Empathy Decline During Medical Training: Insights from a Novelist

Abstract

Modern concerns that medical students and trainees suffer a loss of empathy during medical training have generated handwringing, research, and innovation. But a literary vignette from a well-known American author reveals adverse attitude changes during medical training have been noted for more than a hundred years. Loss of empathy and rise of cynicism among students has been a subject of academic scrutiny for many decades though the focus has shifted from deficiencies of the student to deficiencies of the care delivery system in which they learn. The causes of empathy loss were recognized in the vignette and are little changed: exhaustion due to the stress and burden of working with the acutely ill in high volume, a devaluing of patient suffering due to insecurity about one’s own clinical competence, and working within health care systems that do not celebrate empathy or its sister virtue compassion, as useful or desirable skills on the road to clinical competence. But data is available that links empathetic relationships with many types of improved clinical outcomes. Evidence-based tools for relationship building are available for adaptation in the student/trainee situation. Educators should emphasize the link between empathy and improved clinical outcomes in designing empathy-sustaining curricula.

“Something had happened-something fundamental and disturbing-had happened in the lives of all these young men [medical students] since the time he had known them at college. That strange, subdued, curiously electric and somehow ominous alertness that one felt across the street in that enormous corridor of the great hospital had communicated itself to their own lives, and now was present in this house where they lived…Their faces had taken on a sharp and decisive character since he had seen them -a quality of seriousness and maturity that was evident in the earnest and rather worn concentration of their eyes when they talked. …The life of the hospital is not a life of health, but a life of disease and sickness…So it was therefore, that the lives of all these young men, which the hospital now completely dominated and in fact seemed to hold in a kind of sorcerer’s spell, had been touched by something fatal, morbid and negligent of life…Even their friendly affection for one another was now touched by an almost inhuman detachment of the doctor, as if they now recognized, that individual life and death was not a matter of great moment.

Thomas Wolfe, The Medical Students.¹

The modern concern that medical school and residency training induces empathy decline is not actually modern. To wit, this vignette from the American author Thomas Wolfe (1900–1938) which was informed by a 1921 visit to the bedside of his ailing father at Johns Hopkins Hospital where the older man was receiving radium treatments for advanced prostate cancer. The same visit would underlie the most poignant writing in Wolfe’s “autobiographical” novel, Of Time and the River (1935).² In it, Wolfe described the hospital as a “great engine,” a clinical machine which overrode patient needs and autonomy in favor of its own organizational requirements and processes. Witnessing his father’s broken spirit and cancer-weakened body, Wolfe described a “blind resentment” directed at the hospital and its personnel in a way that sadly would be familiar to today’s physicians.

But towards the medical students, close in age to his own, Wolfe showed not anger, but sympathy with a remarkably prescient understanding of how much joy and empathy they had lost or willingly shed accommodating themselves to the hospital culture that did not value these qualities. He describes callousness, detachment from patients’ suffering, haughtiness, and empathy loss even towards colleagues. He doesn’t blame the students but rather the institutional culture which, miasma-like, enveloped and subjugated all aspects of their lives.

Modern scholars call what Wolfe depicted a “hidden curriculum”; the socialization of students/trainees to the values of the institution: urgent medical care in the biomedical model,^3,4 The vignette, inspired by events more than 100 years ago contextualizes our modern concerns about empathy decline during medical training: troubling, but nothing new.

Concurrent with the observations of the outsider novelist, an insider, Francis Peabody, the Dean of the Harvard Medical School, made similar observations about the consequences of the hospital work burden as the cause of depersonalized, un-empathetic hospital care. In a 1926 address to students, Peabody warned that in hospitals personal relationship with patients loses out to the urgency of treatments, “…[Physicians] must first treat the specific disease, and there then remains little time in which to cultivate more than a superficial personal contact with patients.” Peabody’s lament seems even truer now that the electronic medical record has become a jealous master of students’ and trainees’ time, and compassionate patient-relationships compete with the great engine’s need for “throughput and positive margin.” Modern educators mourn the diminished opportunity to pursue the intimacy honored in high-minded aphorisms such as Maimonides’ “The physician should not treat the disease but the patient who is suffering from it”⁵ or Osler’s famous restatement, “The good physician treats the disease, the great physician treats the person who has the disease.”⁶ The psychological dilemma of simultaneously holding lofty ideals while working in a base system can lead to moral injury.⁷

