Empathy in the clinical context is referred to as 'clinical empathy,' the term which expands beyond merely 'being in someone's shoes' or 'acknowledging feelings of others' and have cognitive, emotive, behavioral, and moral domains14,15. The cognitive attribute of empathy in contrast to sympathy (intense emotions) makes it a skill that can be learned, taught, and assessed16. In a six-year longitudinal study of medical students in Japan, the targeted medical education program with the emphasis on communication skills training for empathy development has been proven to improve the quality of patient care significantly17. Engaging medical students in focused communication skills training has enhanced empathy in several other research studies18. Medical professionalism will be fragmentary without empathy training.
Empathy in medical students represents the future of doctor-patient relationships and compassionate care during residency training & clinical practice19. The curricular activity of the art of expressing clinical empathy towards the patients has been undervalued in medical education20. The primary emphasis of clerkship training used to be only on developing clinical thinking by achieving expertise in history taking and physical examination. Unfortunately, empathetic communication and rapport building are perceived as less important skills to learn than the medical students' clinical skills as they progress to the higher level of clinical training during medical school 21.
American Board of internal medicine (A.B.I.M.) has recommended the training of empathy and humanistic qualities as an integral part of graduate medical education during the first and second year of medical school 22. Most of the students swore by the Hippocratic Oath as they enter this noble profession of medicine with the goal to serve and ease human sufferings. In an empiric study conducted at the Jefferson medical school, Hojat et al. have reported that empathy among the medical students gradually declined as they proceeded to a higher level of medical education during medical school 23. Results of the systemic review of 11 studies by Neumann et al.; to evaluate empathy in medical students has also demonstrated a significant decrease in empathy during medical school in 3 longitudinal and six cross-sectional studies24. Ironically, the need of empathy from physicians in training is crucial at the point of bed-to-bench transition during the third year when they interact with patients and their families. Redesigning the curriculum to change the focus of this training from the first two years to the last two years of training has been focused on the recent years.Also, understanding the underlying causes of the decline in medical student's empathy and addressing these issues is a crucial part of medical education. There is limited insight available regarding the factors responsible for this conflicting behavioral change during the transition from pre-clinical years to clinical clerkships. As reported in the literature, distress in the form of burnout due to study and work overload, depression, low self-esteem, etc., is considered as a major cause of the empathy decline in medical students25,26,27,28. Other reasons for lack of empathy in medical professionals include biographical experiences, personality traits, lack of role-models, improper learning environment, ill-treatment by superiors, & social support, etc29, 30,31,32,33. A survey was done to understand the medical student's perception of factors affecting empathy during medical education. The results showed that professional growth-promoting clinical experiences and mentoring were the top most important medical students' factors rated by the medical students34.
Medical students can thrive and learn to achieve clinical expertise but creating a strong & trustworthy doctor-patient relationship is an art every medical student must learn. As with the clinical skills, the 'use it or lose it' principle is also applicable to the medical professionalism attributes such as empathy. Medical students can be trained via lectures, simulations, discussions of video clips, reviews of their clinical encounters, experiential learning, focused empathy training, role-playing, creative arts, poetry writing, literature reviews, and dramas23. Some of the approaches tried by medical educators to reinforce and maintain the practice of empathy among undergraduate medical students have been found to significantly effective35. Training and evaluating the medical students in providing holistic, patient-centered care during clerkships assures that what learned in the classrooms will be translated into compassionate bedside care. In addition to succeeding in providing patient-centered care, physicians can also reap the benefits of practicing empathetic skills. Studies have shown a significant reduction in burnout, increased professional satisfaction, and well-being among those who express empathy in their practice35, 36, 37.
With globalization in the modern era, physicians and patients from diverse ethnocultural backgrounds encounter with each other more frequently. Approximately 24% of residents and 26% of physicians from various specialties practicing in the United States are I.M.G.s38. International medical graduates face several communication barriers as they switch between different cultural environments. In a qualitative analysis of communication barriers perceived by I.M.G.s, Dorgan et al. have reported two broad categories -education-related barriers and Interpersonal barriers39. Educational barriers include science-focused training without emphasizing the physician-patient communication and lack of formal communication training, and interpersonally related barriers entail unfamiliar dialects, new power dynamics, and different rapport-building expectations39. Forming a substantial part of the U.S. physicians' workforce, I.M.G.s training concerning empathy should be equally emphasized while adopting empathy enhancing interventions in the graduate medical education (G.M.E.) curriculum to optimize patient-centered care.
Several complex neurological conditions affect the quality of life of patients. Patients and their families rely on physicians to exchange information, decision-making, and emotional support during these tough periods of their lives. Breaking bad news such as diagnosing fatal diseases such as Amyotrophic Lateral Sclerosis, educating patients about their addiction to opioids, declaring the diagnosis of non-epileptic seizures, and disclosing the medical errors, affect patients and families psychosocially. These challenging issues can significantly influence the doctor-patient relationship in either way. However, accepting these challenges as the opportunities to express empathy can strengthen the doctor-patient relationships while providing patient-centered care. Learning and practicing how & when to provide empathetic care by communicating effectively, the medical students can deal comfortably with the real-life complex clinical scenarios in daily practice. With this philosophy, we designed the ENC-OSCEs specifically for complex neurological conditions.
The O.S.C.E.s are used for both formative and summative evaluation of the students. The feedback from the O.S.C.E.s (including feedback from standardized patients) will be a part of the medical school performance evaluation (M.S.P.E.). Our pilot study is a primer to show the impact of educational intervention during the neurology clerkship on S.P.s' perception of physician's empathy and the need of focused intervention strategies for I.M.G.s as they enter into neurology residency training in our institute.
We found that both M4 and M3s performed better than international graduates in terms of empathy scores as perceived by standardized patients. Student feedback on the ENC OSCE was highly positive, ranging from 'humbling experience' to 'highlight of clerkship.' Randomly chosen videos of different O.S.C.E. encounters were reviewed with patients and their families who have repeatedly validated its authenticity and its reflection of a real-life encounter, with some saying that they felt it was them as the S.P.s in the video. The school of medicine highlighted the opioid counseling O.S.C.E. as one of the educational tools being developed/taught to students in combating opioid addiction/epidemic in its L.C.M.E. report. To our knowledge, our study is unique in the comparative evaluation of empathy among the A.M.G.s and I.M.G.s as perceived by standardized patients & scored on J.S.E. utilizing an innovative ENC-OSCEs model.
We believe that sustaining the skill of empathy or regaining the lost art of medicine during the practice is a challenging but certainly not impossible task for medical educators. The metamorphosis of medical students into compassionate physicians/ caregivers can be achieved through focused training during their clerkship rotation.