Walking a fine line: is it possible to remain an empathic physician and have a hardened heart?

Cognitive empathy of osteopathic students: a longitudinal study with data comparisons to the Project in Osteopathic Medical Education and Empathy (POMEE)

CONTEXT

Establishing an empathic bond of trust with patients is a characteristic that physicians need, because patients feel that physicians are more caring if they sense that they are empathetic. Former cross-sectional studies have shown an erosion of cognitive empathy as medical students progress through their education.

OBJECTIVES

This study aims to measure the changes in student cognitive empathy as they progress through their undergraduate osteopathic medical education. Cognitive empathy scores are compared to the nationwide norms established by the Project in Osteopathic Medical Education and Empathy (POMEE) study by Mohammadreza Hojat, PhD, and colleagues.

METHODS

During orientation to medical school, and at the beginning of each subsequent academic year, and just before graduation, the graduating classes of 2017-2019 participated in this longitudinal study by filling out the Jefferson Scale of Empathy-Student Version (JSE-S). A total of 345/459 Osteopathic Medical Student (OMS) I-IV students (75.2 % of the graduates) filled out the forms for all five time points. Desired specialty choice and sex were also collected. Specialty choice was divided into Core and Non-Core groups. Core specialties are "people-oriented" and have a large amount of patient contact and continuity of care, while Non-Core specialties are "technical- or procedure-oriented" and have little or no patient contact and/or continuity of care.

RESULTS

Men selecting Non-Core specialties had significant drops in JSE-S scores (p=0.001); whereas men who selected the Core specialties did not have a significant decrease. For women, there was no significant drop in JSE-S scores for those selecting either Core or Non-Core specialties. When compared to POMEE norm data, none of the Campbell University School of Medicine students had JSE-S scores that were above the 50th percentile.

CONCLUSIONS

Students selecting Core specialties do a better job of maintaining their cognitive empathy, which aids their ability to establish an empathic bond of trust with patients, when compared to students who desire Non-Core specialties. JSE-S scores not above the POMEE 50th percentile is concerning and indicate either a curricular change to better enhance empathic communication skills and/or better applicant selection.

Empathy for a Black Woman Victim of Police Sexual Violence: The Roles of Crime-Related Stress and Stereotype Attributions

Police sexual violence has been ranked as the second most common form of misconduct among police officers. Moreover, there is evidence that Black women are at heightened risk of being victims of such police violence. A report titled Say Her Name: Resisting Police Brutality Against Black Women has brought international attention to the minimal empirical focus on such police violence toward Black women. To address this lacuna in the literature, using an incident of police sexual assault of a woman, we assessed whether victim's race and participants' level of crime-related stress (i.e., stress due to crime victimization) would influence empathic responding toward the victim. Prolific participants (N = 411) first completed a measure of crime-related stress. They then read an article describing a White police officer's sexual assault of a Black or White woman. Next, participants completed a racial stereotype-related measure (i.e., Black women's higher sexual proclivity) and a stereotype-unrelated measure (i.e., perceived victim untrustworthiness), and reported their victim-directed empathic responding. At high stress levels, participants reported less empathy for the Black (relative to White) victim. At low stress levels, there was greater Black victim-directed empathy. The race effects on empathy were mediated by heightened attribution of Black women-related stereotypical beliefs to the Black victim at high stress levels and by diminished attribution at low stress levels. In sum, we addressed the lacuna in the literature on police sexual violence against Black women while providing evidence that stress can play a critical role in the occurrence of the oft-cited outgroup-directed empathy deficit.

The different role of trait empathy and state social exclusion empathy on subsequent feelings about gambling outcome：Evidence from event-related potentials and time-frequency decompositions

Empathy plays an essential role in determining how we understand and respond to others' emotional experiences. Previous studies have mainly focused on the influencing factors of physical pain and monetary loss empathy, as well as on their effects on subsequent feelings. However, little is known about social pain empathy and its influence on subsequent feelings, and the role of personal trait empathy. In this study, we performed Cyberball Games and gambling tasks to explore the effect of social exclusion empathy on subsequent feelings for gambling outcomes (others' losses and gains) by analyzing the brain activity of excluded and non-excluded players at the gambling outcome feedback stage. It was found that both feedback-related negativity (FRN) and theta-band oscillatory are more negative for loss outcome than gain for the excluded players, while these effects cannot be found for the non-excluded players. Furthermore, we only observed a larger P300 amplitude in the gain outcome than that of loss, regardless of the players' role. More interestingly, we found state social pain empathy is negatively correlated with the d-FRN amplitude under non-excluded conditions, while trait empathy is positively correlated with P300 amplitude regardless of the players' role. These results provide insight into the different roles of state social pain empathy and trait empathy on subsequent gambling outcomes. Furthermore, different from previous studies, the current results show that d-FRN could reflect the state empathy discrepancy rather than the biomarker of state empathy.

Having Heart: Affective and Cognitive Empathy Scores vs. Residency Specialty Match at an Osteopathic Medical School

BACKGROUND

Past studies examining the cognitive empathy of medical school graduates grouped the various residency selections vs. parsing them out. This study examines both affective and cognitive empathy scores of osteopathic medical school graduates entering eleven different residency specialties.

