An Experiential Learning Activity on Empathy in Chiropractic Students: A Descriptive Report

Abstract

Objective

The purpose of this report is to describe an experiential learning activity on empathy for first-year chiropractic students.

Methods

An experiential learning exercise utilizing standardized patients was developed for incoming students to highlight a potential decrease in empathy during their education, and to impart the importance of empathy in the Doctor-Patient relationship.

Results

The learning activity on empathy was delivered to 747 first year students over 4 academic years. This consisted of a group briefing, standardized patient encounter, group debrief and subsequent video reflection.

Conclusion

An experiential learning activity was developed and implemented to address the potential deterioration of empathy in first-year chiropractic students.

Introduction

The importance of empathy in health care practitioners is quite clear, with a renewed awareness of mental health issues and their known contribution to a patient’s overall health.¹ Empathy is defined as “the ability to perceive the meaning and feelings of another and to communicate those feelings to others”.² Empathy refers to a cognitive process that enables an individual to put oneself into the mind of another person to understand what they are feeling.¹

Clinical empathic behaviors are forged through years of practice but are also influenced during training and the initial development of a professional identity. “It has been shown that empathetic medical students are more concerned than others about the contribution of psychosocial factors in health and illness, which suggests that these students may be more receptive to the biopsychosocial, rather than the biomedical model of disease.”³ Recent literature has called for “embedding empathy-based education in the curriculum of medical, nursing, and allied health programs early in the course of study”.² Within medical and nursing education, empathy-based content is seen but predominantly on an elective basis.^2,4 The focus of these curricula predominantly centers on the practitioner and the employment of self-compassion and self-care strategies to avoid burnout.²

As health profession students progress through their education, a decline in empathy is observed as measured using the Jefferson Scale of Physician Empathy.^3,5 This may be due to “battered student syndrome” – the negative educational experiences of pre-professional students due to the strenuous nature of the curriculum.³ This deterioration of student humanity is seen across disciplines, between years of study, and within a variety of specialist residency programs.³ As for the reasons behind this, some caution that “the emphasis of modern medical education on the doctor’s emotional detachment, affective distance, and clinical neutrality can be misinterpreted or misplaced, thus contributing to a decline in empathy among medical students, and ultimately influencing doctors’ compassion.”³ A deliberate emotional detachment from the needs of the patient is contrary to research showing that empathic behaviors of physicians relate directly with levels trust.6, 7

There is a scarcity of education literature specifically relating to empathy in chiropractic students. Due to documented decreases in empathy in other health professional students, pre-emptive educational interventions should be considered for chiropractic students including the application of experiential learning – the creation of learning through reflection on experience.^2,5 Experiential learning is prevalent in health professions education and has been shown to be effective in developing clinical skills.8, 9 This increasingly popular method of learning is found in many disciplines including nursing, medicine, social work, and physiotherapy.¹⁰ Additionally, the use of standardized patient feedback has been positive among students for both professional and clinical development and utilized in many health professions training.^4,11 Despite being used predominantly for developing diagnostic skills, experiential learning has also been utilized in health professions education for other purposes including non-diagnostic skills.^1,2 Therefore, the purpose of this paper is to describe an experiential learning activity on empathy for first-year chiropractic students.

Methods

An experiential learning exercise was developed at the Canadian Memorial Chiropractic College (CMCC) for incoming students to highlight a potential decrease in empathy during their education and impart the importance of empathy in the Doctor-Patient relationship. As incoming students have varied levels of familiarity with active and experiential forms of education, the timing of this type of exercise early in their schooling was important.

Prior to beginning formal classes, students participate in an orientation week comprised of academic and social activities. One of the aims of the week is to introduce students to the types of learning they will experience in the following 4 years of the program, including a high reliance on active, experiential activities. The positioning of this experiential learning activity prior to beginning classes kept the focus on personal attributes rather than the application of specific knowledge.

Developmemt

A mock activity was devised where students interact with a patient with low back pain. Briefing and debriefing sessions were designed to create a safe environment and to integrate the learning. In-person training and preparatory materials were delivered to clinical interns acting as standardized patients to ensure a consistent portrayal of someone with low back pain.

Low back pain is the main cause of years lived with disability worldwide and is one of the most common things chiropractors treat in their clinic,^12,13 so this appeared to be a relevant topic to initially expose students to. Students come from a variety of backgrounds, but a mock patient with low back pain was selected as students could likely relate, given its prevalence and impact on a patient’s life.

Resources

The interaction between student and standardized patient took place in a mock clinic environment, and the interaction was video recorded for subsequent student review. Assessors were not present during the experience. Standardized patients are commonly used throughout medical and health professional education in the development of clinical competencies and behaviors.¹¹ They are also used throughout the curriculum for other learning and assessment activities, portraying many different roles. Volunteer interns were trained and utilized as standardized patients portraying someone with low back pain. Input from interns informed the details of the case, while ensuring the individual standardized patient had some autonomy to fill in the gaps as robust details were deliberately not included. An example of the case details is provided below.

“You will just be playing the role of someone with uncomplicated localized low back pain after weeding in the garden the day before. Nothing sinister is present in the history, and you’ve been referred to chiropractic by your mother who swears by it. Other than those couple details, you can make it up as you go along!”

