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

Ryan Syrek, MA


July 29, 2019

'An Uphill Battle'

Shreya Kangovi, MD, MSHP, an associate professor at the University of Pennsylvania's Perelman School of Medicine, is on the frontlines in the fight against empathy decline. "The first strategy is to hire individuals who are more naturally empathic by virtue of their life experience and personality traits. The second strategy is to train other types of personnel to try to enhance their levels of empathy. You can basically either hire for it or train it," she explains. "If you haven't lived the experiences and if you don't have intrinsic empathy, it's a little bit of an uphill battle, but it's not impossible."

Kangovi and her colleague, Horace M. Delisser, MD, associate dean for diversity and inclusion at the Perelman School, developed a course called IMPaCT, designed as an innovative elective rotation for health professional students who are facing such an uphill climb. "Med students are apprenticed to a community health worker for 2-4 weeks and essentially learn from them how to be a community health worker." Her intent is to use the IMPaCT model to tackle aspects related to empathy that have proven particularly problematic in the past.

"Historically for doctors and nurses, the way that schools taught about things like cultural competence or cultural humility was just didactic lectures like anything else. It doesn't take long to realize that that's a flawed approach." Her course immerses medical trainees into the community, but she is careful to avoid pitfalls associated with traditional service learning.

"There are three problems with traditional service learning: Number one, health professional students are inherently a transient workforce with shifting priorities." She further explains, "The second problem is it really doesn't do anything to address power dynamics and actually reenforces them. Some third-year medical student is now in a homeless health clinic taking care of the most vulnerable and sickest people in the population. That's crazy. It's not a good set-up because it still places the health professional student in a position of power vis-à-vis the community member." The third problem is that traditional service learning "doesn't teach the students to challenge or understand the larger structural forces that created some of the inequities in the first place."

Kangovi believes that the apprenticing course is a better process to help develop empathy "because you are actually walking in someone's shoes." The trainees who elect to participate in the rotation learn from an interview guide who asks deeper questions of patients, including things like, "Where were you born? What was your childhood like? What are moments that you're proud of? What are some hard things that you've had to overcome? What are some things that bring you joy?" As she explains, "This type of conversation gets you to a very different point of empathy compared with what we're all taught to do."

In this training model, patients aren't relying solely on a medical trainee. Their main point of contact remains stable, a community health worker. This is intended to alleviate the first problem of transience. Issues about power dynamics are also improved by apprenticing with someone who is already a part of the community. Finally, the immersive process is designed to encourage students to recognize the larger issues at work in these communities.

According to Vidya Viswanathan, a medical student who has completed the course, it works. "I learned a lot from the humility and accommodation of community health workers," she asserts. "In shadowing community health workers and attempting to emulate them, I realized that I could never fully do what they did—I could never claim to be from the community. But I could work to understand the needs of my patients in that community and prioritize those needs in my clinical decision-making."

I will take with me the simple truth that delivering good care often means meeting someone where they are.

The lessons Viswanathan learned are complex and involve recognition of invisible structures at play in the communities in which her patients live. Some lessons were easier to explain, however. "I will take with me the simple truth that delivering good care often means meeting someone where they are." Kangovi reiterates that no one course or approach can remedy all empathy issues. "It's not only about training; it's about hiring and the whole infrastructure."


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