METHODS

Participants from the Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM) classes of 2017-2019 completed the Balanced Emotional Empathy Scale (BEES; measuring affective empathy) and the Jefferson Scale of Empathy, Student version (JSE-S; measuring cognitive empathy). Empathy scores were compared to residency choice upon graduation. The specialty choices were broken into two groups: Core specialties (i.e., people-oriented) that include Family Medicine, Internal Medicine, Obstetrics and Gynecology (OB/Gyn), Pediatrics, and Psychiatry. The remaining specialties are considered Non-Core specialties (i.e., technical/procedure-oriented) and included Anesthesiology, Diagnostic Radiology, Emergency Medicine, General Surgery, Neurology, and Orthopedics. Results are compared to data from the nationwide Project in Osteopathic Medical Education and Empathy (POMEE).

RESULTS

Women graduates tended to have larger BEES and JSE-S scores than men. Affective empathy scores were the largest for students selecting Core specialties. Four of these Core specialties were in the top four positions out of the eleven specialties selected by eight or more graduates. None of the eleven specialties was ranked higher than the 50th percentile compared to BEES score norms. Cognitive empathy scores were also the largest for students selecting Core specialties. All five of the Core specialties were in the top six positions out of the eleven specialties. None of the eleven specialties ranked greater than the 39th percentile when compared to OMS-III and OMS-IV POMEE data. Only women entering Psychiatry had a JSE-S score that was greater than the 50th percentile.

CONCLUSIONS

Osteopathic graduates selecting the five Core specialties have BEES and JSE-S scores that are, usually, larger than students entering Non-Core specialties. For either survey instrument, both Pediatrics and Family Medicine were first and second out of a possible 11 positions, respectively. Most CUSOM graduates had JSE-S scores lower than their peers in other osteopathic medical schools that participated in the POMEE study. When the CUSOM data are compared to allopathic data, there is no clear evidence that osteopathic students have substantially higher affective or cognitive empathy scores than their allopathic peers. Therefore, it appears that medical students who select osteopathy for its tenant of a more holistic approach to patient care are no more empathetic than students studying allopathic medicine. Several suggestions are made on how to potentially increase student empathy during undergraduate medical education.

The Relationship between Cognitively-Based Clinical Empathy and Attitudes toward Death and Dying in Medical Students

Empathy has a potentially complicated relationship with dealing with death and dying. Having clinical empathy can improve interactions with dying, but educational interventions aimed at fostering empathy may cause medical students to connect emotionally with dying patients and behave unprofessionally out of self-defense. Cognitively-based clinical empathy should lead to positive attitudes toward death and dying by adhering to the principles of detached concern and professionalism. Hypotheses: The main components of cognitively-based clinical empathy are negatively correlated with (1) difficulty communicating with dying patients and their relatives, and (2) avoidance of death and dying. Method: This cross-sectional study included 372 medical students from two universities in Konya, Turkey. Data were collected via a survey consisting of three parts: socio-demographic information, the Turkish version of Jefferson Scale of Empathy-Student Version (JSE-S), and the Turkish Approach to Death and Dying Patients Attitude Scale. Independent samples t-test and one-way analysis of variance were used for comparative analysis. Bivariate and partial correlation analyses were used to assess the associations between variables. Results: Perspective-taking and compassionate care were significantly and moderately positively correlated with difficulty communicating with the dying and their relatives. Perspective-taking and compassionate care had significant, but weak positive correlations with avoiding death and dying. There was no significant correlation between standing in the patient's shoes and either communication or avoidance. Conclusions: Both hypotheses were rejected. The present findings raise questions regarding whether the JSE-S is an effective operationalization of cognitively-based clinical empathy. Perspective-taking and compassionate care as measured by the JSE-S may reflect a propensity to engaging emotionally that leads to negative attitudes toward death and dying in medical students. If so, reducing the negative effects of emotional engagement seems crucial for developing positive attitudes toward death and dying in medical students.

Compassion in the Clink: When and How Human Services Workers Overcome Barriers to Care

A key assumption in past literature has been that human services workers become emotionally distant from their charges (such as clients or patients). Such distancing is said to protect workers from the emotionally draining aspects of the job but creates challenges to feeling and behaving compassionately. Because little is known about when and how compassion occurs under these circumstances, we conducted a multiphased qualitative study of 119 correctional officers in the United States using interviews and observations. Officers’ accounts and our observations of their interactions with inmates included cruel, disciplinary, unemotional, and compassionate treatment. Such treatment varied by the situations that officers faced, and compassion was surprisingly common when inmates were misbehaving—challenging current understanding of the occurrence of compassion at work. Examining officers’ accounts more closely, we uncovered a novel way that we theorize human services workers can be compassionate, even under such difficult circumstances. We find that officers describe engaging in practices in which they (a) relate to others by leveling group-based differences between themselves and their charges and (b) engage in self-protection by shielding themselves from the negative emotions triggered by their charges. We posit that the combined use of such practices offsets different emotional tensions in the work, rather than only providing emotional distance, and in doing so, can foster compassionate treatment under some of the most trying situations and organizational barriers to compassion.