A timeline of the experience is provided in Figure 1.

Fig. 1.

Timeline of Activity.

Briefing (10 Minutes)

Immediately prior to the experience, students were provided a group briefing to explain what they would be doing and answer questions on how to approach this formative exercise. The intention of the briefing was to ensure psychological safety of participants, and to relay the instructions for the interaction.

Encounter (5 Minutes)

Students were asked to talk with a standardized patient and discuss the patient’s complaint and the impact it had. An audio prompt was given for the student to begin the interaction and also for completion 5 minutes later.

De-Briefing (20 Minutes)

To further guide the students through the reflective process, a faculty-led group “debrief” session was conducted immediately following the activity to internalize their experience and develop relevant learning points about displays of empathy. Drawing from student’s verbal and non-verbal attributes, the potential impact they could have on the doctor-patient relationship was highlighted. The purpose of the exercise and its implications for future learning experiences was relayed by the faculty member, and themes elicited from the students. Individual reflection on the themes of the discussion was encouraged to gain the full value of the exercise. As a key component of experiential learning, the individual reflective component was highlighted. Learning items to be covered during the debrief are listed below in Figure 2.

Fig. 2.

Learning items for discussion and debrief.

Results

Regardless of a student’s prior knowledge or experience with chiropractic care or low back pain, active listening and empathetic behaviors were identified. The video recording of the student’s individual encounter was released to them within 24 hours, and these recordings are referred to in other activities and assessments within the curriculum. Written assignments within clinical education courses refer to this experience and the student recording as a baseline to compare with for continued introspective reflection. Students retain these recordings and assignments to demonstrate their continued development.

Student attributes were identified as part of the debriefing process in a shared conversation lead by an experienced faculty member. These verbal and non-verbal attributes are listed in Figure 3.

Fig. 3.

Verbal and Non-Verbal Student Attributes Identified Following a Simulated Patient Interaction.

As of April 2024, this exercise has been implemented 4 times with a total of 747 students completing this exercise. Fifteen student interns each year were trained as Standardized Patients, and 4 faculty served annually as group de-briefers for the encounter. After 747 students participated in this exercise, no adverse events or withdrawals from the activity have taken place, as indicated by the counselor on site during these activities. Informal feedback from intern Standardized Patients, students, and de-briefing faculty indicate satisfaction with this introductory experiential learning activity. Two representative quotations from Standardized Patients are included below in Figure 4.

Fig. 4.

Representative Quotations from Standardized Patients.

Discussion

The chiropractic profession itself has long subscribed to the biopsychosocial model of disease and employs patient-centered approaches to care. The literature overwhelmingly demonstrates a positive effect of practicing in a patient-centered manner, both in enhancing patient outcomes and in avoiding litigation.⁶ Therefore, teaching and re-enforcement of positive empathic behaviors appears essential to prepare our graduates for practice.

In chiropractic education programs, lectures (pre-recorded or in-person) remain the dominant vehicle for delivery of content.¹⁴ A chiropractic student’s pre-clinical learning also includes active small groups, hands-on laboratory sessions, and both mock and authentic clinical experiences. Although this learning is participative in nature, these activities may or may not include reflective components – the defining characteristic of experiential learning.

Experiential learning is by its nature a continuous process, informed by experience but created through the process of reflection.¹⁵ This exercise utilizing experiential learning methodology is the first of many activities under the umbrella of experiential learning, modelling the lifelong process of personal and professional growth. Exercises such as the one presented can help prepare students to reflect on experience and learn how to apply these strategies in the future.

The positioning of this learning activity early on in a student’s education is one of its strengths. Early clinical encounters are being seen across health professions education,^8,11 and the utilization of simulated patient encounters provides a safe way to begin this clinical aspect of a student’s education.¹⁶ Focusing on a practitioner’s attributes (rather than patient diagnoses) allows for early experiential learning and subsequent reflective practice. This descriptive study outlined an experiential learning activity using standardized patients to highlight empathy.

Limitations

This study presents an example of how experiential learning can be utilized outside of the development of specific diagnostic skills. No repeated or objective measurement of empathy has been completed, so the effectiveness of the intervention is unknown.

Future Studies

Future studies should consider outcome measures such as the Jefferson Scale for Empathy, while still maintaining the overall intention of the activity. The design roadmap illustrated above can be utilized for other content areas, but caution should be exercised in selecting appropriate topics along with measuring the intended results.

An important next step is to provide additional learning opportunities to solidify the knowledge and apply the lessons learned to future experiences. Kolb and Lewis state that “adults demand relevance and seek opportunities to test ideas against their own accumulated experience.”¹⁷ The experience described above does not maximize its effectiveness as a stand-alone exercise, and additional re-enforcement is needed in other courses and years of the program. Horizontal and Vertical integration of the curriculum along with appropriate increasing levels of complexity can help in the development of an empathic and reflective practitioner. An increased focus on empathy development and preservation has subsequently informed the development of additional simulations and mock clinical scenarios within the curriculum. Being able to look back to this initial recorded experience has allowed students to reflect on how far they have come.

Conclusion

An experiential learning activity utilizing standardized patients was developed to address the potential deterioration of empathy in first-year chiropractic students. Experiential learning provides a viable option to not only deepen a student’s clinical learning, but also to refine professional behavior.