Changing behavior and promoting clinical empathy through a patient experience curriculum for health profession students

Abstract

Objectives

The authors sought to explore how a curriculum that uses a patient experience simulation followed by reflection can lead to clinical empathy in learners and whether this experience leads to behavioral change. Further, in response to critiques of common pragmatic approaches to clinical empathy teaching in which empathy is operationalized and taught through formal trainings and checklists, the study aimed to contribute insights regarding how clinical empathy may best be taught to health profession students.

Methods

Twenty‐six senior medical students participated in an in situ patient experience simulation during a 4‐month period in 2021–2022 in an academic emergency department. The simulation was followed by a written reflection and a structured debrief. A thematic analysis was performed on transcripts of the group debriefs.

Results

In the group debriefs, learners described several empathetic behavioral changes they made after this intervention. First, learners discussed performing more small acts of kindness to improve patient care and humanize the patient experience. Second, learners discussed seeking to improve their communication through acknowledgment and validation of the patient experience. Finally, learners described actions to keep patients informed through frequent check‐ins and setting expectations on time.

Conclusions

The findings suggest that empathy may not be simply transactional for health profession students and that an understanding of the patient experience leads to actions that improve the patient experience and alleviate suffering.

INTRODUCTION

Empathy and patient‐centered care are important attributes of compassionate and effective medical providers. Studies link positive physician–patient relationships and physician empathy to improved health care outcomes, enhanced adherence to recommendations, and improved patient satisfaction. ¹ , ² , ³ , ⁴ , ⁵ Additionally, empathy is beneficial to providers as it is associated with lower rates of physician burnout and lower medical–legal risks. ⁶ , ⁷ Medical schools and training programs have taken note of these outcomes; thus, scholarship on empathy‐enhancing educational interventions is abundant. ⁸ , ⁹ Despite this emphasis on teaching empathy in the health professions, there is not clarity on which curricula are effective nor if they cultivate behavioral change in learners.

Simulations, especially those where the student takes the role of patient and is asked “to literally stand in patients’ shoes” are described as particularly effective for developing empathic behaviors in health professional students. ¹⁰ , ¹¹ Indeed, while learners will never know how it truly feels to be their patients, assuming the role of patients and experiencing that perspective may support the development of clinical empathy. ¹¹ , ¹² One such type of role‐playing simulation involves in situ patient experiences where learners take on the role of patients in a clinical setting. There is a small body of literature in medical education supporting this format. ¹³ , ¹⁴ For example, Nelson and colleagues ¹⁵ created the EM Intern as Patient Simulation that occurs during residency orientation. In this successful small‐scale study, incoming emergency medicine (EM) interns took on the role of patients or family members during a 3‐hour in situ simulation in the emergency department (ED). The authors found that interns experienced firsthand the physical discomfort, emotional stress, and confusion that patients and families endure during the ED care process. ¹⁵ While these findings were valuable, there remain important questions about whether patient experience simulations have an impact on the clinical empathy of health professional students and how that impact occurs.

But what is clinical empathy? Halpern ¹² defines clinical empathy as an “emotional attunement” that allows clinicians to recognize the patient perspective, validate patient feelings, and act accordingly to enhance care. Likewise, King ¹⁶ describes an affective, cognitive, and behavioral dimension to empathic practice. In a recent critique, however, Vinson and Underman ¹⁷ noted that in medical training, clinical empathy has been largely operationalized and taught through skills and checklists. They argue that clinical empathy is frequently taught in formal curricular settings through discussions, trainings, and evaluations and is “carefully broken down into discrete, observable, and teachable skills … Whether or not a trainee truly feels empathy is almost beside the point.” In their work, Vinson and Underman highlight the transactional aspect of current education around clinical empathy where students learn communication skills and follow behaviors only to create a specific emotional experience for the patient. This process deemphasizes the vital internal feelings and emotional activation of a truly empathic medical professional learner.

