Korean Medical Education Review (의학교육논단)

Yonsei university college of medicine (연세대학교 의과대학)
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Beyond Cognitive Empathy: Suggestions for Strengthening Medical Students' Empathy

인지적 공감을 넘어: 의과대학생의 공감능력 증진을 위한 제안

  • Youngjoon Lee (Department of Medical Education, Yonsei University College of Medicine)
  • 이영준 (연세대학교 의과대학 의학교육학교실)
  • Received : 2023.10.16
  • Accepted : 2024.03.05
  • Published : 2024.06.30
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Abstract

A physician's empathy plays a crucial role in patient-centered care, and in modern medicine, patients, their caregivers, and society demand a high level of empathy from healthcare providers. The conceptualization of clinical empathy, which has emphasized cognitive empathy since the mid-20th century, has been widely accepted in medical schools and the healthcare industry without much critical ref lection. This study provides an overview of the ongoing debates on empathy versus sympathy and cognitive empathy versus affective empathy to clarify the concept of empathy. Based on recent research findings, clinical empathy is proposed to encompass three components: cognitive empathy, affective empathy, and empathic motivation. It is suggested that fully demonstrating these components requires empathic communication skills. Additionally, the cognitive characteristics of medical students and the features of the academic environment demonstrate the need for education to strengthen their empathy skills. Considering this, proposed intervention methods that medical schools can consider include utilizing tutoring programs and debriefing processes for team activities, which can facilitate problem-solving as a coping strategy for stress. Learning communities can create an environment where students can receive social support and recover from stress. Medical schools can contribute to the development of students' professional identities as practicing clinicians who embody empathy and respect by cultivating professors as positive role models. Additionally, utilizing scales to assess the empathic nature of doctor-patient communication or incorporating patients and caregivers as evaluators can actively improve empathic communication skills.