The Complex Relationship Between Veterinarian Mental Health and Client Satisfaction

A relatively high risk of poor mental health has been described among Canadian veterinarians, but no published studies have explored the impact that veterinarian mental health may have on veterinary clients and patients. In order to investigate the association between veterinarian mental health and veterinary client satisfaction, veterinarians were randomly sampled and recruited throughout southwestern Ontario, Canada, from November, 2017, through January, 2019. Sixty participating veterinarians completed an enrollment survey that included psychometric scales measuring resilience, perceived stress, anxiety, depression, emotional distress, emotional exhaustion, depersonalization, personal accomplishment, burnout, secondary traumatic stress, and compassion satisfaction. Nine hundred and ninety-five companion animal clients of these veterinarians were recruited in-clinic over 2–3 days and completed a post-appointment survey including the Client Satisfaction Questionnaire. The associations between clients' satisfaction scores (as the outcome variable) and each of the veterinarians' mental health measures (as the explanatory variables) were assessed using separate, multilevel, multivariable linear regression models. The associations between client satisfaction and veterinarian mental health measures were non-linear and complex; in several of the models, relatively higher client satisfaction was unexpectedly associated with poor veterinarian mental health states, while lower client satisfaction was associated with mental health scores suggesting wellness. Given that client satisfaction may impact client adherence to medical recommendations, client loyalty, and business income, the association with veterinarian mental health may have broad implications and warrants further investigation.

Challenges in promoting clinical empathy skills in medical students: A content analysis study

Background: Empathy is a key clinical skill in the medical profession, and many studies have reported a decline in it among medical students during their years of education; especially, in the clinical stage, and this affective decline persists in the physician-hood. This study aimed to explore the participants' perceptions about challenges for promoting clinical empathy in training stages. Methods: A qualitative design using content analysis was applied. Semi-structured interviews were applied to obtain data. Individual interviews were conducted with 14 interns and six clinical professors. The data were analyzed through conventional content analysis and the credibility, trustworthiness, and conformability of the data were confirmed. Results: Data analysis led to the extraction of two main categories, including overt and covert challenges, and also four categories and nine sub-categories. Conclusion: Resolving clinical empathy challenges in medical students requires financial and human resources, and training on the principles of effective doctor-patient interactions. Furthermore, professionalism should be strengthened in professors, and both official and hidden curricula should be revised accordingly.

The relationship between empathy and stress: a cross-sectional study among undergraduate medical students

PURPOSE

Empathy is critical for medical doctors, as it enables them to conduct good patient-centred care. Medical students are expected to learn this ability as part of their education and training.

METHODS

Using a cross-sectional design, the present study was conducted to identify whether the empathy levels of medical students are affected by their stress levels. A translated version of the Perceived Stress Scale-10 was used to measure the students' stress levels, while the Jefferson Scale of Physician Empathy was used to measure their empathy levels.

RESULTS

A total of 464 students from one medical school in Indonesia participated in the study. Stress levels among medical students peak in their first year of study and maintain a downward trend over the following years. The students' empathy levels increased during their first 3 years, declined significantly upon entering the first clinical year, and increased during the second clinical year. However, no correlations were found between stress level and empathy level.

CONCLUSION

These findings suggest that there may be other underlying factors that contribute to empathy decline among medical students upon entering their first clinical year. Further research should be conducted to identify these factors. The bounced-back of empathy level to a higher level in the second year highlights the importance of student adaptation in the clinical learning environment and the support system.

Brain activity sustaining the modulation of pain by empathetic comments

Empathetic verbal feedback from others has been shown to alleviate the intensity of experimental pain. To investigate the brain changes associated with this effect, we conducted 3T-fMRI measurements in 30 healthy subjects who received painful thermal stimuli on their left hand while overhearing empathetic, neutral or unempathetic comments, supposedly made by experimenters, via headsets. Only the empathetic comments significantly reduced pain intensity ratings. A whole-brain BOLD analysis revealed that both Empathetic and Unempathetic conditions significantly increased the activation of the right anterior insular and posterior parietal cortices to pain stimuli, while activations in the posterior cingulate cortex and precuneus (PCC/Prec) were significantly stronger during Empathetic compared to Unempathetic condition. BOLD activity increased in the DLPFC in the Empathetic condition and decreased in the PCC/Prec and vmPFC in the Unempathetic condition. In the Empathetic condition only, functional connectivity increased significantly between the vmPFC and the insular cortex. These results suggest that modulation of pain perception by empathetic feedback involves a set of high-order brain regions associated with autobiographical memories and self-awareness, and relies on interactions between such supra-modal structures and key nodes of the pain system.

Anecdote or Reality: Are People From the South and/or Rural Areas of the USA More Empathetic?