Building on previous work, the goals of the current research were to explore whether and how simulation and taking the perspective of a patient, followed by reflection, can lead to clinical empathy in learners. In the process, we endeavored to examine students’ experiences of clinical empathy and to explore whether these personal experiences contribute to behavioral change, a strong marker of curricular effectiveness. ¹⁸ In this way, we hoped to contribute insight about ways that clinical empathy may be taught in more effective, less transactional ways.

METHODS

Participants

All senior medical students rotating in the Maine Medical Center (MMC)–Tufts University School of Medicine EM clerkship were invited to participate in the patient experience curriculum during four consecutive 1‐month‐long clerkships in 2021–2022. MMC is a busy, Level 1 trauma center with 80,000 ED visits a year and each month six to eight students rotate through the ED. Twenty‐six students (12 female, 14 male) were invited and all chose to participate in the simulations and in the written reflections. Of these, 24 participated in end‐of‐clerkship group debriefs. Those that did not join the group debriefs had scheduling conflicts or illness. This study was approved by the MaineHealth and University of Illinois Chicago institutional review boards.

Simulation

During the first week of their 4‐week rotation, students participated in an in situ simulation in the ED. Half the students had the role of “patient” injured in a bicycle accident and half had the role of “family member” who supported the patient (Appendix S1 for simulation script and description). Faculty met each patient outside the ED, used stage makeup to apply a bruise to the student ankle and gave the student baggy clothing to wear (which could be safely cut off during the trauma exam). Students were provided a brief orientation on rules and safety during the simulation and were asked to enter ED triage complaining of neck and leg pain. From there, learners were registered, triaged, placed in a cervical collar (C‐collar), and evaluated in trauma bays by senior EM residents and two nurses. The other half of the learners assigned the role of family member went through the process of arriving at the ED and locating their family member after an accident. The complete simulation lasted 3 h and included a full trauma assessment, continuing ED care, time in the waiting room, transport to radiology, splint placement, the need for pain medications, the need to use the bathroom, using crutches, receiving discharge instructions, and locating the outpatient pharmacy. Throughout the simulation, learners were given brief cues designed to highlight features of the ED experience and move the simulation forward, such as asking for radiology results, expressing pain, or advocating for a family member. As part of the educational experience, learners were asked to write a reflection after the simulation to process the encounter and think about what surprised them most about being in the patient or family role (Appendix S2 for narrative reflection exercise).

Data collection

At the end of the clerkship, all students participating in the curriculum were invited to a 1h group debrief about the simulation and their subsequent shifts in the ED. There were four group debriefs, each with six to eight students. The debriefs were facilitated by first author (SN) and a second research team member (CG or BP) was present as a recorder. A facilitator guide (Appendix S3) was used to structure the discussion. During the debrief, crosstalk and sharing of ideas were encouraged. Learners were asked to identify things they learned from the simulation and behavioral changes that they made during their EM rotation because of the experience. At the conclusion of the debrief, there was a short didactic on clinical empathy and its effect on patient outcomes. This was meant to reinforce learning from the simulation and to provide a framework for considering empathy in future practice. All debrief sessions were recorded and then transcribed by a CITI‐certified transcriptionist. Responses were deidentified, kept confidential, and reviewed only by research team members.

Data analysis

Using thematic analysis and an inductive, constructivist approach, one investigator (SN) performed open‐ and focused‐coding on the debrief transcripts. ¹⁹ Specifically, she read through each transcript and performed open coding to develop a codebook. This initial codebook was then reviewed by two additional team members (CG and BP) who were present at the debriefs and recorded field notes. Once there was consensus on the codebook, SN performed focused coding with phrases as units of analysis. Initial memos were created from the focused coding and then organized and collapsed to develop broader themes in the data using integrative memos in consultation with the analysis team (CG, BP, LH). Illustrative quotes were selected and lightly edited for clarity and brevity. All data were pulled from the group debriefs. The learner reflections, written immediately after the simulations, will be analyzed in a following publication.

