Exploring student perceptions of empathy development during medical school – A phenomenological study

ObjectiveEmpathy is an essential attribute of a good doctor. There are multiple dimensions to empathy, yet many curricula are limited to empathy display. This study’s aim was to understand the relationship between teaching, learning and development of empathy from the perspective of medical students.MethodsA qualitative approach was used with interpretivist methodology. Ten final year medical students from a single UK University were interviewed. Findings came from inductive thematic analysis.ResultsFive major themes were identified: ‘The Empathic Process’; ‘Self’; ‘Patient’; ‘Teacher/Clinician’; ‘Environment’. Sub-themes included personal qualities, patient factors, role-models and assessment. Students value authentic patient encounters, focused feedback and opportunities for debriefing. Barriers include cognitive load, time-pressures and being observed. Students can maintain empathy through self-checking and addressing biases.ConclusionsStudents are aware of their motivations and barriers towards empathy development and can describe meaningful experiences relating to this during medical school. Students acknowledge controversy surrounding assessment of empathy, but clearly value authentic patient experiences and an environment which is free from scrutiny and distractions.Practice implicationsIn addition to teaching communication skills, undergraduate programmes should focus on students’ inner growth. This may be achieved by guiding students through meaningful reflection and open dialogue with supportive mentors.     

Training in communication and emotion handling skills for students attending medical school: Relationship with empathy,emotional intelligence,and attachment style

ObjectiveTo describe the Emoty-Com training, its impact on medical students’ attitudes towards doctors’ emotions and to explore the association between students’ empathy, emotional intelligence (EI), and attachment style (AS) with post-training performance scores.MethodsThe 16-hour Emoty-Com training was delivered to all second-year medical students of Verona and Milan (Italy) Universities. At pre-training, students filled out three questionnaires assessing empathy, AS and EI and responded to three questions on attitudes towards doctors’ emotions in the doctor-patient encounter. The same three questions and a final evaluation test were proposed at post-training.Results264 students participated in the study. The training reduced students’ worry about managing emotions during doctor-patient relationships. Gender was associated with specific subscales of empathy, EI, and AS. Final performance scores were associated with students’ attitudes towards emotions but not with empathy, EI, and AS.ConclusionThe Emoty-Com training increased students’ self-efficacy in handling their own emotions during consultations. Students' performance scores were related to their attitude towards doctors’ emotions in clinical encounters.Practice ImplicationsThe Emoty-Com training suggests ways to teach and evaluate emotion-handling skills for medical students. Possible links between empathy, EI, AS, and the attitudes towards doctors’ emotions during the years of education are highlighted.     

The relationship between medical students’ empathy and burnout levels by gender and study years

ObjectiveTo investigate the multifaceted factors affecting empathy in medical students.Methods1293 medical students from 15 South Korean medical schools participated in an online survey. Affective empathy was measured with the ‘empathy concern’ and ‘personal distress’ dimensions from the Interpersonal Reactivity Index for Medical Students (IRI-MS). Cognitive empathy was assessed with IRI-MS’ ‘perspective taking’ and Jefferson Scales for Physician Empathy for Student (JSPE-S). Maslach Burnout Inventory for Medical Students (MBI-MS) assessed the burnout levels of the participants.ResultsA significant gender difference in affective and cognitive empathy was found using JSPE-S. Different patterns were seen in the empathy dimensions between the study years and genders. Burnout scores showed no gender differences, while exhaustion and cynicism increased, and academic efficacy decreased with seniority. Academic efficacy was a consistently influential factor for both affective and cognitive empathy in both genders, all study years and the three domains of burnout.ConclusionAcademic efficacy was a significant factor influencing both affective and cognitive empathy.Practical implicationsThe comprehensive nature of empathy in medical students may be better investigated by applying multi-dimensional empathy measurement tools and by analyzing multiple factors such as gender, study year and burnout.     

