A Systematic Review of Educational Interventions and Their Impact on Empathy and Compassion of Undergraduate Medical Students 

Abstract

Background

A compassionate and patient-centred care leads to improved clinical outcomes. Promoting empathy and compassion of medical students is a forerunner of their wellbeing, emotional stability, and a patient-centred care. However, there is slender evidence about best educational interventions that can inculcate empathy and compassion skills. Our objective was to conduct a systematic review of research evaluating the associations between spectrum, effectiveness, frequency of teaching modalities and their outcomes on compassion and empathy to highlight best practices.

Methods

We searched the Web of Science, PubMed, Scopus, and EBSCO Host. Selected studies were required to have used unique educational interventions for promoting empathy and compassion of medical students.

Results

We analysed 24 articles from the initial yield of 2,861. Twenty-two were quantitative studies with a mean of 12.8 on MERSQI. Twelve were randomized controlled trials while 5 measured outcomes with single group pre- and post-tests. There was no association found between duration, frequency and complexity of an educational intervention and its effectiveness. Twenty used multimodality curricula, and of those 18 reported statistically significant positive improvement in empathy, while 3 of 4 single modality were effective. Only three studies looked for long-term effects of educational interventions. Fourteen studies evaluated Kirkpatrick’s level one (self-reported knowledge), 2 level three (behaviour), and 6 level four (patient outcomes). We identified six major educational constructs of teaching empathy and compassion; communication, mindfulness, early clinical exposure, technology-enhanced learning, comics and arts and culture. 

Conclusion

Our review couldn’t identify a standard teaching construct in place and highlighted that different teaching tools carry similar impact in promoting compassion and empathy and a sustainable program rather than a single training activity is essential.

Introduction

The quality of the interaction between physicians and patients influences patient outcomes in clinical settings. A fundamental pillar of healthcare mission is based upon compassionate care that forecasts greater patient trust and satisfaction, superior patient-physician connections, and better patient outcomes.[1] Within healthcare organizations, compassionate care entails diverse responsibilities of healthcare professionals in explaining their roles, establishing rapport, and in spending time on attentively listening to the patients’ concerns.[2] Compassionate healthcare is characterized by reflections of others’ concerns, respect for persons, and contextualized understanding of the patient as a key player of health systems.

The two leading elements of patient centred care include empathy and compassion. Empathy refers to “the ability to understand the feelings of another person”.[3] In the medical field, empathy pertains to a multifaceted strand with moral, cognitive and behavioural enlightenment.[4] When applied with objective reasoning, empathy promotes the impact of medical care and facilitates physician-patient communication.[5] Both empathy and compassion are generally considered to be interchangeable terms. However, empathy (understanding of patient feelings) is necessary to trigger compassion (emotional response including actions to alleviate patient sufferings).[6]

There is a compelling evidence in literature that treating patients without compassion can lead to deleterious outcomes.[7] An absence of compassionate care results in poor quality of care and higher risk of complications through medical errors. Unfortunately, despite an explicit emphasis on the vital role of compassionate patient care, healthcare professionals often miss opportunities to be compassionate, rather they pay attention to biomedical data and management plans. From another perspective, sustaining compassion in medicine is hard as compassion fatigue prevails in approximately 20 to 70 % of healthcare professionals.[8] Educators have argued that a great majority of medical students enter health care with a strong set of espoused ideals for providing high-quality, patient-centred care.[9] Unfortunately, during their training, medical students witness dissonance between the personal and professional conducts of their faculty and clinical teachers, students become more frustrated, less empathic and more distanced from patients.[3]

By and large, the ethos of most health care professional curricula uses typical biomedical models that primarily focus on teaching, training, and practice of clinical medicine with less emphasis on patient’s’ psycho-social well-being. Thus, medical and health sciences students start their educational journey with idealism but tend to end up with being cynical and less compassionate. This has been rightly termed as compassion crisis in healthcare systems.[10] In the absence of integration of biomedical knowledge with understanding of human behaviours will potentially further detach medical and health sciences students and healthcare professionals from the patient’s emotions and contextualized perspectives.[11]

The analysis of existing body of literature underscores a need to inculcate standard teaching modalities within medical curricula that can enrich traits of empathy and compassion in undergraduate medical students. Currently, there is scare evidence of a horizontal or vertical integration of teaching programs of empathy and compassion in undergraduate medical curricula. Furthermore, there is little evidence about the effectiveness and quality of teaching programs for empathy and compassion. We conducted this systematic and integrative review of the literature to summarize and report the published work on educational interventions for empathy and/or compassion curricula in undergraduate medical students. This review also aims to highlight best practices to implement an evidence-based empathy and/or compassion curriculum in undergraduate medical training.

