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Why teaching empathy is important for the medical degree
¿Por qué es importante la enseñanza de la empatía en el Grado de Medicina?
Unidad de Educación Médica, Facultad de Medicina, Universidad de Navarra, Pamplona, Spain
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Díez-Goñi, M.C. Rodríguez-Díez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "N." "apellidos" => "Díez-Goñi" "email" => array:1 [ 0 => "ndiez@unav.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.C." "apellidos" => "Rodríguez-Díez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Educación Médica, Facultad de Medicina, Universidad de Navarra, Pamplona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Por qué es importante la enseñanza de la empatía en el Grado de Medicina?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Empathy is considered a basic skill when learning medicine, because it is a fundamental quality in the physician–patient relationship.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">1</span></a> Several authors and scientific societies have commented on its importance. Cowley holds that medical schools need students who are better able to understand their patients and can therefore apply the most appropriate treatment.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">2</span></a> The General Medical Council includes numerous references to empathy and describes it as a quality that leads to a good physician.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">3</span></a> The Association of American Medical Colleges states that physicians should be compassionate and comprehensive in caring for their patients and that the teaching of empathy should be an essential objective in undergraduate education.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">4</span></a> Chapter 3 of the Medical Deontology Code of the Spanish Medical School Organization states that (1) physicians should be careful of their attitude, language, methods, image and, in general, their behavior in order to promote full patient trust and that (2) medical care requires a full relationship of understanding and trust between physician and patient.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">5</span></a> In short, experts highlight the value of empathy, and medical schools should therefore strive to teach it to students.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Empathy is difficult to define and measure and requires clear conceptualization, both in the context of medical education and in patient care. Empathy has classically been divided into two components: cognitive and affective. A number of researchers have only (or predominantly) considered the cognitive component,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">6</span></a> which involves the ability to understand the patient's experiences and perspective and to communicate this understanding<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">7</span></a> while “remaining distant”, without involving a personal emotional response. According to Platt, to be empathic requires a process that is developed in various phases (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>),<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">8</span></a> which makes it possible to teach and to be learned.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">9</span></a> However, other authors have emphasized the affective or emotional component of empathy, which is manifested by feeling and sharing the pain and suffering of others as a passive response to their emotions.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">7,9</span></a> Finally, there is a third group with an inclusive vision, which considers that empathy includes both the emotional and cognitive dimensions.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The benefits of empathy are that it increases patient satisfaction,<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">11</span></a> with improved clinical results due to better physician–patient communication and relationships. With patients more able to express their symptoms and concerns, a better case history and diagnostic accuracy can be obtained,<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">12</span></a> and adherence to the treatment and recommendations is also improved.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">13</span></a> This contributes to fewer medical errors and malpractice suits.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">14</span></a> Costs are also reduced because improved communication decreases the number of diagnostic tests performed.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">15</span></a> Moreover, empathy appears to positively influence the physicians themselves, which is related to professional satisfaction, lower stress and less burn-out, as well as higher assessments of their clinical competence.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">16</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What is the current state of affairs concerning the empathy of medical students?</span><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the evidence showing the benefits mentioned above, the teaching of empathy is still poorly reflected in teaching programs. In general, students who enroll in medical schools are idealistic and are excited to become physicians. However, there are several factors that change this attitude<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">17</span></a> and that have been the object of study. In the United States, there has been a recent and significant reduction in empathy during medical and specialization studies, for which there is growing concern among medical professors.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">18,19</span></a> However, this reduction is not so apparent in the European studies.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A number of studies have correlated the reduction in empathy among students to exposure to patients and the clinical setting, a reduction that is more pronounced during the final years.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">22</span></a> The reasons for this reduction include the following: (1) excessive academic workload, which increases anxiety among students and decreases their empathy. More than 80% of students have some manifestation of anxiety, and more than 50% have more than 3 manifestations, including burnout, low-quality of life, depression, insomnia and stress<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">23</span></a>; (2) the lack of relevance of empathy in the student's curriculum (“hidden curriculum”). Students have emphasized that the acquisition of theoretical expertise and skills on humanistic knowledge are prioritized (conveyed in the informal and hidden curriculum). Although empathy is stressed as important, it is not prioritized, and the time restrictions force students to leave it aside<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">24</span></a>; (3) performing rotations with practitioners who have a large patient load<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">25</span></a>; and (4) the student's perceived need to distance themselves from patients and their loss of idealism. Some students struggle to reconcile reasoning with emotions and see the latter as a threat to the former, rather than applying a more comprehensive vision. However, there are philosophical arguments and empiric tests that indicate that emotions, to an appropriate degree, can be an important source of information and a starting point for self-reflection, which could help physicians identify important aspects in the consultation.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">26</span></a> Students often want to control and repress these emotions (regarding death, suffering, medical error, etc.) because they do not know how to handle them. This greater emotional distance decreases empathy.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">27</span></a> Gender and age can also affect empathy,<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">28,29</span></a> as shown by studies that have observed that women are more receptive to emotional signals, which can lead to better understanding and, therefore, to a better empathic relationship (both cognitive and emotional).<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">16</span></a> Other studies have shown a correlation between right hemisphere activation and empathy in women, as well as an increase in this difference with men as their age increases.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">30</span></a> Hegazi and Wilson stated that empathy (both cognitive and affective) does not change in male medical students, while affective empathy increased in female students.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">12</span></a> It is unclear whether this is a result of the medical education process or simply a natural development with age.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">How can we measure empathy?</span><p id="par0030" class="elsevierStylePara elsevierViewall">There are various instruments for measuring empathy in the general population through self-assessment. These instruments include the interpersonal reactivity index, the empathy scale, the emotional empathy scale and the balanced emotional empathy scale.