A Pilot Study to Compare the Standardized Patient's Perception of Empathy Among the American Medical Graduates and International Medical Graduates Applying for Residency Training in the United States


 Background:Empathy is an essential ingredient of patient-centered care. Traditional neurology clerkship does not provide a structured way to teach, evaluate and inculcate the virtue of empathy among our medical students while dealing with various complex neurological conditions. We designed an innovative Objective Structured Clinical Evaluations (O.S.C.E.s) entitled as Empathetic Neurological Care (ENC) O.S.C.E.s as a part of clerkship evaluation to assess empathy among American Medical Graduates (A.M.G.s) and International Medical Graduates (I.M.G.s) and establish the need of training of empathy skills to future professionals.Study Objective: We aim to illustrate the model of Empathetic Neurological Care (ENC) O.S.C.E. & to report the comparative analysis of empathy scores among the A.M.G.s and I.M.G.s.Methods: This is a pilot study comparing empathy among A.M.G.s and I.M.G.s, measured by the Standardized Patients (SPs) using the Jefferson Scale of Empathy (7-point Likert type scale) during pre-designed ENC-OSCEs. The proposed curriculum included complex neurological cases involving breaking bad news (e.g., delivering the diagnosis of A.L.S.), opioid addiction counseling, disclosing medical error (stroke), and explaining the diagnosis of non-epileptic seizures.Results: 12 students (6 AMGs, 3 Males/ 3 Females and 6 IMGs 4 Males/2 Females) completed the OSCE. A.M.G.s scored higher in empathy scores graded by S.P.s than I.M.G.s (P=0.0004). Conclusion: A.M.G.s scored higher empathy as compared to I.M.G.s by the S.P.s during ENC-OSCEs. We highlight the importance of focused empathy training with assessment during neurology clerkship rotations for A.M.G.s & the need of formal curricular training as a part of the orientation program at the beginning of residency training for I.M.G.s.

Realizing the importance of the cultivation of professional attitude and essential communication skill of expressing empathy in tomorrow's physicians, the medical schools and health institutions across the world are increasingly focusing on developing a curricular communication training 6,7,8  The evaluation by S.P.s during the O.S.C.E.s was used for both formative and summative evaluation. The feedback from S.P.s was done immediately after the O.S.C.E., and the comments from S.P.s were included in the faculty evaluation of the student. These comments have been a part of the student's M.S.P.E.

Discussion:
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 domains 14,15 . The cognitive attribute of empathy in contrast to sympathy (intense emotions) makes it a skill that can be learned, taught, and assessed 16 . 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 signi cantly 17  Redesigning the curriculum to change the focus of this training from the rst 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 con icting 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 students 25 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 dramas 23 . Some of the approaches tried by medical educators to reinforce and maintain the practice of empathy among undergraduate medical students have been found to signi cantly effective 35 . Training and evaluating the medical students in providing holistic, patientcentered 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 bene ts of practicing empathetic skills. Studies have shown a signi cant reduction in burnout, increased professional satisfaction, and well-being among those who express empathy in their practice 35,36,37 .
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 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.

Conclusion:
As seen in our pilot study, A.M.G.s scored higher than I.M.G.s in empathy evaluation by S.P.s. We wish to highlight the importance of a designed curriculum to train and evaluate medical students during their clerkships to inculcate empathy as a professional skill while dealing with complex neurological conditions during neurology clerkship rotations. We also wish to highlight the need of empathy-building training as a part of the orientation program/ residency curriculum explicitly addressing the needs of international medical graduates from diverse ethnocultural backgrounds.
Assessment of empathy by the standardized patients can serve as constructive feedback to the medical students and reinforce the practice of empathy as a second nature. Our ENC-OSCEs model may serve as a promising tool to improve the neurology patient experience.

Future direction:
Future large-scale studies are needed to validate J.S.E. as a tool to evaluate empathy during medical encounters of complex neurological conditions. We intend to do a large-scale study to direct our attempts to enhance empathy among both A.M.G.s and I.M.G.s as they enter into residency training and eventually the US-physicians workforce. At our institute, the ENC OSCEs will be offered to incoming neurology residents with constructive feedback as a part of their orientation. New O.S.C.E.s on end-of-life discussion in a patient with a massive stroke, telemedicine encounter of a chronic migraine patient, counseling of a patient with Huntington's disease will be added to the ENC OSCEs.

Limitations Of The Study:
We have conducted this pilot study with a small number of participants, and to establish the effectiveness of our intervention, we intend to do a large-scale study in the future with more number