Although numerous studies have analyzed empathy scores of allopathic and osteopathic medical students and how these scores fluctuate throughout undergraduate medical education, little is known about whether demographics have an impact on medical students' empathy scores. Using the Balanced Emotional Empathy Scale (BEES) and Jefferson Scale of Empathy (JSE) surveys to measure affective and cognitive empathy, respectively, this present study examined the relationship between empathy scores with the following demographic data from first and second year students at a southeastern US osteopathic medical school: the classification of whether students came from a rural or urban background, the region of the US students lived in prior to matriculation to medical school, and the town/city size of where they were currently living at the time of applying to medical school. Data analyses showed only one statistically significant data point (p < 0.04) that revealed first year osteopathic medical students (OMS-I) from towns with < 10,000 occupants had higher JSE scores in comparison to students coming from towns with 50,000-99,999 occupants. However, trends could be established. For example, anecdotally, it is often presumed people from the southern United States tend to be friendlier than those from the northern states; however, contrary to this, the data revealed OMS-I students from the southern United States had a slightly lower BEES scores than OMS-I students from the northeastern states. JSE scores were nearly identical across all four US census bureau regions. Additionally, OMS-I students coming from an urban background had a higher BEES scores than those coming from a rural background. Compared to population norms, combined male and female BEES scores for OMS-I and -II students were within ± 0.5 s.d. of the norm and are considered to be "average" scores. Combined OMS-I JSE scores were below the population norm at the 37th percentile, and combined OMS-II JSE scores were also at the 37th percentile, except for students from the western region at the 44th percentile.

The influence of role-modeling on clinical empathy of medical interns: A qualitative study

INTRODUCTION

Clinical empathy ascertains the quality of doctor-patient relationship and entails beneficial outcomes for both parties. Role-modeling is a major factor in promoting clinical empathy skills of medical students. The present study attempted to explain the importance of role-modeling in clinical empathy of medical interns. It was also intended to obtain a better and more profound understanding of the subject based on the experiences of medical interns.

METHODS

In this qualitative conventional content analysis, semi-structured individual interviews were conducted with 14 medical interns and 6 clinical professors. The participants were selected by purposive sampling. All interviews were recorded, transcribed, and analyzed. Trustworthiness, credibility, and confirmability of the data were confirmed.

RESULTS

Data analysis led to the emergence of a theme called role-modeling, and two subcategories: "advertent role-modeling" and "inadvertent role-modeling". Advertent role-modeling included "influenced by the charismatic personality of professors", "critique of faculty members' communicative behaviors with patients", and "observation of the faculty members' performance". Inadvertent role-modeling included "crystallization of human values in communication behaviors" and "compliance with hierarchical behavior".

CONCLUSION

Role-modeling was the main theme of the present study. To improve clinical empathy skills, particular attention should be paid to role-modeling. Informing clinical professors and medical students on role-modeling, strengthening students' empathetic behaviors by role model professors, and recruitment of professors with strong communication skills are among the recommended strategies of this study.

The influence of role-modeling on clinical empathy of medical interns: A qualitative study

INTRODUCTION

Clinical empathy ascertains the quality of doctor-patient relationship and entails beneficial outcomes for both parties. Role-modeling is a major factor in promoting clinical empathy skills of medical students. The present study attempted to explain the importance of role-modeling in clinical empathy of medical interns. It was also intended to obtain a better and more profound understanding of the subject based on the experiences of medical interns.

METHODS

In this qualitative conventional content analysis, semi-structured individual interviews were conducted with 14 medical interns and 6 clinical professors. The participants were selected by purposive sampling. All interviews were recorded, transcribed, and analyzed. Trustworthiness, credibility, and confirmability of the data were confirmed.

RESULTS

Data analysis led to the emergence of a theme called role-modeling, and two subcategories: "advertent role-modeling" and "inadvertent role-modeling". Advertent role-modeling included "influenced by the charismatic personality of professors", "critique of faculty members' communicative behaviors with patients", and "observation of the faculty members' performance". Inadvertent role-modeling included "crystallization of human values in communication behaviors" and "compliance with hierarchical behavior".

CONCLUSION

Role-modeling was the main theme of the present study. To improve clinical empathy skills, particular attention should be paid to role-modeling. Informing clinical professors and medical students on role-modeling, strengthening students' empathetic behaviors by role model professors, and recruitment of professors with strong communication skills are among the recommended strategies of this study.

Virtual morality in the helping professions: Simulated action and resilience

Recent advances in virtual technologies have allowed the investigation of simulated moral actions in aversive moral dilemmas. Previous studies have employed diverse populations to explore these actions, with little research considering the significance of occupation on moral decision-making. For the first time, in this study we have investigated simulated moral actions in virtual reality made by professionally trained paramedics and fire service incident commanders who are frequently faced with and must respond to moral dilemmas. We found that specially trained individuals showed distinct empathic and related personality trait scores and that these declined with years of experience working in the profession. Supporting the theory that these professionals develop resilience in moral conflict, reduced emotional arousal was observed during virtual simulations of a distressing dilemma. Furthermore, trained professionals demonstrated less regret following the execution of a moral action in virtual reality when compared to untrained control populations. We showed that, contrary to previous research, trained individuals made the same moral judgements and moral actions as untrained individuals, though showing less arousal and regret. In the face of increasing concerns regarding empathy decline in health care professionals, we suggest that the nature of this decline is complex and likely reflects the development of a necessary emotional resilience to distressing events.

