Our study evaluated a comics-based empathy and communication training course for fourth- and fifth-year endocrinology residents. Participants felt the curriculum to be impactful as medical learners, teachers, and practitioners, appreciating the opportunity to share negative experiences and provide support to one another. Participants enjoyed the comics as an educational medium, particularly in their ability to powerfully and concisely communicate the patient perspective. Opinion on the relevancy of the course was mixed, but residents largely appreciated having a course focused on empathy and communications training.
All participants described a desire to practice in an empathic manner. This mirrors our previously reported findings on the importance that undergraduate medical students place on empathy, and suggest these values persist into post-graduate training [11, 12]. Participants acknowledged however, that their levels of empathy tended to fluctuate as they progressed through residency, reporting increased feelings of burnout and impatience. Contributing factors included the stress of increasing responsibility, long work hours, and competing work-life priorities, and are similar to those reported in the literature [8]. The inverse relationship between burnout and empathic practice is well established, and our results highlight the importance of educational interventions at this level to promote wellness.
Numerous studies have described the benefit of empathy training [2, 10, 11, 19, 20], and many novel methods of have been tried, including exposure to poetry and short stories, and having residents role play as patients [21, 22]. However, our paper is the first to investigate the role of a comics-based curriculum in empathy training. A strength of our method lies in the longitudinal nature that an academic curriculum provides. Short term, targeted interventions have been shown to have short term empathy increases, with post-intervention decreases [19, 23]. Repeat, targeted interventions in contrast, showed a sustained improvement in empathy [23].
Participants appreciated the novel use of comics as an educational medium. Depictions of the patient experience helped them better understand the patient perspective, particularly for topics like patient non-compliance, and allowed them to maintain empathy in these situations. Feedback on the comics is in agreement with previously reported benefits [10], with participants reporting that comics were able to powerfully and concisely communicate concepts, while having sufficient depth to inspire further discussion. Residents recalled using depicted techniques when faced with similar situations in a clinical environment, and most participants felt the curriculum had a lasting impact on their empathic practice.
Participants also appreciated the curriculum as an institutional commitment to wellness and humanism. Hearing strategies their colleagues used to navigate challenging situations helped to normalize less successful outcomes. Such feedback is in keeping with a recent study by Daskivich et al. [24] that sought the input of a resident panel to identify interventions to reduce burnout. This panel highlighted the importance of personal support from co-residents and staff, as well as having institutional policies in place to address wellness. While limited to one participant, a notable finding is that the curriculum not only improved the wellness of that participant, but also acted as a reminder of the importance of wellness when taking on junior learners. Such an impact suggests the curriculum may behave as a vehicle for perpetuating resilience in future generations.
Participant feedback on the curriculum was mixed, highlighting the difficulty in designing a curriculum for adult learners. A key principle of adult education is to incorporate the practical experience that students bring [25]. Our participants came from diverse backgrounds with non-standard foundational knowledge. That some felt the curriculum to be redundant, while others appreciated its content is to be expected. Where the course was most successful was in allowing group discussion amongst participants. As senior medical learners, participants possessed a wealth of experience and were themselves resources to their peers. Allowing them to self-direct their education and incorporate their experiences is a key component of adult education, and the positive feedback around this aspect of the course clearly demonstrates its importance [25].
Strengths of this study include the use of a novel intervention to explore empathy and burnout. While we have shown success in the use of comics in junior medical learners, this is the first time we have demonstrated such an impact on the empathic practice and wellness of medical residents. Limitations include a small sample size and a highly specific cohort of participants.