Materials And Methods

In our study, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[12] The PRISMA tool provides an evidence-based minimum set of data for a standard reporting in systematic reviews and meta-analyses.

Literature search strategy

We searched four major electronic databases of Web of Science, PubMed, Scopus and EBSCO Host for the English-language articles, published during 2015-2020. Our search strategy was adapted from a previously published systematic review on education for compassion and empathy.[13] We tweaked this work further to explicitly focus on medical students. The final search was performed on July 22^nd, 2020 and a detailed search strategy is attached as Appendix 1. We looked into three core concepts and their associated Medical Subject Headings (MeSH) terms and keywords: Compassion and empathy, medical students, and educational interventions (Compassion OR Empathy OR Caring AND Medical students AND Education OR Training OR Workshop OR Simulation). A hand search of reference lists of the relevant articles yielded some more studies which were included in the final list of selected articles.

Data collection, eligibility criteria and selection of articles

We included original research studies that i) carried out research on undergraduate medical students; and ii) showed a clear educational intervention for empathy and/or compassion; and iii) measured educational outcomes about compassion and/or empathy. These articles showed educational outcomes after training interventions to improve empathy (the understanding component) and compassion (i.e. the action component). The original studies included controlled trials, randomized controlled trials, pre/post-test and post-test only designs. Review and editorial articles, commentaries, experts’ opinion, short communications, and letter to the editor were excluded from our search. One reviewer (PM) screened all titles and abstracts. Then SSG reviewed titles and abstracts of the selected articles to standardize the search process of this study.

Data extraction and data synthesis

Two researchers (PM and SSG) thoroughly scanned the full text of articles that met inclusion criteria and then using a standard data extraction form charted the required information. The researcher SYG independently reviewed the entire process and filled gaps in data mining, data extraction and synthesis. We considered the following components during data extraction; types and designs of studies, primary objectives of studies, quality of studies, invitees’ study level, response rate, self-reported or objective measurements in each study, and type, duration, frequency, skills taught and modality of educational interventions. We also recorded the outcomes according to the following four levels of the Kirkpatrick’s model [14];

1. Self-reported changes in knowledge, skills and attitude
2. Changes in knowledge
3. Changes in behaviour
4. Patient- reported outcomes

We identified and classified the primary outcomes of the selected studies according to Kirkpatrick’s level. A number of studies assessed multiple competencies such as empathy and compassion and self-compassion, and the highest-level outcome was considered as the primary outcome. While, in the studies where the primary outcomes did not relate to compassion or empathy, we used the highest-level empathy-specific variable as the primary outcome (Box 1 and 2)

Box 1: The checklist used for screening abstracts to determine the eligibility of studies for their full-text analysis.

Box 2: The data mining rubric used in our study to record characteristics of each study (n=24)

Effectivenessof educational interventions

To identify best educational practices for teaching compassion and/or empathy, we determined the effectiveness of interventions in the selected studies, where effective was defined as a statistically significant improvement in primary educational outcomes as measured by p value or effect size, where applicable.

Quality assessment

We used Medical Education Research Study Quality Instrument (MERSQI), a tool designed for evaluation of quantitative educational research studies [15]. The MERSQI checklist has 10 items in 6 domains: study design, sampling, type of data, validity evidence, data analysis, and type of outcomes with a maximum score of 3 in each domain. A study can have a maximum MERSQI score of 18 (highest quality). PM and SSG individually scored each study and in case of score discrepancies, SYG assessed the scoring and discussed and made the final decision.