Empathy in paediatric intensive care nurses part 2: Neural correlates

AIMS

To determine if there are brain activity differences between paediatric intensive care nurses and allied health professionals during pain intensity rating tasks and test whether these differences are related to the population observed (infant or adult) and professional experience.

BACKGROUND

The underestimation of patients' pain by healthcare professionals has generally been associated with patterns of change in neural response to vicarious pain, notably reduced activation in regions associated with affective sharing and increased activation in regions associated with regulation, compared with controls. Paediatric nurses, however, have recently been found to provide higher estimates of infants' pain in comparison to allied health controls, suggesting that changes in neural response of this population might be different than other health professionals.

DESIGN

Cross-sectional study.

METHODS

Functional MRI data were acquired from September 2014-June 2015 and used to compare changes in brain activity in 27 female paediatric care nurses and 24 allied health professionals while rating the pain of infants and adults in a series of video clips.

RESULTS

Paediatric nurses rated infant and adult pain higher than allied health professionals, but the two groups' neural response only differed during observation of infant pain; paediatric nurses mainly showed significantly less activation in the medial prefrontal cortex (linked to cognitive empathy) and in the left anterior insula and inferior frontal cortex (linked to affective sharing).

CONCLUSIONS

Patterns of neural activity to vicarious pain may vary across healthcare professions and patient populations and the amount of professional experience might explain part of these differences.

Validation of the German version of two scales (RIS, RCS-HCP) for measuring regret associated with providing healthcare

BACKGROUND

The regret intensity scale (RIS) and the regret coping scale for healthcare professionals (RCS-HCP) working in hospitals assess the experience of care-related regrets and how healthcare professional deal with these negative events. The aim of this study was to validate a German version of the RIS and the RCS-HCP.

METHODS

The RIS and RCS-HCP in German were first translated into German (forward- and backward translations) and then pretested with 16 German-speaking healthcare professionals. Finally, two surveys (test and 1-month retest) administered the scales to a large sample of healthcare professionals from two different hospitals.

RESULTS

Of the 2142 eligible healthcare professionals, 494 (23.1%) individuals (108 physicians) completed the cross-sectional web based survey and 244 completed the retest questionnaire. Participants (n = 165, 33.4% of the total sample) who reported not having experienced a regret in the last 5 years, had significantly more days of sick leave during the last 6 months. These participants were excluded from the subsequent analyses. The structure of the scales was similar to the French version with a single dimension for the regret intensity scale (Cronbach's alpha: 0.88) and three types of coping strategies for the regret coping scale (alphas: 0.69 for problem-focused strategies, 0.67 for adaptive strategies and 0.86 for the maladaptive strategies). Construct validity was good and reproduced the findings of the French study, namely that higher regret intensity was associated with situations that entailed more consequences for the patients. Furthermore, higher regret intensity and more frequent use of maladaptive strategies were associated with more sleep difficulties and less work satisfaction.

CONCLUSIONS

The German RIS and RCS-HCP scales were found valid for measuring regret intensity and regret coping in a population of healthcare professionals working in a hospital. Reporting no regret, which corresponds to the coping strategy of suppression, seems to be a maladaptive strategy because it was associated with more frequent sick day leaves.

Exploring the Facets of Empathy and Pain in Clinical Practice: A Review

BACKGROUND

Empathy is an essential element in providing quality patient care. The significance of empathy is even more striking in pain medicine, as chronic pain is notorious for the way it can compromise an individual, leaving him or her isolated and feeling misconceived. This review examines the role of empathy in pain medicine practice.

METHODS

Current and past literature focusing on empathy and pain was searched for in PubMed, Science Direct, MEDLINE (Ovid), MEDLINE (Ebsco), Research Gate, and Google Scholar in July 2015. Search dates were not limited and languages included English only. Search terms were "empathy and pain," "empathy and chronic pain," "physician empathy and pain," "neural mechanisms and empathy," "empathy in clinical practice," "empathy and stigma," and "empathy and medical students". To select relevant publications, the title and abstract of every publication were examined, and when in doubt, the rest of the publication was read.

RESULTS

Four major themes were identified: (1) the neural basis for empathy and pain; (2) the value and challenges of practicing empathy pain medicine; (3) stigma and empathy for pain; and (4) empathy and physician education and training.

CONCLUSION

The review reveals that empathy deserves an unchallenged place in medical care, especially in pain medicine and medical education. It highlights the need to nurture empathy at all levels of professional expertise from medical student to senior doctors.

