Medical Students' Empathy Plunges in Third Year, Says Study

A study published in a recent issue of Academic Medicine found that medical students' feelings of empathy erode sharply during their third year of medical school -- just as they are shifting from largely didactic learning activities toward hands-on patient-care. And although students who eventually choose family medicine and other primary care specialties start higher on the empathy scale and dip less steeply, they, too, become more cynical, said the study.

According to family medicine education experts, this erosion of empathy is a significant and problematic issue, because physicians' feelings of concern are related to better patient outcomes.

Empathy "is particularly important in primary care and the management of chronic illness," said William Shore, M.D., who is professor of family and community medicine at the University of California, San Francisco, or UCSF, School of Medicine. "When patients feel they have been heard and understood, their adherence to medical management plans is increased. And physician satisfaction is also improved," he told AAFP News Now.

Amy McGaha, M.D., assistant director of the AAFP Division of Medical Education, agreed. "While the technology and basic science components are critical to the practice of medicine, we can't focus on these at the expense of the caring part of the profession."

The Academic Medicine study, which was conducted from 2002-2008 by researchers at Jefferson Medical College, Philadelphia, showed that empathy, as measured by the Jefferson Scale of Physician Empathy, in the study group of 456 students dropped from a mean score of about 115 of a possible 140 on orientation day to about 109 by the end of students' third year.

The study authors described this change in empathy -- the ability to understand another's concerns -- as "substantial and practically important."

When sorted by gender, the data showed that women medical students consistently outscored men on the empathy scale in every year of medical school. But women's empathy did drop during their third year, although to a lesser degree than did men's.

The study also compared data for medical students who eventually pursued residency training in "people-oriented" specialties, such as family medicine, internal medicine and pediatrics, with data for those who pursued training in "technology-oriented" specialties, such as anesthesiology, radiology and surgery.

Medical students who chose people-oriented specialties scored higher on the empathy scale during all years of medical school than those who chose technology-oriented specialties. But both groups' empathy scores continued the pattern of decline by the end of the third year, although the size of the decline from year 0 to year 3 in the technology-oriented group was more than double that seen in the people-oriented group.

The study authors suggested that reasons for the decline include a lack of role models, the volume of materials to learn, time pressures, and patient and environmental factors, such as overly demanding patients and restrictions on caregivers' autonomy.

The study also cited students' overreliance on computer-based diagnostic and therapeutic technology that "limits their vision for the importance of human interactions in patient encounters" and the promotion of physicians' emotional detachment leading to "a benign neglect of the art of patient care."

Empathy among some students (27 percent), however, did not decline, and the study suggested there may be "protective factors that defuse the harmful influences."

In his academic setting, Shore said he, too, has noticed a decline in empathy in the third year of medical school when students start having patient responsibilities. This drop is definitely a problem, he said, particularly in family medicine and other primary care specialties, because empathy has been related to improved patient outcomes and patients' feelings of trust in their physicians.

In fact, one of Shore's colleagues at the university, Laura Hill-Sakurai, M.D., is developing a research study with third-year students to look at similar issues.

"Anecdotally, many patients have shared that they are uncomfortable being treated as a generic entity -- a 30-year-old with asthma or a 40-year-old with diabetes. I often hear patients tell me they want to be understood as the person they are, who has asthma," said Hill-Sakurai, who is associate professor of family and community medicine at the school.

The Academic Medicine study suggested that various approaches to enhance empathy in medical education can be effective, including analyzing students' audio- or videotaped encounters with patients, being exposed to role models, role-playing, shadowing a patient, and studying literature and the arts along with medicine.

Shore said some of these approaches already are in place at the UCSF School of Medicine. Students watch videotapes of themselves with both standardized and actual patients in their third year. In the family medicine clerkships, students' videotapes with actual patients are analyzed. Standardized patients give feedback to students.

"Anecdotally, we have watched students display greater awareness of patient emotions after these feedback sessions," Shore said.

Role models are especially important, he said. Third-year students participating in a special program that provides care to underserved patients receive special mentorship. In a separate program, students receive extra mentorship to help them build relationships with patients, Shore said.

Finally, he said, medical education in the third year can be highly fragmented, with students moving from site to site to experience the many types of care associated with a skyrocketing variety of specialty care opportunities. The fragmentation prevents students from forming deep relationships with patients.

In response, UCSF has promoted programs in the third year that permit students to have more continuity with both patients and teachers, Shore said. In one program, students work with the same patients, teachers and learning site for their entire third year. In another, students do their family medicine rotations in six months instead of six weeks.

"These experiences provide more continuity for students with patients, teachers and clinical sites," Shore said.