Quality assurance

All researchers (PM, SSG and SYG) objectively reviewed the workflow of selection of studies. In case of discrepancies, the researchers reached consensus by comparing the studies with inclusion criteria and key words. The discrepancies, inconsistencies and controversies were resolved with consensus until all the concerns were resolved.

Results

Figure 1 outlines the workflow and algorithm of studies selection in this study. Our initial search yielded 2,861 studies. After removing duplicates, we screened 754 titles and abstracts. This led to identification of 244 articles for a detailed full-text review. This helped us to exclude another 227 articles whose content did not meet the inclusion criteria. A hand search of reference lists of remaining articles along with 15 review articles identified 7 additional articles for inclusion. Finally, authors agreed on a list of 24 articles [16-39], that had used 24 unique educational interventions either de novo, validated or adapted from previous publications and explicitly met inclusion criteria of our research. The summarized and comprehensive information about each article is presented in Table 1.

A maximum number of 9/24 (37.5%) articles were published in 2017 (Figure 2), while 11/24 (45.8 %) studies originated from the USA (Figure 3). The sample size varied greatly across the selected studies, ranging from 10 to 299 participants. Our research included a total of 2,657 respondents with a mean of 110. Table 2 outlines the range of study designs that were used in the selected 24 studies. Most studies (21/24; 87.5%) were single-center, 11 (50%) were randomized controlled trials[20, 22, 23, 25, 26, 29, 30, 34, 37, 38], 4 (16.6%) controlled trials.[16, 18, 27, 31] Five (20.8%) studies measured outcomes with single group pre- and post-tests.[24, 28, 32, 33, 35] Our research identified 22/24 studies with their reported quantitative data that allowed us to calculate their MERSQI scores as shown in Table 3. All studies used statistical means to evaluate effectiveness. Collectively all studies have a total MERSQI score of 283 with a mean of 12.8. The study by Adriana Foster et al.[26] secured the highest MERSQI score of 17 from a maximum of 18. Finally, 10/22 (45.5%) studies scored greater or equal to 13 on MERSQI checklist.

Most curricula (20/24, 83.3%) used multiple educational modalities and 90% of studies turned out to be effective in achieving their primary outcomes (Table 4). A variety of teaching modalities were employed; didactics [19, 25, 27, 28, 30, 32, 36, 37, 39], small-group discussions [22-24, 27, 29, 32-34], reflection exercises [17, 22, 24, 32, 36] and simulations.[19, 23, 25, 28, 32, 34, 38] Likewise, virtual hangouts and technology-enhanced interventions [18, 24, 26, 35] were also significantly effective. A great majority of studies were conducted in multiple sessions within one academic year.

Only one study instituted the Balint training groups [23], while four studies [20, 25, 30, 37] used adapted mindfulness based curricular tools (75% effective ratio) developed by Kabat-Zinn.[40] We did not observe any clear association between duration, frequency and complexity of an educational intervention and its effectiveness. For example, 75% (3/4) of single modality curricula were effective while multimodality curricula turned out to be effective in 90% (18/20) of the selected studies. Likewise, 80% (4/5) of single cross-sectional curricula were effective than 75% (3/4) of longitudinal curricula.

According to the four-level outcome-based Kirkpatrick model, 14/24 (58.3%) studies had a primary outcome pitching on level one; self-reported changes in attitudes and behaviour [17, 19-22, 24, 27, 28, 30, 31, 33, 36, 37, 39] as illustrated in Figure 4. Two (4.8%) studies evaluated level three outcome (behaviour), while six (25%) studies evaluated level four (patient outcomes) either by standardized or simulated patients or by a third party observation.[16, 23, 26, 29, 32, 38] Table 5 outlines an inventory of the validated instruments for outcome assessments used in the selected studies. The most commonly used self-assessment outcome tool was the Jefferson’s Scale of Empathy by 15/24 (62.5%) studies [18-20, 22-24, 27-29, 31, 33, 35-38] that recruited 1,973 students. Conversely, 6/24 (25%) studies [20, 22, 25, 30, 35, 37] used a combination of tools to probe the impact of their interventions on behaviours and attitudes of medical students towards empathy and/or compassion and to determine the impact of self-compassion on behaviour change.[25] Only three studies looked for the long-term effects of educational interventions.[19, 28, 37]