Medical student empathy: interpersonal distinctions and correlates

Attention to interpersonal behaviors, communication, and relational factors is taking on increasing importance in medical education. Medical student empathy is one aspect of the physician-patient relationship that is often involved in beneficial interactions leading to improved clinical outcomes and patient satisfaction. As an interpersonal quality, empathy is a social behavior well-suited to be examined from an interpersonal perspective. The present study used the interpersonal theory of clinical, personality, and social psychology to examine the construct of empathy and theorize about likely interpersonal correlates. One hundred and sixty-three students from an academic health center in the southeastern United States participated in this study. The medical student version of the Jefferson Scale of Empathy was used to assess empathy and its factors: Perspective taking, compassionate care, and walking in the patient's shoes. Interpersonal assessments included the International Personality Item Pool-Interpersonal Circumplex, the Interpersonal Support Evaluation List, and the UCLA Loneliness Scale. Distinct interpersonal styles and correlates emerged among empathy and its factors. While all factors of empathy were related to interpersonal warmth, perspective taking and compassionate care were also associated with submissiveness. Of note, only walking in the patient's shoes was correlated with both social support and less loneliness. These findings are discussed in light of interpersonal theory with particular attention paid to the implications for medical education and professional development.

Ethical erosion in newly qualified doctors: perceptions of empathy decline

OBJECTIVES

This study sought to understand whether UK Foundation doctors perceived the phenomena of ethical erosion and empathy decline during their initial period of clinical practice, and if so, why this occurred.

METHODS

This qualitative study used semi-structured interviews with nine doctors in their first year of clinical practice at Royal Bolton Hospital, UK. Participants were invited to discuss the definition of empathy, how individuals acquire and maintain empathic ability, perceptions of ethical erosion in the self and others, and how clinical experiences have influenced their empathic ability. The interviews were transcribed, and analysed to identify emergent themes.

RESULTS

Each participant reported a conscious acknowledgement of empathy decline in their own and their colleagues' early clinical experiences as doctors. Stressful working environments, the prioritisation of patients' physical rather than psychological well-being, and the attitudes of senior colleagues were all suggested as possible causes. Some doctors believed that specialties with reduced patient contact had a culture which precluded empathy, and influenced their own practice. In addition, some described how their value judgements of patients had affected their ability to empathise. However, all doctors perceived that empathy skills were desirable in senior clinicians, and some believed that educational interventions may be useful in arresting ethical erosion.

CONCLUSIONS

Newly qualified doctors are aware of ethical erosion in themselves and their colleagues as they begin clinical practice. This has serious implications for patient care. Improving working conditions may reverse this trend. Empathy skills training within undergraduate and postgraduate curricula may be a useful intervention.

Reflections on empathy in medical education: What can we learn from social neurosciences?

The role of empathy in human social interaction has been examined in several research fields, including medical education (ME) and social neuroscience (SN). SN yields insights into empathy based on neurobiological processes, and such information may also be relevant to ME. In this reflection article, the authors first critically review current definitions and concepts of empathy in ME and link them to recent SN findings. In the light of recent evidence from SN, research in ME regarding the positive and negative effects of empathy for physicians and patients is discussed, as well as the question whether (future) physicians differ from the general population with regard to empathic skills. Commonly used SN paradigms and ME approaches to assess empathy are contrasted, a joint approach is advocated, and implications for further interdisciplinary studies are outlined. Finally, the authors delineate the contribution of SN to the question of whether empathy is teachable, and argue that SN findings represent a potential for new ME training approaches. In conclusion, the authors discuss how the incorporation of perspectives on empathy from different research areas would benefit ME, and suggest the translation and integration of such findings into ME research approaches.

Assessing empathy development in medical education: a systematic review

CONTEXT

Empathy in doctor-patient relationships is a familiar topic for medical scholars and a crucial goal for medical educators. Nonetheless, there are persistent disagreements in the research literature concerning how best to evaluate empathy among physicians, and whether empathy declines or increases across medical education. Some researchers have argued that the instruments used to study 'empathy' may not measure anything meaningful to clinical practice or patient satisfaction.

METHODS

We performed a systematic review to learn how empathy is conceptualised in medical education research. We examined how researchers define the central construct of empathy and what they choose to measure, and investigated how well definitions and operationalisations match.

RESULTS

Among the 109 studies that met our search criteria, 20% failed to define the central construct of empathy at all and only 13% used an operationalisation that was well matched to the definition provided. The majority of studies were characterised by internal inconsistencies and vagueness in both the conceptualisation and operationalisation of empathy, constraining the validity and usefulness of the research. The methods most commonly used to measure empathy relied heavily on self-report and cognition divorced from action, and may therefore have limited power to predict the presence or absence of empathy in clinical settings. Finally, the large majority of studies treated empathy itself as a 'black box', using global construct measurements that are unable to shed light on the underlying processes that produce an empathic response.

CONCLUSIONS

We suggest that future research should follow the lead of basic scientific research that conceptualises empathy as relational - an engagement between a subject and an object - rather than as a personal quality that may be modified wholesale through appropriate training.

Individual risk factors for physician boundary violations: the role of attachment style, childhood trauma and maladaptive beliefs

OBJECTIVE

The assessment and remediation of boundary-challenged healthcare professionals is enhanced through examination of individual risk factors. We assessed three such factors--attachment style, childhood trauma and maladaptive beliefs--in 100 attendees (mostly physicians) of a CME professional boundaries course. We propose a theoretical model which draws a causal arc from childhood maltreatment through insecure attachment and maladaptive beliefs to elevated risk for boundary violations.