Reflexivity

Our research team consisted of three EM faculty (SN, CG, and LW), one EM resident (BP), and one medical school faculty (LH). SN and CG have experience in curriculum design and qualitative research. LW was the EM clerkship director and supported simulation implementation. BP cowrote the simulation, was a resident physician during several simulations, and provided member checking from a trainee perspective. LH was a sociologist and an expert in qualitative methods. While SN was the primary investigator and did the coding, the research group shared perspectives often during the analysis, and fieldnotes from group debriefs were used to triangulate the analysis. These discussions promoted credibility and trustworthiness of our study. ²⁰

RESULTS

Experience of learners in the simulation

During the debrief, learners were invited to share their experiences as patients and family members and to reflect on aspects of the simulation that resonated with them. Learners eloquently discussed the physical discomfort and emotional distress of the ED process, a new or expansive perspective for many. Physical discomfort resulted from wearing a C‐collar, staring at bright lights, being cold, and not being able to care for themselves independently. One student described the feeling of being immobilized “staring at the ceiling, you can't look around, you can't do anything, just being stuck in that position.” Emotional distress was also a dominant theme, with learners expressing feelings of vulnerability and powerlessness—emotions that were both surprising and instructive to students. Many noted the intensity and sensory overload of the trauma exam: lying on one's back, hearing voices that you did not know, having clothes cut off, “I felt like there were one million people touching me … it made me feel super vulnerable.” Care often felt hectic and chaotic, and learners were surprised at how disoriented and powerless they felt. Other learners were taken aback by how “isolating” the experience felt, especially with continued care in the hallway where they at times felt ignored and burdensome. One learner remarked, “the most challenging aspect was just waiting … and having no idea what was happening.” Learners speculated that in a real medical emergency, this confusion and anxiety would be magnified, intensifying the stress and vulnerability experienced during the simulation.

Practice changes

While learners participated in the simulation and wrote their reflection during the first week of their EM rotation, the structured group debrief was not until the end of the month. Having the group debrief at the end of the rotation gave learners time to reflect on what they had learned in the simulation and to experiment with practice changes during their clinical shifts.

Small gestures of kindness improve patient care and the provider experience

A powerful lesson learned through the simulation was that small acts of kindness can improve the ED experience for patients and family members. Learners felt this directly when they were offered a blanket or a chair or when staff simply took time to connect with them as people. Many learners commented that their practice had changed in this regard and that they now sought out these simple acts and small gestures of kindness to improve patient care.

One thing I've learned and have been trying to incorporate throughout this rotation is that the smallest gestures can alter the course of how [patients] perceive their stay in the hospital. Whenever we were checked on and just told the next step of the plan … it just changed your attitude and your outlook altogether … [I] implemented that during the rotation, asking … is there anything I can do for you and there is almost always something small that I can immediately fix for them, and patients are so appreciative of it.

Other learners noted a new emphasis on reducing patient discomfort.

The overall discomfort of the patient experience is something that I bear in mind now and [I] … try to discontinue uncomfortable interventions as soon as possible … like getting your IV out, turning the blood pressure cuff off once we don't need [it] every ten minutes, taking the c‐collar off … I am trying to be more attuned to the fact that it is an uncomfortable world out there and we can make it better.

Learners reflected that performing acts of kindness not only improved their connection with patients but also supported their on‐shift enjoyment and satisfaction.

Something I learned from this patient experience and something I try to do in the ED is to check back on them and say, “How are you doing now? Can I get you anything, water, blanket?” I think I am doing it for the patient, but I am also doing it for my burnout. That makes me feel good at the end of a shift knowing I built a connection with this person.

The value of acknowledging and validating the patient experience

After experiencing the patient experience curriculum, learners explicitly acknowledged the discomfort of the ED experience and tried to normalize it for patients. Students felt that recognizing and articulating this discomfort was helpful in demonstrating empathy.