Figure 5 illustrates the leading constructs used in education interventions that showed positive impact on empathy and compassion of medical students in our study. A maximum of 10 studies used communication skills [19, 20, 22, 23, 26, 28, 29, 32, 37, 38], followed by mindfulness by 5 studies [20, 25, 30, 37], early clinical exposure by four [16, 17, 21, 31], technology-enhanced learning by virtual patient hangouts, computerized tasks, hot spotting by another four [18, 24, 26, 35], and comics [36], and arts and culture.[27]

Discussion

Our study elucidates major findings of 24 studies that have collected data from 2,657 medical students using educational interventions on empathy and compassion. Overall, there is a positive impact of a range of teaching modalities on understanding and application of empathy and compassion in medical field. The body of evidence from our research has deduced that effective communication skills, mindfulness, early clinical experience, comics, arts and culture, and technology-enhanced learning by virtual patients, hangouts and hot spotting are essential elements for effective teaching of empathy and compassion.

In our study, a substantial body of evidence has stressed on empathetic communication for better patient outcomes.[16, 23, 26, 29, 32, 38] Communication is the foremost determinant of a safe clinical practice and ensures satisfaction of both patients and healthcare providers.[41] The outright benefits of timely and professional communication in the medical field are far ranging; greater patient understanding and compliance, superior clinical outcomes, improved patient safety and alleviation of patient stress.[42] Kelley et al. have argued that verbal communication between a healthcare professional and a patient enacts an empathetic connection to the patient that carries a powerful transformative and healing power.[43] Pity, sympathy, fellow-feeling, comfort, commiseration, assuagement, and reflexive encouragement constitute effective strands of practicing empathy and compassion. Identification of compassionate opportunities, conformation, and appreciation with pursuit provide patient’s empathy and compassion. In the study by Beard et al., the researchers measured patients’ satisfaction about clear communication by medical students comparing the Veterans Affairs Longitudinal Undergraduate (VALUE) program with a control group of patients matched with disease severity.[16] The results were analysed by longitudinal student involvement using VALUE group (patient education, communication, and collaboration) and a control group without the VALUE program. The VALUE students showed significant improvement in care coordination among their patients and physicians. Educators should provide regular and sustainable opportunities to medical students to develop and validate their interpersonal communication skills that can potentially improve empathetic communication. LaSasso et al., have studied the impact of SALTED (Set-up, Ask, Listen, Type, Exceptions, Documentation) technique and role-plays in a case controlled trial on medical students.[29] At the start and end of clerkships, both groups completed the JSE. While faculty and standardized patients examined and graded students’ history-taking and communication skills as well as their empathic behaviours using the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) at the end of clerkships. The mean scores of JSE of both groups increased from pre-test to post-test. This analysis reflects the use of a wide range of tools and techniques (VALUE, SALTED, JSE, JSPPPE) by different studies for incorporating, measuring and enhancing empathy and compassion in medical students. 

In clinical practice, a compassionate care has shown a strong association between improved clinical outcomes, quality of life and well-being.[44] Among health professionals, empathetic and compassionate care helps in mitigating the risk of burnouts.[45] From the neuroscience perspective, a study on the functional magnetic resonance imaging has shown that empathy activates distinct pain centres of the brain; whereas focusing on compassion activates the reward pathways.[46] These findings propound that a synchronous teaching and practice of empathy and compassion enhance patient and clinician well-being. Such outcomes may be accomplished with great success if educators can inculcate structured training programs for empathy and compassion in undergraduate and residency programs. However, there is a compelling evidence of empathy decline during the course of educational and training programs[47] and there is an urgent need for developing evidence-based curricula that can secure a sustained change in attitudes and behaviours[48] Historically, the Balint groups have been used to facilitate physicians and students in promoting and sustaining their empathy skills[7] The study by Céline Buffel du Vaure et al.[23] used the Consultation And Relational Empathy Measure (CARE) scale in a two-site randomized controlled trial on medical students in a weekly Balint group forum for two months. Results of this group were compared with the group of routine education. This study endorsed the impactful efficacy of the Balint groups using CARE to improve the humanistic dimensions of empathetic skills among medical students.