METHODS

We administered the Experiences in Close Relationship Questionnaire (ECR-R), Childhood Trauma Questionnaire (CTQ), and Young Schema Questionnaire (YSQ) to 100 healthcare professionals (mostly physicians) attending a CME course on professional boundaries. Experts rated participant autobiographies to determine attachment style and early adversities. Correlations and relationships among self- and expert ratings and between different risk factors were examined.

RESULTS

Five percent of participants reported CTQ total scores in the moderate to severe range; eleven percent reported moderate to severe emotional neglect or emotional abuse. Average attachment anxiety and attachment avoidance were low, and more than half of participants were rated “secure” by experts. Childhood maltreatment was correlated with attachment anxiety and avoidance and predicted expert-rated insecure attachment and maladaptive beliefs.

CONCLUSION

Our findings support a potential link between childhood adversity and boundary difficulties, partly mediated by insecure attachment and early maladaptive beliefs. Furthermore, these results suggest that boundary education programs and professional wellness programs may be enhanced with a focus on sequelae of childhood maltreatment, attachment and common maladaptive thinking patterns.

Individual risk factors for physician boundary violations: the role of attachment style, childhood trauma and maladaptive beliefs

OBJECTIVE

The assessment and remediation of boundary-challenged health care professionals is enhanced through examination of individual risk factors. We assessed three such factors - attachment style, childhood trauma and maladaptive beliefs - in 100 attendees (mostly physicians) of a continuing medical education (CME) professional boundaries course. We propose a theoretical model that draws a causal arc from childhood maltreatment through insecure attachment and maladaptive beliefs to elevated risk for boundary violations.

METHODS

We administered the Experiences in Close Relationships Questionnaire Revised (ECR-R), Childhood Trauma Questionnaire (CTQ) and Young Schema Questionnaire (YSQ) to 100 health care professionals attending a CME course on professional boundaries. Experts rated participant autobiographies to determine attachment style and early adversities. Correlations and relationships between self-ratings and expert ratings and among different risk factors were examined.

RESULTS

One fifth of participants reported moderate to severe childhood abuse; sixty percent reported moderate to severe emotional neglect. Despite this, average attachment anxiety and attachment avoidance were low, and more than half of participants were rated "secure" by experts. Childhood maltreatment was correlated with attachment anxiety and avoidance and predicted expert-rated insecure attachment and maladaptive beliefs.

CONCLUSIONS

Our findings support a potential link between childhood adversity and boundary difficulties, partly mediated by insecure attachment and early maladaptive beliefs. Furthermore, these results suggest that boundary education programs and professional wellness programs may be enhanced with a focus on sequelae of childhood maltreatment, attachment and common maladaptive thinking patterns.

The relationship between different facets of empathy, pain perception and compassion fatigue among physicians

BACKGROUND

Medical practitioners such as physicians are continuously exposed to the suffering and the distress of patients. Understanding the way pain perception relates to empathetic dispositions and professional quality of life can contribute to the development of strategies aimed at protecting health professionals from burnout and compassion fatigue. In the present study we investigate the way individual dispositions relate to behavioral measures of pain sensitivity, empathy, and professional quality of life.

METHODS

A secure Web-based series of self-report measures and a behavioral task were administered to 1,199 board-certified physicians. Additionally, surveys were used to obtain measures of demographic and professional background; dispositional empathy (empathic concern, personal distress, and perspective taking); positive (compassion satisfaction) and negative (burnout and secondary traumatic stress) aspects of their professional life. In the behavioral task, participants were asked to watch a series of video clips of patients experiencing different levels of pain and provide ratings of pain intensity and induced personal distress.

RESULTS

Perceived pain intensity was significantly lower among more experienced physicians but similar across specialty fields with varying demands of emotional stress. Watching videos of patients in pain, however, elicited more personal distress among physicians in highly demanding medical fields, despite comparable empathy dispositions with other fields. The pain of male patients was perceived as less intense than the pain of female patients, and this effect was more marked for female physicians. The effect of dispositional empathy on pain perception and induced personal distress was different for each sub-component, with perspective taking and empathic concern (EC) being predictive of the behavioral outcomes. Physicians who experience both compassion satisfaction and fatigue perceive more pain and suffer more personal distress from it than those who only suffer the negative aspects of professional quality of life.

CONCLUSIONS

Professional experience seems to desensitize physicians to the pain of others without necessarily helping them down-regulate their own personal distress. Pain perception is also related with specific aspects of empathy and varies depending on context, as is the case with the gender of their patients. Minimum levels of empathy appear necessary to benefit from the positive aspects of professional quality of life in medicine.

The relationship between different facets of empathy, pain perception and compassion fatigue among physicians

BACKGROUND

Medical practitioners such as physicians are continuously exposed to the suffering and the distress of patients. Understanding the way pain perception relates to empathetic dispositions and professional quality of life can contribute to the development of strategies aimed at protecting health professionals from burnout and compassion fatigue. In the present study we investigate the way individual dispositions relate to behavioral measures of pain sensitivity, empathy, and professional quality of life.