One of my takeaways was to recognize that a lot of the things we do to people kind of inherently suck, and having [family member] in a c‐collar and hearing him saying “This is hurting my back, this is hurting my neck, and this sucks to be stuck here,” reinforced to me that those things are miserable … It helped me during this past month because we have a lot of patients that are in c‐collars and they go “Man this is hurting my back,” and I can go “Yeah those things suck,” and the patients go “Yeah they really do,” and I'm like “I'm sorry, we will try to get you out of that as soon as we can.” It's a five second interaction. It doesn't take any time to do, but it seemed like people really appreciate it.

Learners reflected that they were now more cognizant of the patient experience. Students recognized that patients were often scared, anxious, and confused and that the concerns of patients might differ from the priorities of providers. They explained that it is important to validate patient concerns and to explore how they might be addressed.

Sometimes the patient's worries might not be a priority in the given moment but validating that and hearing them out and setting up a plan … [to] address those other problems gives [the worries] validity so they are not worried and so they are not freaking out. They know you are listening and that you are going step‐by‐step with what you can manage.

That validation often involved learners taking time to communicate their understanding of the patient's experience back to the patient to check for accuracy. Finally, learners recognized the importance of making personal connections with patients in the ED and felt empowered to ask about and connect on details of patients’ lives.

One thing I have tried to do more this month after this activity is … to find something non‐medical to talk about, just make an attempt to get to know them as a person and not just a patient.

The value of frequent check‐ins and setting expectations on time

After the patient experience curriculum, learners described seeking out additional ways to improve their communication with patients and families. Many learners mentioned the importance of introductions and explicitly defining roles in the health care team to decrease confusion for patients.

Things I have been changing—being really up front when I walk in and I say, “Hey this is my name, I am the medical student. Is it okay if we chat for a little bit and I am going to update the doctor?”

Learners state that they now incorporate frequent patient check‐ins and updates into their clinical care and realize how that practice makes patients feel not only recognized but also allows patients to better understand the care that they are receiving. Even brief check‐ins were felt to have value in keeping the patient connected to the care process, to alleviate anxiety and discomfort.

One thing I started doing more is giving updates. Even if it's just, “Hey we are still waiting on those labs”… I've started doing that just walking by the room. I'll poke my head in and say, “Just giving you an update here.” I feel like that has been nice for me, too, because then it keeps track of what's going on for each patient that I am seeing.

Students felt empowered to undertake these updates during their ED clinical shifts. A few students noted that check‐ins not only benefited the patient but also benefitted them as clinicians. These small interactions helped students to stay on track with care and created connections with patients.

A specific way of keeping patients informed was creating expectations about next steps and setting timelines. Learners reflected on the challenges of waiting for things to happen during the simulation, both as patients and as family members.

I am gonna be more clear about time expectations. I know it's hard to give people a timeframe in the emergency department, but even just saying it's going to be two hours, even if it's wrong … you can go back and tell them that it's going to be longer, but just giving them something that they can look to.

Students noted that time moves differently for providers than for patients and families. While hours in the ED may go by quickly for providers as they care for patients, for a singular patient the passage of time may feel slow and uncertain.

I learned that time moves differently as a patient … As a provider I am in and out of rooms and it seems like time is going fast, and I look down and go wow it's been six hours, my shift is almost over. As the patient [in the simulation] … the two and a half hours in the emergency department felt like forever, so I have been trying to go back in and check on patients and … remind them of where we are in the process and what we are waiting for. I think it's helpful for people to know we haven't forgot about them.

Explaining the purpose of steps in the care process was equally important to explaining the timeline. Several learners noted that they now try to use plain language to provide anticipatory guidance. If learners did not know an answer about next steps, they tried to find that information for their patients and thereby established themselves as patient advocates.

I learned … I need to explain what's happening to patients … like break it down, because in a stressful environment it's hard to understand what's going on. I think that added stress makes you more confused. [I try to] really make sure that they understand what's happening to them and what the next steps are … [I] would try to check in with them and be their advocate and hopefully [they] know they had me on their team.