In our research, a great majority of studies have measured self-reported changes in knowledge and skills of participants and only two studies could tap into behavioural changes after an intervention.[25, 35] Sustained training sessions are essential for achieving such paradigm change in behaviours. Although literature has shown some controlled trials on empathy, a precursor for compassion, but there is scarce information on compassion training of medical students or healthcare professionals.[49] One such compassion enhancing training exercise is provided by mindfulness, “a continuous awareness of present moment experience in a calm and non-judgmental manner”.[50] Mindfulness is a multi-factorial construct that contains healthy lifestyle, health education, wellness, empathy, compassion, good quality of life, regular exercise, sleep and hygiene, yoga and guided imagery.[51] Training for enhancement of mindfulness can potentially enhance compassionate care in clinical practice[52], close physician-patient relationship and can help alleviate physician burnout.[53] Mindful meditation, attention to breathing, didactic learning, reflection, mindful walking, journalism, and sitting meditation are some of the most popular mindfulness training exercises that have shown to enhance empathy and compassion in medical students and healthcare workers[25] In the study by van Dijik et al.,[37], the authors incorporated a stress reduction training curriculum based on mindfulness strategies to improve the mental health of medical students during clinical clerkships. This intervention led to an insignificant betterment of mental health of students which was followed up longitudinally over a 20-month period. However, the researchers could not detect a difference in JSE at 12 months in the studied cohort of students. Such findings necessitate the incorporation of a sustained empathy training program, particularly empathetic communication, for undergraduate medical students.

Technology-enhanced learning has gained popularity in several branches of medical education. Likewise, virtual patients (VPs) and standardized patients (StPs) are used as attractive alternatives to real patients with promising results.[24] Unfortunately, research has shown an empathy decline in medical students’, particularly in the third year of medical school.[54] At this stage, medical students enter clinical clerkships that witness their encounters with patients and their relatives. A suitable ramification to sustain empathy and compassion is the use of VPs and StPs that can provide a constant source for medical students’ experiential learning and behavioural development without endangering patient safety. Experiential learning such as patient shadowing or wellness programs can potentially enhance cognitive and behavioural dimensions of empathy. The long-lasting impact of experiential learning is further endorsed by a study conducted by Modi et al., which showed that volunteering students had better empathy than the non-volunteered medial students[31], who showed a decline in empathy over time. The intelligent use of arts, culture and humanities in medical education is an emerging and promising approach that can revitalize the declining empathy in medical students.[36] Comics “the combined use of images and text, sequentially, to tell a story, where the images complement and/or enhance the text”[55] is a powerful means of portraying complexities of medical knowledge. Graphical illustration with juxtaposed texts, depicts stories in a tangible manner which help to amalgamate the pictorial and textual cues highlighting an innovative use of technology enhanced learning and comics. Our research has shown some evidence that comics may serve as a distinct tool to promote empathy in medical education[56]. Finally, interprofessional education and practice carries great potential to promote empathy and compassion by alleviating anxiety, stress and burnout associated with medical education.[57, 58]

Our results highlight educational interventions pitching at improvement of knowledge outcomes can be significantly effective, followed by behaviours and, finally, patient outcomes. This is understandable for some reasons; medical students are attuned to work hard to acquire knowledge which can be easily measured as an educational outcome. Behavioural change in students and improvement in patient outcomes demand a sustained interplay of generic and acquired traits and, therefore, it’s hard to achieve. Another interesting finding of our research springs from the fact that frequency, duration and teaching modalities didn’t have any bearing on the effectiveness of the educational intervention. Even single session interventions were as effective as longitudinal curricula and such curricula did not have a sustained and long-lasting impact. However, experiential learning drills lead to emotional and behavioural remodelling that can result in durable personality developments.

Study Limitations

In our systematic review, the identified 24 studies evaluated empathy and/or compassion curricula for undergraduate medical students. Though we aimed at highlighting best practices in teaching empathy and/or compassion, this turned out to be difficult due to profound heterogeneity in the educational interventions, measurement tools used and the types of accomplished outcomes.