Shadowing patients: experimentar empatía en estudiantes de Medicina

IntroductionShadowing patients is one of the educational proposals to maintain and experience empathy in medical students. It is about observing, from the sidelines, a patient during a medical visit. The objective of this pilot study is to analyze the perceived and observed patients’ emotions during the experience of shadowing patients, and their relationship with medical empathy.MethodsTwenty-three fifth-year medical students (69.6% women, aged 22.6 ± 1.1 years) participated in the theoretical-practical workshop based on the observation and identification of patients’ emotions in a hospital waiting room. The Jefferson Scale of Physician Empathy (Hojat, 2002) and the Self-Assessment Manikin (Bradley and Lang, 1994) were applied.ResultsMost students experienced sadness (87%), and observed sadness (87%) and impatience (8.7%) in the patients. No statistically significant correlation between medical empathy and valence/arousal of experienced emotions was observed.DiscussionThe workshop of shadowing patient was low cost and easy to implement, stimulated the observation ability to identify the patients’ emotions, helped medical student to be more aware of their empathic skills, and complemented the theoretical training of medical students.     

Empathy,well-being and stressful experiences in the clinical learning environment

ObjectiveThis study examines whether students in the clinical phase show reduced well-being and lower empathy scores compared to preclinical students. Furthermore, it explores students’ most stressful experiences.MethodsA cross-sectional mixed-methods study was conducted among medical students of the revised patient- and student-centred curriculum at Witten/Herdecke University (Germany). An online survey included questions regarding empathy (JSPE-S), well-being (WHO-5), distressing factors in the learning and clinical environments, mistreatment and thoughts of dropping out.Results176 (34 %) of 517 medical students completed the questionnaire, 73 being preclinical and 103 clinical students. Despite lower well-being, clinical student did not demonstrate lower empathy levels. Main stressors during the clinical phase were negative physician role models and financially focussed care rather than challenging patient encounters. Compared to preclinical students, clinical students showed more mistreatment experiences and higher ratings towards thoughts of dropping out.ConclusionOur results illustrate contemporary challenges to establishing a learner-centred clinical environment that nurtures well-being and empathy of medical students. The sustainment of empathy despite more stressful experiences and lower well-being may be due to protective factors.Practice ImplicationsThe paper suggests activities to support clinical students to find ways to adapt the clinical learning environment to students’ needs.     

Tell Me More®: A medical student focused humanistic communication model to enhance student professional identity formation through meaningful patient encounters

IntroductionThe Tell Me More (TMM)® program provides a template for guided interviews to help providers procure an expansive social history from patients and connect with them as people beyond their illness. (TMM)® may provide a dual benefit: it improves the patient’s experience with their healthcare team and the medical students' experience in developing their identity as a physician. Our aim was to characterize the impact of the patient-student conversations in TMM® on the participating medical students through analysis of their written reflections throughout the program.MethodsStudents conducted interviews with hospitalized patients using the TMM® template, Through narrative medicine and individualized posters, patients were able to highlight their unique qualities.ResultsQualitative analyses of 63 journal reflections from 14 students, across 7 hospital settings, identified 6 themes. These included connection, humanism, discovery, impact, privilege, and perspective.ConclusionReflective practice as a learning pedagogy created an opportunity to enhance the medical students’ awareness of empathy and compassion during the TMM® program. Documentation of reflections assured students would process the encounter as a profound learning experience and develop their professional identity formation as a student preparing to become a physician.Practical implicationsTMM® provides an opportunity for medical students to practice and apply their interpersonal and communication skills through authentic patient encounters.     

Attachment styles as predictors of self-reported empathy in medical students during pre-clinical years

ObjectiveTo assess medical students’ attachment profile and to explore its relationship with empathy dimensions.MethodsThree cohorts of medical students were consecutively enrolled in the study at the beginning of their second year, before their clinical internship experience, and assessed using the Attachment Style Questionnaire (a self-report measure of attachment styles) and the Interpersonal Reactivity Index (a self-report measure of empathy). t-test, partial correlations, and multiple linear regression models were used to analyze relationships between attachment styles and gender, age, and empathy dimensions.ResultsA total of 361 out of 450 (80.2%) Italian second-year medical students participated in the study. Female students considered interpersonal relationships more important and showed a higher need for approval than did their male counterparts. Among the attachment styles, considering relationships as secondary to achievement was the most important significant predictor of both emotional and cognitive empathy variables.ConclusionsThis study shows that the attachment styles of medical students are related to self-evaluated empathy, over and above the effects of gender and age differences.Practice implicationsThe Attachment Style Questionnaire may be a useful tool for medical educators to identify medical students with low empathy scores during their pre-clinical years of study.     

