A recent study Rosenthal, et al (1) in the journal Academic Medicine, studied the Jefferson Empathy Scale in medical students at the Robert Wood Johnson Medical School . This study was born out of a committee that included medical students, residents, and faculty. Their purpose was to design a curricular intervention that could be done in the third year of medical school that would help to preserve empathy throughout the year.
The purpose of the study was "to evaluate JSPE-MS scores of two consecutive medical school classes in order to assess the impact of an empathy-preserving curricular innovation". At RWJ Med school they believed that there is a decrease in empathy across the third year of medical school. Anecdotally, I think that most medical educators know this to be true.
Wiggleton and colleagues (2) found moral distress, burnout, and depression in third year students. In this study, the authors described 50 potentially distressing situations which medical students might encounter in clinical rotations. Situations included: a patient had very advanced disease because they faced barriers to accessing care; a member of the team was disrespectful to someone below them in team ranking; optimal care was not provided as a result of alcoholism, drug use or homelessness; and our team provided care that only prolonged a patient's suffering. Over half of these situations had been experienced at least once. 35% of the situations caused mild to moderate distress.
Diseker and Michielutte (3) found that empathy decreased before and after clinical experiences in the third year. The author's administered the Hogan empathy scale to all medical students. They found the empathy scale to be negatively correlated to MCAT scores. (see my previous blog about the MCAT). And they found that there was a significant decline in the empathy score from the beginning of medical school to the end.
Hojat and colleagues (4) found empathy significantly declined across the third year of medical school. They found that empathy did not really change that much in the first and second year, but the decline during the third year persisted until graduation. Interestingly, 27% of the students did not have any decline in empathy.
So, in this study the authors designed a curricular intervention that was given in the clinical year. Their intervention was six interactive sessions that were given during each of the required third-year clerkships. The sessions were one hour long and included time for debriefing on intense experiences, reflective essays/blogs, and discussions of role models, patient care, morally distressing events, and the students' reactions.
This intervention seems fairly simple and similar to a longitudinal experience that our school has in the third year of medical school. The authors were able to document a lack of change in empathy across the third year. There was no statistically significant change in pretest/posttest empathy scores (pre = 115.4, post = 113.9, p =.135). One interesting fact was that student who entered family medicine, internal medicine and pediatrics had significantly higher empathy scores than those entering other specialties such as surgery, urology, otolaryngology, and anesthesiology.
Hopefully, there will be more interventions designed to help our students during the third year. It is hard. They are vulnerable and are often treated like crap. Dr. Steven Kanter (5) in his opening editorial in the March issue of Academic Medicine, reminds us that we need to think with our head as well as our heart to provide the best patient care. If we damage our students they will no longer have the ability to think with their heart, to care for their patients. OK, I will get off the soap box for a while.
(1) Rosenthal S, et al Humanism at Heart: Preserving Empathy in Third-Year Medical Students. Acad Med 2011;86(3):350-358.
(2) Wiggleton C, et al. Medical students' experiences of moral distress. Acad Med 2010; 85:111-117.
(3) Diseker RA, Michielutte R. An analysis of empathy in medical students before and following clinical experiences. J Med Educ. 1981;56:1004–1010.
(4) Hojat M, et al. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182–1191.
(5) Kanter S. Think With Your Head and With Your Heart. Acad Med 2011;86(3):273.