Conclusion

In this study, we have recognized major educational constructs of communication, mindfulness, early clinical exposure, technology-enhanced learning, comics and arts and culture for teaching empathy and compassion. Duration and frequency of a range of educational interventions have no impact on quality and effectiveness. In order to mitigate the risk of decline of empathy and compassion, a sustainable program rather than a single training activity is essential. Our research could not secure a single best-evidence teaching modality for empathy and/or compassion and the current evidence advocates the use of a blend of constructs for teaching empathy and compassion in undergraduate medical students.

Declarations

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are included in this submitted article.

Competing interests

The authors declare that they have no competing interests.

Funding

The publication of this article will be funded by the RCSI-MUB if accepted by the journal.

Authors contributions

SS made a substantial contribution to the conception of the work, created the search strategy, conducted the literature search, hand searched and screened the titles and abstract, extracted the data collected, analysed and interpreted the data, drafted the initial manuscript. Other team members SYG and MSBY critically evaluated the search strategy and revised the manuscript for important intellectual content. All members (SS, SYG and MSBY) approved the final version, and agreed to be accountable for all aspects of the work.

ORCID

Shaista Salman Guraya https://orcid.org/0000-0003-2903-8697

Salman Yousuf Guraya https://orcid.org/0000-0001-5183-023X

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Tables

Table 1: A tabulated summary of the 24 studies in this systematic review

Abbreviations: VALUE : Veterans Affairs Longitudinal Undergraduate Medical Education, HCA: Health Care Assistant, JSE: Jefferson Scale of Empathy, SCS: Self-Compassion Scale, MCSF-C : Marlowe- Crowne Short Form C, TMS: Toronto Mindfulness Scale, B-DES: Brief Differential Emotions Scale, VAS: Visual Analogue Scale, CARE : Consultation And Relational Empathy Measure, BSI: Brief Symptom Inventory, MHC-SF: Mental Health Continuum-Short Form, LiSat-9: Life Satisfaction Questionnaire, FFMQ: Five Facet Mindfulness Questionnaire, IBI: Irrational Beliefs Inventory, MBSR: Mindfulness Based Stress Reduction Training, CAU: Clerkships As Usual, QCAE: Questionnaire of Cognitive and Affective Empathy, OE: External observer, SP: Simulated patients, HAI: Healthcare Associated Infections, CDG: Case Discussion Group, VSG: Video Show Group, EMR: Electronic Medical Records, METT: Micro Expression Training Tool, SETT: Subtle Expression Training Tool, CBCT: Cognitively-Based Compassion Training, CLHS: Compassionate Love for Humanity Scale, R-UCLA: UCLA Loneliness Scale, DASS: Depression Anxiety and Stress Scale, PSS: Pittsburgh Sleep Scale, SUI: Substance Use Inventory, MMP: Mindfulness Meditation Program, AAS: Adapted Altruism Scale, BMI: Beliefs towards Mental Illness Scale, PSCOM-PQ : Penn State College of Medicine Professionalism Questionnaire Student Form, BPTI: Basic Personality Traits Inventory, GRAS: Groningen Reflection Ability Scale, VCR: Virtual Classrooms, LMS: Learning Management system SM: Social Media;

^aA bold outcome indicates that a statistically significant positive effect on the primary outcome was reported.

^bThe MERSQI is scored out of a possible 18, with higher scores indicating higher-quality studies.

Table 2: The range of study designs used in the selected studies about empathy and compassion in medical students (n=24)

Table 3: The quality of the 22 quantitative studies as measured by the Medical Education Research Study Quality Instrument (MERSQI).

NB. Scores on the MERSQI can range from 5 to 18, with a higher score indicating a higher-quality research study.

Table 4: Educational interventions with frequency and duration used in the selected studies (n=24)

^aEffective indicates that a statistically significant positive effect on the primary outcome was reported. ^b Ineffective indicates that the reported effect was not statistically significant or statistical analysis was not reported. 

NB. Individual studies used multiple types of educational interventions; therefore, number of studies are greater than 24 and percentages add to greater than 100.

Table 5: An inventory of the validated instruments for outcome assessments used in the selected studies (n=24)