Action as key to provider empathy

After completing the patient experience curriculum, students were motivated to improve their care of ED patients and recognized the importance of tangible actions as part of providing good and empathic care. For many, these tangible actions distinguished clinical empathy from other forms of empathy or sympathy. Doing something for the patient really mattered to learners.

That really hits on the importance of [clinical empathy], like the feeling, the empathy and maybe communicating is one piece of it, but being able to have an action that follows that potentially alleviates suffering in some way, is the endpoint.

Many students stated the simulation experience made them more cognizant of their patients’ physical and emotional distress and that it influenced their actions to alleviate patient suffering. For example,

I would recall how uncomfortable I was during the simulation. I feel like most shifts I was working this month [I would think about it] and it would help me… go check on this patient again and remember they are having a terrible time even if I'm having fun.

I learned that being a patient is very scary and disorienting … it made me realize the importance of reaching out and putting my hand on the patient's shoulder, getting them a blanket and just taking time to check in with them … [it] gives them back their agency and humanity.

During the group debrief, learners spoke about trying to understand the patient experience and perspective, noting that this cognitive aspect of empathy was helpful in making a connection and providing enhanced care. Students felt that being attuned to the patient's needs and humanity allowed them to be more empathetic.

At the same time, learners noted the importance of keeping a professional distance from the patient and not internalizing or taking on their emotional hardship. A few students struggled with the concept of “walking in the patient's shoes” and noted that they would never truly understand a patient's reality. Nonetheless, recognizing the challenges and needs of the patient, validating those needs and acting on this understanding in a therapeutic way felt important to learners.

I think the classic definition of empathy is being able to really feel what another person is feeling. I think that provider empathy is subtly different. It is the ability to appreciate what the other person is feeling because … I don't think it is sustainable to actually enter into the hardship and anguish of every patient; I don't think that would be healthy for a provider. But having the mental check point where you acknowledge the hardship that a patient is going through is provider empathy to me.

DISCUSSION

Our patient experience curriculum included an in situ patient experience, a guided written reflection, and an end of clerkship group debrief. At the conclusion of the curriculum, learners felt they were more attuned to the patient experience and felt empowered to act on that understanding in a therapeutic way. Consistent with prior research on in situ simulation, learners reported having a better understanding of the physical and emotional discomfort that patients feel in the ED. ¹⁵ More importantly, our learners reported they made changes to their clinical practice because of the curriculum.

Prior work emphasizes that students can learn skills to convey clinical empathy to patients, ¹⁷ but the results of our curriculum suggest that role‐playing simulation followed by reflection may contribute to the affective and cognitive dimensions of clinical empathy, leading to behavioral changes in learners. This is crucial, as behavioral change is a key indicator of curricular effectiveness, ranking just below patient care outcomes in the Kirkpatrick model. ¹⁸ We found that providing students with a concrete experience where they assume the patient/family role and then encouraging them to reflect and process their experience produced a sensitivity to many aspects of the clinical environment and an emotional awareness of the patient experience. This cognitive and emotional understanding led to reports of behavioral changes and improved patient‐centered care. This method contrasts with more common educational strategies focusing on a skills‐based approach to empathy training. ¹⁷ As such, our findings support Halpern's idealized conceptualization of clinical empathy, where emotional attunement to the patient experience allows the clinician to validate patient feelings and act accordingly to enhance care. ¹² The findings also have synergy with Thirioux's model, where empathy is the capacity to feel and understand not only the emotional and affective experiences of others, but also motor and somatosensory experiences and their associated mental state, all while consciously maintaining the self–other distinction. ²¹

Our learners described several behavioral changes made after completing this curriculum. First, learners performed more small acts of kindness to improve patient care and humanize the patient experience. Second, they sought to improve their communication through acknowledgement and validation of the patient experience. And third, they endeavored to keep patients informed through frequent check‐ins and setting expectations of time. These tangible actions and behavior changes were critical components of clinical empathy and distinguished clinical empathy from other forms of empathy and sympathy. While communication skills such as good eye contact, appropriate language choice, and welcoming body language are important, the behavior changes noted by our participants directly alleviated suffering and improved the patient experience. Thus, our findings suggest that the development of clinical empathy should optimally involve more than the behavioral checklist approach critiqued by Vinson and Underman ¹⁷ : the use of simulation and reflection can lead to emotional attunement and a desire to provide better quality care.

