Empathy during Medical Education


There is a significant decline in empathy occurs during the third year of medical school. This decline occurs during a time when the curriculum is shifting toward patient-care activities.

  • There is a significant decline in empathy during third year of medical school, regardless of gender or specialty interest.
  • Every year women scored significantly higher than men.This seems to be regardless of population studied. It also appeared in Italian Physicians and Japanese medical students.
  • Except for scores at baseline, students interested in people-oriented specialties scored significantly higher than students interested in tech-oriented specialties.
  • The magnitude of the decline (effects) was much smaller for women and students interested in people oriented specialties.

Why is empathy important?
Responsiveness to the emotional state of another plays a fundamental role in the patient doctor relationship (PDR) as well as in other human interaction. Sympathy and empathy are not the only responses in the PDR. Other responses can be consolation, kindness, politeness,compassion, and pity.

What is empathy (the long version)?
The most clarifying definition of empathy is based on viewing it as a process. This process of empathy consists of the following stages.

  • The patient expresses feelings by way of verbal and non-verbal communication. Patients are not always aware of these expressions.
  • The doctor also notices these emotions in himself more or less voluntary, more or less conscious. He or she coming aware of these feelings usually comes after the fact (affective empathy).
  • Realizing these feelings as being from the patient is the cognitive empathy. Together with everything the doctor knows about the patient as a patient and as a person, he or she is coming to know the inner feelings of the patient(cognitive empathy).
  • The doctor can now express these feelings for the patient or act on them for the patient(expressed empathy).
  • The patient receives this empathy (received empathy).

What is the difference with sympathy?
Empathy is an effortful process by which we try to comprehend another’s experience, while sympathy would be a direct perceptual awareness of another person’s experience akin to the phenomenon of sympathetic resonance. Sympathy does not necessarily require feeling any kind of congruent emotions on part of the observer, a detached recognition or representation that the other is in need or suffers might be sufficient.

The authors of a recent study in which they followed a cohort of medical students (n=456) with the Jefferson Scale of Physician Empathy at five different times also stress important distinctions between empathy and sympathy:

expressing empathy, as opposed to expressing sympathy, is more objective and accurate,
intellectual rather than emotional, altruistic, requires more effort but conserves energy, has more positive effects on the clinician (such as personal growth and career satisfaction), and leads to better patient health outcomes

Empathy is a cognitive skill with an affective root that can be taught, and that attitudes toward it can be reliably assessed.

The authors also discuss causes of this decline during medical education which to my opinion can sometimes be applied to residents and specialists.

  • Lack of adequate role models.
  • A high volume of materials to learn.
  • Time pressure, sleep loss.
  • Overreliance on computer-based diagnostic and therapeutic technology which limits their vision for the importance of human interactions in patient encounters.
  • To much emphasize on market-driven health care systems and evidence based medicine.

The most important factor to my opinion, as also stated in the accompanying editorial, is the impact of role models. Inappropriate role models such as the use of vulgar humor, unprofessional behavior or keeping a to great professional distance to the patient and their care result in a negative effect on empathy by those who still have to find their way into the medical profession. In the future another danger is awaiting such as the restrictions due to the increasing load of administrative work, many hospital guidelines restricting autonomy. Medicine is not Business.

In another commentary by Howard Spiro he emphasizes the change from listening to a patient towards using the computer for looking at images and lab results. He states

The eye is for accuracy, but the ear is for truth.

I think this especially applies to our somatic colleagues.

Since empathy is partly a cognitive skill and since it can be measured the autors suggest 10 approaches for enhance empathy during medical training.

  • improving interpersonal skills
  • analyzing audio- or video-taped encounters with patients
  • being exposed to role models
  • role-playing (aging game)
  • shadowing a patient (patient navigator)
  • experiencing hospitalization
  • studying literature and the arts
  • improving narrative skills
  • watching theatrical performances
  • engaging in the Balint method of small-group discussion.

Related post on this blog:

Patient Doctor Relationship Series: Empathy

Hojat, M., Vergare, M., Maxwell, K., Brainard, G., Herrine, S., Isenberg, G., Veloski, J., & Gonnella, J. (2009). The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School Academic Medicine, 84 (9), 1182-1191 DOI: 10.1097/ACM.0b013e3181b17e55
Spiro, H. (2009). Commentary: The Practice of Empathy Academic Medicine, 84 (9), 1177-1179 DOI: 10.1097/ACM.0b013e3181b18934
Crandall, S., & Marion, G. (2009). Commentary: Identifying Attitudes Towards Empathy: An Essential Feature of Professionalism Academic Medicine, 84 (9), 1174-1176 DOI: 10.1097/ACM.0b013e3181b17b11