Exploring life with a long-term condition using asynchronous online communication

ObjectiveWe describe the development and evaluation of a novel programme that uses an online patient portal system to provide medical students with early and authentic experience of patient interaction.MethodsFocus group discussions were held with students, tutors and patients who had taken part in the first year of the programme.ResultsThe programme provided an opportunity for early patient interaction in a safe environment. Students were able to practice communication skills learnt elsewhere in the course as well as identifying some of the different skills required for asynchronous online interactions. The approach gave opportunities to develop understanding of aspects of life with a long-term condition.ConclusionUsing an online patient portal system to interact with a patient enabled students to develop and apply their communication skills in a safe environment and gain a holistic view of a patient’s experience.Practice implicationsMedical students need to be equipped with the skills needed to communicate electronically with patients. Current medical curricula currently focus on more traditional models of the consultation. Further research is needed to establish best practice in this rapidly growing area.     

The associations between reflective ability and communication skills among medical students

ObjectivesAssess associations between medical students’ reflective ability demonstrated in written narratives, and communication skills demonstrated later in simulated-patient breaking bad news interactions.MethodsWe analyzed 66 medical students’ reflective ability, using ‘REFLECT’ rubric and four newly developed parameters: Noticing Explanations provided to patients, Noticing Emotions, Remoteness/Connectedness in their writing, and mentioning Self-Emotions. ‘BAS’ and ‘SPIKES’ questionnaires measured students’ communication skills. Spearman and Chi-square tests examined correlations among all variables. Multiple regressions examined associations between reflective ability and demographic variables with communication skills.ResultsSignificant positive correlations between students’ reflective ability, measured by REFLECT and three of the new parameters, and global communication skill scores. Reflective ability of Noticing Explanations in writing was associated with ability to tailoring information to patients’ needs and address emotions.ConclusionsHigh reflective ability may improve communication skills. Specifically, ability to notice explanations to patients may enhance later capability to tailor information to patients and address emotions empathically.Practice implicationsEncourage educational interventions enhancing reflective ability; specifically observation and detailed writing about how explanations are given to patients and patients’ reactions to them. This process may help students develop competency to share and tailor difficult information sensitively—a critical skill when communicating bad news.     

Learning communication from erroneous video-based examples: A double-blind randomised controlled trial

ObjectiveAppropriate training strategies are required to equip undergraduate healthcare students to benefit from communication training with simulated patients. This study examines the learning effects of different formats of video-based worked examples on initial communication skills.MethodsFirst-year nursing students (N = 36) were randomly assigned to one of two experimental groups (correct v. erroneous examples) or to the control group (no examples). All the groups were provided an identical introduction to learning materials on breaking bad news; the experimental groups also received a set of video-based worked examples. Each example was accompanied by a self-explanation prompt (considering the example’s correctness) and elaborated feedback (the true explanation).ResultsParticipants presented with erroneous examples broke bad news to a simulated patient significantly more appropriately than students in the control group. Additionally, they tended to outperform participants who had correct examples, while participants presented with correct examples tended to outperform the control group.ConclusionThe worked example effect was successfully adapted for learning in the provider-patient communication domain.Practice ImplicationsImplementing video-based worked examples with self-explanation prompts and feedback can be an effective strategy to prepare students for their training with simulated patients, especially when examples are erroneous.     

Teaching medical students to express empathy by exploring patient emotions and experiences in standardized medical encounters

ObjectivesTo increase medical students’ ability to detect contextual and emotional cues and to respond empathetically to patients.Methodsa training course in communication skills and patient-centered care with different teaching activities (didactic, reflective and interactive: workshops and encounters with simulated patients) was delivered to third-year medical students just before their clerkships. The program was evaluated by an external observer (OE) and simulated patients (SP) in 2 or 3 videotaped encounters.ResultsStudents improved significantly from baseline to 3rd interview in all communicative skills and domains explored both in OE (32.4%) and SP (38.3%) measurement. At the end of the course students detected significantly more clues and made more empathetic expressions.ConclusionsThe course seems to improve the ability of students to explore the illness experience, showing more empathy in a more genuine way. This was carried out in consultations lasting 10 min.Practical implicationsThe program is effective and feasible to be applied as a regular formative activity. Further research is needed to assess whether this training program is applicable to students in more advanced educational levels and if it has any additional outcomes.     

