it was like, “Wow , how hard this must be," and now instead it's like “Which hemisphere? What deficits do you have? Can you feel the contralateral face?" It's like, those kinds of things are kind of goofy, but that's how you start to think.” Biomedical focus works against empathy: Biomedical focus works against empathy “And I think that unfortunately we get all of the cold, calculated facts in school without any oversight to say “Whoa, stop, step back for a second and realize we're talking about a disease that, like diabetes, that's an epidemic in our country, that every person that has diabetes is suffering." No one really says that to you. It's just kind of assumed that because you're a human being you're going to remember that.” Students have empathy for non-empathic attendings: Students have empathy for non-empathic attendings “But you can tell that they want them, you can tell that the empathy's there, but they're making jokes (about patient) almost , to try to compensate .” “Sort of like a protective mechanism” “Yah , it's almost like a thousand yard stare of soldiers that have seen too much and, it's just a compensatory mechanism .” “They want to empathize, they want to try to put themselves in their shoes and all that kind of stuff, but it's hard to do it when they've seen every diabetic patient that they've ever known still come with high blood sugars, high hemoglobin a1c's, whatever. And it's just difficult to have to go through it again .” Unempathic faculty work against empathy: Unempathic faculty work against empathy “For example, in the first two years, there are plenty of ways professors and faculty can show empathy, and sometimes they choose not to. I also feel like I've had attendings who are wonderful with patients, excellent role models, but they didn't have an interest in any minute of day in getting to know me or a resident, or teach us…” “I think the modeling is important, I think in every interaction you can show empathy, it doesn't necessarily have to be [patient care[... I felt like in the first two years you would have instructors …there are some you don't feel like you can approach, but those classes are very important. To a student it says "well, it doesn't matter" because today this is the most important thing I need to learn, and it has nothing to do with being a nice person .” Biomedical focus works against empathy: Biomedical focus works against empathy “Because when you're sitting in grand rounds and you have an anatomy test in 3 days and you're like "I haven't even looked at the leg, I gotta go do this right now." And you're sitting there going "I sort of remember this," and then they're like “Well thank the patient for coming," and you're going to clap. And you're like, it's difficult, again, it's the time constraint, it's not that we don't care, it's that we have so much to learn and so little time to do it .” Biomedical focus works against empathy: Biomedical focus works against empathy “I mean, just talking about preceptorship , things like that that our physicians have really small time constraints, and trying to learn from them is very difficult, and then on top of that we're learning a lot of material, so for us to get all of this hard science per se and balancing that with EPC, which, the sciences this last year far outweigh EPC and empathetic learning, so a lot of times that would be the thing we would put to the wayside the day before the exam as we were learning all the exams. So, I think that time was probably the biggest constraint. And having that balance between sciences and empathetic learning” Biomedical focus works against empathy: Biomedical focus works against empathy “When you discuss a disease, you never discuss a patient when you're learning about a disease, you discuss a disease, a process, an infection, or a genetic mutation. You never talk about a group of people, and it's not like we can't talk about that stuff, it's just that we choose not to, or those that are instructing us choose to take the tact that their teachers took: which is "I'm going to teach you about a disease process." It's not just in medicine, it's in research. In biomedical research, you almost would never walk into a lab meeting of a lab studying some sort of cancer and see them talking about how people deal with cancer. They're going to be talking about only a receptor that's mutated, no mention about cancer. I wonder if that's not a bigger detriment than we think it is. Because if you just pretend like people know about or care about that stuff, and then just address the things that you think they don't know, then eventually those innate parts of us that care about a disease and a person, they're going to start to die away because you don't ever feed it, you don't ever address it, you don't ever tend to it. All you ever think about when you think about leukemia is a receptor, you don't think about the patient .” Empathy not role-modeled: Empathy not role-modeled “I think I've heard them discuss [empathy] more than I've actually observed it. [Group agrees] Like, iI know with my preceptor, a lot of his patients really loved him, but whenever he would go in a room off to a side in his office and talk about the patient we just saw, it was then where I really saw his empathy, but when he was actually with the patient it was more like "ok, here's what we need to do." “I had the exact opposite. Like, whenever she (attending) was with a patient she was wonderful, kind, she could treat children just as well as she could treat a 90 year old woman, and we would walk out and she would make these little snarky comments about the patient, like "I've seen that patient for 30 years and she hasn't changed a thing about her life .” Can empathy be taught?: Can empathy be taught? Group grappled with this-not entirely sure Most felt that one has to have some innate ability to empathize- that this should be screened for in medical school admissions Most felt that there were some colleagues who would not be able to learn empathy Can empathy be taught?: Can empathy be taught? All felt there must be room for physician’s personal style (not fake, mimicking) Most felt that simulated patients did not help develop empathy Its hard to empathize with someone you know is acting Students were still focused on learning HPI Many felt that learning about particular problems via reading or simulated patients helped them “know what to say” when the real situation arose Can empathy be taught?: Can empathy be taught? Some felt empathy develops naturally from working with patients, taking cues from patients Many felt that self-reflection and integrating experiences help, but that they rarely have time for this Role modeling was seen as very important Can empathy be taught?: Can empathy be taught? “I think that this is one of the things that you don't teach like a course, but it's more of something you do by example. And if somebody doesn't pick it up, well, am I responsible for that? But this is one of the things that you learn by example .” Understanding the empathy trajectory: Understanding the empathy trajectory “I was going to say that from interacting with my classmates this year that everyone has come into their own and seems to have much more deeper and more meaningful empathy for other individuals. I do think, I know that articles say there is a decrease in empathy particularly in the 3rd year, but I wonder how much of the empathy people report in the first 2 years is kind of theoretical, it's "I think that I have empathy for other people" and when I'm all rested and well-fed, and feel good about myself I have empathy for other people, but then in the trenches that doesn't always pan out the way people expect .” Understanding the empathy trajectory: Understanding the empathy trajectory I agree that it starts low, what happens is your actual empathy stays the same in 3rd year, but you're like “Oh man, this is what empathy is? this is awful, this is so much harder to have than I thought."