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">6</span></a> Hojat et al. developed a scale that assessed mainly medical empathy, taking into account the cognitive component: Jefferson Scale of Physician Empathy (JSE).<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">31</span></a> After the validity and reliability studies, the scale was improved<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">6,7,16</span></a> and validated in various countries,<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">32–34</span></a> including Spain.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">35</span></a> The questionnaire specifically for medical students (JSE-S) consists of 20 questions, each of which is assessed on a Likert scale of 7 points (1<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>strongly disagree, 7<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>strongly agree). The final score is calculated by adding up each question, in such a way that a higher score corresponds to greater student-perceived empathy. One advantage of the questionnaire is the balance between questions written positively and negatively, which decreases confusion (e.g., the tendency to always agree or disagree with the listed questions).<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">36</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient's perception of the physician's or student's empathy can also be assessed with the Jefferson Scale of Patient's Perceptions of Physician Empathy (JSPPPE), which consists of five questions, each of which is assessed on a Likert scale of 7 points (1<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>strongly disagree, 7<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>strongly agree). The higher the score, the better the patient's perception of the physician's empathy. This scale has been employed in studies with physicians in training. A correlation has been observed with patient satisfaction, interpersonal confidence and compliance with medical advice.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">37</span></a> The scale has been used with medical students during the Structured Objective Clinical Evaluation (<span class="elsevierStyleItalic">Evaluación Clínica Objetiva Estructurada</span>) tests with standardized patients.<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">How can empathy among medical students be maintained or increased?</span><p id="par0040" class="elsevierStylePara elsevierViewall">A number of intervention studies have shown a quantitative increase in empathy among medical students after the intervention with workshops on communication skills, interpersonal skills, literature and medicine, spirituality, wellbeing and role playing.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">39</span></a> A recent meta-analysis observed that simulation can be an appropriate method for teaching empathy.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">40</span></a> In the United States, 94% of medical schools include standardized patient participation, both in teaching and in the assessment of empathy.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">41</span></a> In Spain, this participation is being implemented in a number of schools.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We therefore believe that teaching empathy is one of the main commitments to consider in the curricular programs of medical schools, and it is important that we know how to communicate it to students. It seems appropriate to implement workshops in small groups that specifically work on this quality (e.g., through simulations with standardized patients, films or cases).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Furthermore, the training of physicians who accompany students during their rotations is essential. It is fundamental that physicians recognize the current situation and attend workshops to remember the aspects of empathy (through simulation) and assess their empathy through standardized patients in various situations through questionnaires (JSPPPE). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists proposals that can help us put these ideas into practice.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">17</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres875314" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec863509" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres875315" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec863510" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "What is the current state of affairs concerning the empathy of medical students?" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "How can we measure empathy?" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "How can empathy among medical students be maintained or increased?" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-08" "fechaAceptado" => "2017-01-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec863509" "palabras" => array:3 [ 0 => "Empathy" 1 => "Medical students" 2 => "Jefferson scale" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec863510" "palabras" => array:3 [ 0 => "Empatía" 1 => "Estudiantes de Medicina" 2 => "Escala de Jefferson" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Empathy is a basic skill in the exercise of medicine and increases patient and physician satisfaction and improves clinical results.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">However, the teaching of empathy is poorly covered in the teaching plans. A number of studies have observed a reduction in empathy during the final training courses. The reasons for this decline include, the students’ excessive academic workload, the prioritization of acquiring medical expertise over humanistic knowledge, the patient load in hospitals and health centers and the physicians’ need to distance themselves from their patients. Nevertheless, intervention studies through simulation with standardized patients have shown an increase in empathy in students, which can be evaluated through the Jefferson scales: JSE-S and JSPPPE.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The teaching of empathy to medical students is an important commitment in the curricular programs of medical schools.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La empatía es una competencia básica en el ejercicio de la Medicina, ya que aumenta la satisfacción del paciente y el médico, y mejora los resultados clínicos.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Sin embargo, su enseñanza es poco relevante en los planes docentes. Algunos estudios observan una disminución de la empatía durante los últimos cursos de formación. Entre los motivos destacan: la sobrecarga de trabajo académico de los alumnos, la priorización en la adquisición de conocimientos médicos sobre los humanísticos, la presión asistencial en los hospitales y centros de salud, y la necesidad de distanciarse del paciente. No obstante, estudios de intervención mediante simulación con pacientes estandarizados demuestran un aumento de la empatía en los estudiantes que puede ser evaluada mediante las escalas de Jefferson: JSE-S y JSPPPE.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La enseñanza de la empatía a los estudiantes de Medicina es una apuesta importante en los programas curriculares de las facultades de Medicina.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Díez-Goñi N, Rodríguez-Díez M. ¿Por qué es importante la enseñanza de la empatía en el Grado de Medicina? Rev Clin Esp. 2017;217:332–335.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Taken from Platt.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">1</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Recognize intense emotions in the patient. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Imagine how the patient feels. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Let the patient know we understand their emotion. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Legitimize the patient's emotions. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Show respect for the patient's efforts to address their situation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Offer help and support. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1477432.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Phases for effective empathy.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: modified from Schwartzstein.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">17</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Implement curricular changes that support the student's idealism and kindness. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Detect physicians among the trainees who favor this competency. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Refine the acquisition of this skill in the assessment systems, ensuring that the students who progress can achieve this skill. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Support financial and logistical systems that allow physicians to spend more time with patients. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1477431.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Recommendations for improving empathy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:41 [ 0 => array:3 [ "identificador" => "bib0210" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Empathy: can it be taught?" 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