Battling the 'Devil in the Third Year': The Fight to Foster Empathy in Medical Trainees

Ryan Syrek, MA


July 29, 2019

After years of suspicion and searching, they found what they (perhaps) least expected.

In a longitudinal study, Mohammadreza Hojat, PhD, and colleagues discovered that a significant decline in empathy occurs among medical students. It happens precisely when that skill becomes most crucial, when training shifts toward patient care. As the study's title puts it, "the devil is in the third year."

Despite increasing evidence that empathy is not only beneficial in patient care but may be lifesaving, challenges remain in both assessment and training. As Caroline Wellbery, MD, PhD, a professor in the department of family medicine at the Georgetown University School of Medicine warns, "Empathy is declining, and not just in medicine. Empathy has declined in young people in the United States and worldwide."

The Hojat study's findings were released a decade ago, but the environment for empathy training has become more challenging since then. "There are a lot of forces working against empathy," explains Margaret S. Chisolm, MD, professor in the department of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine. "Systemic forces are working against understanding patients, in terms of time and other pressures, the way the curriculum is and what's being modeled."

A snapshot of empathy training among students and residents in the United States necessitates an inventory of the ongoing challenges, an understanding of how empathy is assessed, and a look at current and proposed interventions.

Obstacles to Learning Compassion

One of the biggest challenges may be a failure by all involved to acknowledge shortcomings in empathy among medical trainees in the first place. "I think just recognizing that it's a problem is one obstacle," explains Chisolm. Another problem she identifies is "how medical education curricula are structured. The communication and empathy skills are taught separate from the scientific knowledge parts of the curriculum."

Chisolm was part of a group that examined strategies used to teach empathy to medical students. Although the study found that educational interventions can be effective in enhancing empathy, it also found that simply defining empathy itself remains a problem.

"Empathy is not just reacting to somebody," explains Wellbery, "It also has to do with how you modulate your own emotional reaction relative to the pain that you share with that particular patient. It's important to look at what it is that is actually declining in empathy over the years." A follow-up study by Wellbery and colleagues examined self-reported empathy among fourth-year students who were previously assessed as first-year students. "One of the things that we found was that students' ability to regulate their emotions declines. That simply means that students are experiencing something like burnout and it hampers their ability to modulate their response to whatever they're hearing or feeling in connection with patients."

Although burnout in medical trainees has various causes, the pressure to do well academically is continually cited as a major factor, even at schools that have instituted pass-fail systems. Rachel Casas, MD, assistant professor of medicine at Penn State College of Medicine, recognizes the difficulties in trying to develop and enhance empathy while under that specific stress. "It can be hard to think about empathy when you're in the throes of medical school," she suggests, "with all of the testing that occurs and all of the responsibilities that you have for classes. And then it's hard when you're a resident, with all of the clinical responsibility."

Empathy is not on the test.

Chisolm agrees with Casas's assessment, adding, "Empathy is not on the test, you know? If you have a limited amount of time as a student, and there's stuff that you're going to be tested on and stuff that you're not going to be tested on, then one is given more importance conceptually and practically."

Although empathy scores are not a requirement for residency applications or board certification, a study by Casas et and coworkers attempted to link success in that area with success in other areas. They found that self-reported empathy scores were positively associated with Objective: Structured Clinical Examination (OSCE) communication scores. Even if such findings effectively convince trainees to prioritize empathy education, the challenge is finding a way to encourage development without making it yet another source of stress and contention.

As Wellbery suggests, an unseen barrier to empathy "has to do with the emphasis on competition rather than community. Your interest when you're training is to get ahead, and that means leaving other people behind. Empathy really requires that you feel like you're part of a group."


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