Mindfulness predicts student nurses’ communication self-efficacy: A cross-national comparative study

ObjectivesThe aim of this study was to compare student nurses’ communication self-efficacy, empathy, and mindfulness across two countries, and to analyse the relationship between these qualities.MethodsThe study had a cross-sectional design. Data was collected from final year student nurses in Norway and Sweden. Communication self-efficacy, empathy, and mindfulness were reported by questionnaires; Clear-cut communication with patients, Jefferson Scale of Empathy, and Langer 14 items mindfulness scale.ResultsThe study included 156 student nurses, 94 (60%) were Swedish. The mean communication self-efficacy score was 119 (95% CI 116–122), empathy score 115 (95% CI 113–117) and mindfulness score 79 (95% CI 78–81). A Mann-Whitney test showed that Swedish students scored significantly higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. When adjusted for age, gender, and country in a multiple linear regression, mindfulness was the only independent predictor of communication self-efficacy.ConclusionThe Swedish student nurses in this study scored higher on communication self-efficacy, empathy, and mindfulness than Norwegian students did. Student nurses scoring high on mindfulness rated their communication self-efficacy higher.Practice implicationsA mindful learning approach may improve communication self-efficacy and possibly the effect of communication skills training.     

Relationship between self-reported cognitive and behavioural empathy among medical students

ObjectiveThe aim of this study was to explore the relationship between cognitive and behavioural empathy in medical students.MethodsFourteen 4th year medical students recruited on the basis of their scores on the self-reported Jefferson Scale of Empathy (JSE-S) were divided into two groups: low JSE-S scorers (n = 8) (M = 96.75, SD = 10.3) and high JSE-S scorers (n = 6) (M = 121.3, SD = 2.94). They were discreetly videotaped while taking history with an incognito standardized patient. Students’ behavioural empathy was measured using the Verona Coding System (VR-CoDES-P) and rating of non-verbal behaviour.ResultsPatients expressed the same number of concerns per encounter in both groups but gave more cues to high-scorers (p = 0.029). However, students of both groups demonstrated the same amount of verbal empathy (high: 16% vs low: 15% p = 1.00). High JSE-S scorers’ non-verbal communication tended to be rated slightly higher than low JSE-S-scorers with a higher use of facial expression (p = 0.008).ConclusionThis study did not reveal any differences of students’ verbal empathy to patients’ cues and concerns between low and high JSE_S scorers.Practice implicationsThe VR-CoDES_P is a useful tool to assess medical students and physicians empathic behaviour, allowing to disentangle the different components of empathy.     

Making knowledge clips with patients: What learning mechanisms are triggered in medical students?

ObjectiveTo prepare medical students for a rapidly changing healthcare landscape, where new means of communication emerge, innovative teaching methods are needed. We developed a project-based learning course in which medical students design audiovisual patient information in collaboration with patients and with students in Communication and Information Sciences (CIS). We studied what learning mechanisms are triggered in medical students by elements of a project-based-learning course.MethodsIn this qualitative study, twelve sixth year medical students that participated in the course were individually interviewed. Data were analyzed according to the principles of qualitative template analysis.ResultsWe identified four learning mechanisms: Challenging assumptions about patients’ information needs; Becoming aware of the origin of patients’ information needs; Taking a patient’s perspective; Analyzing language to adapt to patients’ needs. These learning mechanisms were activated by making a knowledge clip, collaborating with patients, and collaborating with CIS students.ConclusionCollaborating with patients helped students to recognize and understand patients’ perspectives. Working on a tangible product in partnership with patients and CIS students, triggered students to apply their understanding in conveying information back to patients.Practice implicationBased on our findings we encourage educators to involve patients as collaborators in authentic assignments for students so they can apply what they learned from taking patients’ perspectives.     

Experiences of empathy training in healthcare: A systematic review of qualitative studies

ObjectiveTo synthesise qualitative studies reporting student, practitioner, or patient experiences of empathy-training in healthcare.MethodsWe included qualitative studies exploring (i) student or practitioner experiences of empathy training, or (ii) patient experiences of being treated by someone who has undergone empathy training. We used the Critical Appraisal Skills Programme (CASP) tool to assess study quality. Thematic synthesis was used to integrate findings from studies and to generate new insights.ResultsOur search yielded 2768 citations, of which 23 (1487 participants) met inclusion criteria. Two clusters of themes were identified from included studies. Firstly, themes related to practitioner/trainee professionalism and wellbeing, where the main finding was that participants experienced benefit from therapeutic empathy training. Secondly, themes related to the understanding and treatment of patients, where the main finding was practitioners’ deeper recognition of the positive impact of empathic care.ConclusionsThis review found that taking part in empathy-focused training can benefit practitioner/student personal growth and professional development, and benefits patient care. This review is limited by the difficulty in defining empathy and heterogeneity amongst included studies.Practice implicationsThese results support a rationale for empathy training and the development of a framework to ensure training is having the desired effect.     