METHODS

A secure Web-based series of self-report measures and a behavioral task were administered to 1,199 board-certified physicians. Additionally, surveys were used to obtain measures of demographic and professional background; dispositional empathy (empathic concern, personal distress, and perspective taking); positive (compassion satisfaction) and negative (burnout and secondary traumatic stress) aspects of their professional life. In the behavioral task, participants were asked to watch a series of video clips of patients experiencing different levels of pain and provide ratings of pain intensity and induced personal distress.

RESULTS

Perceived pain intensity was significantly lower among more experienced physicians but similar across specialty fields with varying demands of emotional stress. Watching videos of patients in pain, however, elicited more personal distress among physicians in highly demanding medical fields, despite comparable empathy dispositions with other fields. The pain of male patients was perceived as less intense than the pain of female patients, and this effect was more marked for female physicians. The effect of dispositional empathy on pain perception and induced personal distress was different for each sub-component, with perspective taking and empathic concern (EC) being predictive of the behavioral outcomes. Physicians who experience both compassion satisfaction and fatigue perceive more pain and suffer more personal distress from it than those who only suffer the negative aspects of professional quality of life.

CONCLUSIONS

Professional experience seems to desensitize physicians to the pain of others without necessarily helping them down-regulate their own personal distress. Pain perception is also related with specific aspects of empathy and varies depending on context, as is the case with the gender of their patients. Minimum levels of empathy appear necessary to benefit from the positive aspects of professional quality of life in medicine.

Acute psychosocial stress and emotion regulation skills modulate empathic reactions to pain in others

Psychosocial stress affects resources for adequate coping with environmental demands. A crucial question in this context is the extent to which acute psychosocial stressors impact empathy and emotion regulation. In the present study, 120 participants were randomly assigned to a control group vs. a group confronted with the Trier Social Stress Test (TSST), an established paradigm for the induction of acute psychosocial stress. Empathy for pain as a specific subgroup of empathy was assessed via pain intensity ratings during a pain-picture task. Self-reported emotion regulation skills were measured as predictors using an established questionnaire. Stressed individuals scored significantly lower on the appraisal of pain pictures. A regression model was chosen to find variables that further predict the pain ratings. These findings implicate that acute psychosocial stress might impair empathic processes to observed pain in another person and the ability to accept one's emotion additionally predicts the empathic reaction. Furthermore, the ability to tolerate negative emotions modulated the relation between stress and pain judgments, and thus influenced core cognitive-affective functions relevant for coping with environmental challenges. In conclusion, our study emphasizes the necessity of reducing negative emotions in terms of empathic distress when confronted with pain of another person under psychosocial stress, in order to be able to retain pro-social behavior.

The temporal decline of idealism in two cohorts of medical students at one institution

BACKGROUND

A number of studies have indicated that students lose idealistic motivations over the course of medical education, with some identifying the initiation of this decline as occurring as early as the second year of the traditional US curricula. This study builds on prior work testing the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school.

METHODS

The original study sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning and end of academic year 2010, on three proxies for idealism. The current study extends that work by administering the same survey items to the same student cohorts at the end of their third and fourth years (MS3 and MS4), respectively. Survey topics included questions on: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions. Linear regression was then used to test the effect of the six cohort/time-points on each composite variable, controlling for demographic characteristics.

RESULTS

Idealism in medicine decreased (β = -.113, p < .001) while emphasis on employment and job security increased (β = .146, p < .001) as motivators of pursuing a career in medicine at each medical school stage and time period. Students were more likely to be motivated by student debt over interest in content in specialty choice (β = .077, p = .004) across medical school stages. Negative attitudes towards primary care were most sensitive to MS group and time effects. Both negative/antagonistic views (β = .142, p < .001) and negative/sympathetic views (β = .091, p < .001) of primary care increased over each stage.

CONCLUSIONS

Our results provide further evidence that declines in medical student idealism may occur as early as the second year of medical education. Additionally, as students make choices in their medical careers, such as specialty choice or consideration of primary care, the influences of job security, student debt and social status increasingly outweigh idealistic motivations.

Decline of medical student idealism in the first and second year of medical school: a survey of pre-clinical medical students at one institution

BACKGROUND

Idealism declines in medical students over the course of training, with some studies identifying the beginning of the decline in year 3 of US curricula.

PURPOSES

This study tested the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school.

METHODS

We sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning (T1) and end (T2) of academic year 2010 on three proxies for idealism, including items asking about: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions; linear regression was then used to test the effect of on each LCV, controlling for race, ethnicity, rural or urban origins, gender, and marital status.

RESULTS

MS2s placed more emphasis on status/income concerns (β=0.153, p<0.001), and much less emphasis on idealism as a motivator (β=-0.081, p=0.054), in pursuing a medical career; more likely to consider lifestyle and family considerations (β=0.098, p=0.023), and less likely to consider idealistic motivations (β=-0.066, p=NS); and were more likely to endorse both negative/antagonistic (β=0.122, p=0.004) and negative/sympathetic (β=0.126, p=0.004) attitudes toward primary care.

CONCLUSIONS

The results are suggestive that idealism decline begins earlier than noted in other studies, implying a need for curricular interventions in the first two years of medical school.