Shortly after the novelist and the dean made their critiques, problematic medical student attitudes were worrisome enough to generate scholarly inquiry and reforms. By 1946, concerns that post-Flexner, medical school admissions were over-emphasizing science comprehension, resulting in students lacking humanistic qualities. These concerns led to the first revision of the Medical College Admission Test, adding a section entitled “Understanding Modern Society.”⁸ By 1955, a researcher summarized eight prior studies of medical student attitudes, dating to 1937, concluding, “… medical students, as a group, tend to have certain attitudes, value systems and defenses which do not seem to be consonant with the demands and gratifications of a service-oriented profession.”⁹ By 1959, there already was academic interest in curriculum reform to sensitize students to “humanistic elements in the doctor-patient relationship,” aimed at enhancing “empathic communication.”¹⁰ The modern debate about whether empathy can be taught or preserved during medical education^11–13 was already underway in the 1950s.

Eventually, validated tools allowed serial measurement of empathetic attitudes¹⁴ revealing a decline in empathy and a rise in cynicism in the clinical years and continuing through residency.^15–17 Both the novelist (without data) and academicians (with data) hypothesized that, beyond fatigue, it was students’ unguided first exposures to actual patient suffering that generated self-doubt and anxieties about competence. In 1955, it was hypothesized that empathy decline may serve as coping mechanism, devaluing patient suffering in pursuit of psychological self-preservation,⁶ an idea which has resurfaced¹⁸ but with a new understanding that the flaw is in the system, not in the individual.

Although empathy is often discussed as a single concept, it is better regarded as a complex multi-dimensional concept with both emotional and cognitive components.^19,20 Recently, a counterview against promotion of general empathy as a goal for society gained prominence critiquing empathy’s narrowness, bias, and weakness as moral guide.²¹ A sister virtue, compassion, has been advanced as a better goal for physicians²² because it is “other-focused” and not “self-focused.”^4,23 Regardless, empathy or compassion depletion during medical training results in inferior clinical outcomes^24,25 and clinicians’ well-being. If clinical competence is the main goal of medical training, empathy/compassion sustenance must be regarded as essential for that competence. Allowing learning environments that induce empathy erosion seems bizarre.

Empathy-enhancing curricula have been pursued for decades, often including humanities content.^26,27 But critics note such curricula will fail if they are quarantined away from the clinical learning that students value.²⁸ Empathy sustenance is optimized if integrated into routine clinical care, becoming a better form of “hidden curriculum.”⁴

Given the stakes, reforms have been sought and instituted. New empathy/compassion competencies for medical school applicants²⁹ and residencies³⁰ have been defined, humanism societies created³¹ to honor those who excel in empathetic relationship building and programs such as Schwartz Rounds explore humanistic aspects of medicine.³² Relationship-centered communication training has been utilized to improve self-rated empathy, reduce burnout,³³ and improve patient experience scores.³⁴ But these are not universal or universally effective.

Thomas Wolfe recognized empathy’s voids writing of his mother’s family, “[They] were cruelly indifferent to poverty, illness or misfortune that was not their own”.³⁵ Failure of empathy preservation will yield worse clinical outcomes and a harvest of cynical and morally injured physicians who feel betrayed by their own adaptation to dysfunctional care delivery systems. Such physicians will be fodder for the next great novelist with a disappointing experience and a genius for observation and description.

Declarations

Human Ethics and Consent to Participate

Not applicable.

Author’s Dedication

For JM, who said it was not necessary.

Conflict of Interest

The author has no relevant conflicts of interest.