Learning how to break bad news from worked examples: Does the presentation format matter when hints are embedded? Results from randomised and blinded field trials

ObjectivesVideo-based worked examples enable medical students to successfully prepare for breaking-bad-news (BBN) encounters with simulated patients (SPs). This is especially true when examples include hints that signal important content. This paper investigates whether the beneficial effect of hints only applies to video-based worked examples or also text-based examples.MethodsOne-hundred-and-forty-seven fourth-year medical students attending a BBN training participated in either of two equally scaffolded, randomised field trials. Prior to encountering SPs, the students worked through an e-learning module introducing the SPIKES protocol for delivering bad news; it contained the same worked example presented to either of four groups as text or video, with or without additional hints denoting the SPIKES steps being implemented.ResultsOnly a main effect of ‘hints’ was revealed, implying that students in the hints groups delivered the news to an SP significantly more appropriately than those in the without-hints groups.ConclusionsIndependent of their presentation format, worked examples with hints best foster students’ BBN skills learning.Practice implicationsIn addition to video, text-based worked examples can effectively prepare students for BBN simulations if hints are included. This offers an affordable alternative to video examples, as text examples can be generated with less effort.     

Meaningful Patient Care Experiences for Minority Graduate School Students

BackgroundIncreasing numbers of underrepresented in medicine minority (URMM) physicians has garnered increased attention. Pipeline programs aid this effort and are designed to expose learners to the healthcare experience and strengthen academic preparedness. This paper describes the clinical experiences of students who participated in a bridge to medical school Master's Degree pipeline program at a community based medical school.MethodsUsing qualitative methodology, the authors sought to explore the clinical experiences of three cohorts of graduate school pipeline students on a path to medical school. Thirty six master's level students responded to an evaluation of opened-ended questions at the conclusion of their clinical preceptorship. The responses to three open-ended questions were analyzed via the constant comparison analysis method.ResultsThe total number of clinical encounters during the clinical preceptorship over the three-year period was 633, a total of 144 h. The most common diagnoses seen were related to cardiovascular disease and diabetes. Three primary themes were identified regarding students’ experiences in the pipeline program: connecting academic and clinical skills, learning the needs of and how to advocate for underserved patients and the need to increase exposure to underserved patient populations across specialties in medicine.ConclusionsThe clinical preceptorship linked academic knowledge with clinical skills and provided an avenue for learning about health disparities and patient advocacy for underserved patients. It also identified a need for increased exposure to underserved patient populations across medical specialties.     

Development and piloting of a Situational Judgement Test for emotion-handling skills using the Verona Coding Definitions of Emotional Sequences (VR-CoDES)

ObjectiveEmotion-handling skills are key components for interpersonal communication by medical professionals. The Verona Coding Definitions of Emotional Sequences (VR-CoDES) appears useful to develop a Situational Judgment Test (SJT) for assessing emotion-handling skills.MethodsIn phase 1 we used a multi-stage process with expert panels (n_panel1 = 16; n_panel2 = 8; n_panel3 = 20) to develop 12 case vignettes. Each vignette includes (1) video representing a critical incident containing concern(s) and/or cue(s), (2) standardized lead-in-question, (3) five response alternatives. In phase 2 we piloted the SJT to assess validity via an experimental study with medical students (n = 88).ResultsExperts and students rated most of the ‘Reduce space’ responses as inappropriate and preferred ‘Explicit’ responses. Women scored higher than men and there was no decline of empathy according to students’ year of study. There were medium correlations with self-assessment instruments. The students’ acceptance of the SJT was high.ConclusionThe use of VR-CoDES, authentic vignettes, videos and expert panels contributed to the development and validity of the SJT.Practice implicationsDevelopment costs were high but could be made up over time. The agreement on a proper score and the implementation of an adequate feedback structure seem to be useful.