Our findings also align with the existing literature on the relationship between empathy and provider burnout, which suggest that empathy can serve as a protective factor for physician well‐being and satisfaction at work. ²² With burnout rates reaching as high as 50% among trainees and medical students, interventions that foster empathy and support well‐being are particularly important. ²³ In fact, burnout is sometimes defined as a pathology of the care relationship. ²⁴ In contrast, our students reported that making connections with patients and providing improved care led to joy and microbursts of satisfaction during shifts. Thirioux et al. ²¹ hypothesize that empathy may decrease the likelihood of provider burnout through creation of a stable, “nonpathogenic” relationship with the patient from which the provider derives satisfaction and comfort. ²⁵ Empathy mitigates depersonalization and allows for the consideration of others. Finally, clinical empathy allows providers to understand the patient's state without assimilating these emotions. Other work on perspective taking and empathy show that high scores in these domains are protective against provider burnout. ²⁶ , ²⁷ Similarly, our findings suggest that teaching students empathy and perspective taking through patient experience simulations and supporting reflection on the benefits of empathic practice may enhance both work satisfaction and patient–provider connections.

LIMITATIONS

There are several limitations to consider when interpreting the findings of this study. First, the researchers facilitating the debriefs and performing the analysis were the same faculty that organized and ran the simulation. Second, one researcher (SN) performed the focused coding of transcripts. To address these potential areas of bias, the research team met often to discuss the data and reflect on their own assumptions and perceptions of the curriculum and findings. These conversations were especially helpful when discussing codes and themes. Third, there was a short didactic at the end of the debrief centered on empathy frameworks. This didactic was designed to reinforce learning from the simulation, written reflection, and clinical work. While most student comments were collected prior to this didactic, learning about empathy frameworks could have influenced student comments late in the discussion. Fourth, this study analyzed the debriefs and we have not yet explored the learners’ written reflections. In future work, we plan to examine how written reflections support learning about patient perspective. Finally, while this study identified self‐reported behavioral change, these changes were not objectively observed. While the themes we heard were powerful, it is possible that learners were overstating the changes they made in clinical work to please the facilitators of the group debrief. Additional research in this area is needed to measure whether behavioral changes do indeed occur, whether these changes persist, and whether they affect patient care and outcomes.

Future work could explore the use of similar curricular interventions with learners in other contexts. While our learners were all senior medical students, given our past experiences with resident physicians, ¹⁵ we are confident that similar curricula would work across training levels. Other patient experience simulations could be created to give insights and perspective into a variety of care settings.

CONCLUSIONS

The patient experience curriculum is a feasible intervention and curricular tool to cultivate an understanding of the patient and family perspective; implementation led to reports of behavioral changes in health profession students. Our curriculum created an emotional and physical experience for learners that promoted a deeper understanding of clinical empathy than might occur in standard skills‐based approaches. Findings suggest that empathy is not simply transactional for health professions students and that gaining an understanding of the patient experience and an emotional attunement to that experience leads to actions that make the patient experience better and alleviate suffering. Further study is needed to understand whether these changes in behavior are durable as learners continue in training and practice.

FUNDING INFORMATION

This work was supported by a MaineHealth Educational Innovations Grant under grant 140.826720, 13001320101.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Appendix S1.

Appendix S2.

Appendix S3.

Nelson SW, Germann C, Yudkowsky R, et al. Changing behavior and promoting clinical empathy through a patient experience curriculum for health profession students. AEM Educ Train. 2024;8:e11048. doi: 10.1002/aet2.11048