Keywords

References

  1. Michael K , Dror MG, Karnieli-Miller O. Students' patient-centered-care attitudes: the contribution of self-efficacy, communication, and empathy. Patient Educ Couns. 2019;102(11):2031-7. https://doi.org/10.1016/j.pec.2019.06.004 
  2. Ratka A. Empathy and the development of affective skills. Am J Pharm Educ. 2018;82(10):7192. https://doi.org/10.5688/ajpe7192 
  3. Han J, Kim D, Kim C, Eo E, Myung SJ, Oh S. A study of Korean Doctor's Role, 2021. Seoul: Korean Medical Association, Research Institute for Healthcare Policy; 2021. 
  4. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 2013;63(606):e76-84. https://doi.org/10.3399/bjgp13X660814 
  5. Hojat M, Louis DZ, Maxwell K, Markham F, Wender R, Gonnella JS. Patient perceptions of physician empathy, satisfaction with physician, interpersonal trust, and compliance. Int J Med Educ. 2010;1:83-7. https://doi.org/10.5116/ijme.4d00.b701 
  6. Neumann M, Wirtz M, Bollschweiler E, Mercer SW, Warm M, Wolf J, et al. Determinants and patient-reported long-term outcomes of physician empathy in oncology: a structural equation modelling approach. Patient Educ Couns. 2007;69(1-3):63-75. https://doi.org/10.1016/j.pec.2007.07.003 
  7. Steinhausen S, Ommen O, Antoine SL, Koehler T, Pfaff H, Neugebauer E. Short-and long-term subjective medical treatment outcome of trauma surgery patients: the importance of physician empathy. Patient Prefer Adherence. 2014;8:1239-53. https://doi.org/10.2147/PPA.S62925 
  8. Decety J, Yoder KJ. Empathy and motivation for justice: cognitive empathy and concern, but not emotional empathy, predict sensitivity to injustice for others. Soc Neurosci. 2016;11(1):1-14. https://doi.org/10.1080/17470919.2015.1029593 
  9. Anderson MB, Cohen JJ, Hallock JE, Kassebaum DG, Turnbull J, Whitcomb ME. Learning objectives for medical student education: guidelines for medical schools. Washington (DC): Association of American Medical Colleges; 1998. 
  10. Jahoda G. Theodor Lipps and the shift from "sympathy" to "empathy". J Hist Behav Sci. 2005;41(2):151-63. https://doi.org/10.1002/jhbs.20080 
  11. Hackney H. The evolution of empathy. Pers Guid J. 1978;57(1):35-8. https://doi.org/10.1002/j.2164-4918.1978.tb05091.x 
  12. Aring CD. Sympathy and empathy. J Am Med Assoc. 1958;167(4):448-52. https://doi.org/10.1001/jama.1958.02990210034008 
  13. Blumgart HL. Caring for the patient. N Engl J Med. 1964;270:449-56. https://doi.org/10.1056/NEJM196402272700906 
  14. Halpern J. From detached concern to empathy: humanizing medical practice. New York (NY): Oxford University Press; 2001. 
  15. Halpern J. What is clinical empathy? J Gen Intern Med. 2003;18(8):670-4. https://doi.org/10.1046/j.1525-1497.2003.21017.x 
  16. Batson CD, Fultz J, Schoenrade PA. Distress and empathy: two qualitatively distinct vicarious emotions with different motivational consequences. J Pers. 1987;55(1):19-39. https://doi.org/10.1111/j.1467-6494.1987.tb00426.x 
  17. Davis MH. Measuring individual differences in empathy: evidence for a multidimensional approach. J Pers Soc Psychol. 1983;44(1):113-26. https://doi.org/10.1037/0022-3514.44.1.113 
  18. Hoffman ML. Is altruism part of human nature? J Pers Soc Psychol. 1981;40(1):121-37. https://doi.org/10.1037/0022-3514.40.1.121 
  19. Ickes W. Measuring empathic accuracy. In: Hall JA, Bernieri FJ, editor. Interpersonal sensitivity: theory and measurement. Mahwah (NJ): Lawrence Erlbaum Associates Publishers; 2001. p. 219-41. 
  20. Hojat M. Empathy in patient care: antecedents, development, measurement, and outcomes. New York (NY): Springer; 2007. 
  21. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry. 2002;159(9):1563-9. https://doi.org/10.1176/appi.ajp.159.9.1563 
  22. Hojat M, Mangione S, Kane GC, Gonnella JS. Relationships between scores of the Jefferson Scale of Physician Empathy (JSPE) and the Interpersonal Reactivity Index (IRI). Med Teach. 2005;27(7):625-8. https://doi.org/10.1080/01421590500069744 
  23. Hojat M, DeSantis J, Shannon SC, Mortensen LH, Speicher MR, Bragan L, et al. The Jefferson Scale of Empathy: a nationwide study of measurement properties, underlying components, latent variable structure, and national norms in medical students. Adv Health Sci Educ Theory Pract. 2018;23(5):899-920. https://doi.org/10.1007/s10459-018-9839-9 
  24. Truax CB, Carkhuff R. Toward effective counseling and psychotherapy: training and practice. Chicago (IL): Aldine; 1967. 
  25. Wilmer HA. The doctor-patient relationship and the issues of pity, sympathy and empathy. Br J Med Psychol. 1968;41(3):243-8. https://doi.org/10.1111/j.2044-8341.1968.tb02029.x 
  26. Singer T. The neuronal basis and ontogeny of empathy and mind reading: review of literature and implications for future research. Neurosci Biobehav Rev. 2006;30(6):855-63. https://doi.org/10.1016/j.neubiorev.2006.06.011 
  27. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA. 2005;293(9):1100-6. https://doi.org/10.1001/jama.293.9.1100 
  28. Reach G. The mental mechanisms of patient adherence to long-term therapies: mind and care. New York (BY): Springer; 2015. 
  29. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992;267(16):2221-6. https://doi.org/10.1001/jama.1992.03480160079038
  30. Zaki J, Ochsner KN. The neuroscience of empathy: progress, pitfalls and promise. Nat Neurosci. 2012;15(5):675-80. https://doi.org/10.1038/nn.3085 
  31. Gladstein GA. Understanding empathy: integrating counseling, developmental, and social psychology perspectives. J Couns Psychol. 1983;30(4):467-82. https://doi.org/10.1037/0022-0167.30.4.467 
  32. Wundrich M, Schwartz C, Feige B, Lemper D, Nissen C, Voderholzer U. Empathy training in medical students: a randomized controlled trial. Med Teach. 2017;39(10):1096-8. https://doi.org/10.1080/0142159X.2017.1355451 
  33. Kelm Z, Womer J, Walter JK, Feudtner C. Interventions to cultivate physician empathy: a systematic review. BMC Med Educ. 2014;14:219. https://doi.org/10.1186/1472-6920-14-219 
  34. Batt-Rawden SA, Chisolm MS, Anton B, Flickinger TE. Teaching empathy to medical students: an updated, systematic review. Acad Med. 2013;88(8):1171-7. https://doi.org/10.1097/ACM.0b013e318299f3e3 
  35. Baron-Cohen S. The essential difference: men, women and the extreme male brain. London: Penguin Books; 2004. 
  36. Baron-Cohen S. Empathizing, systemizing, and the extreme male brain theory of autism. Prog Brain Res. 2010;186:167-75. https://doi.org/10.1016/B978-0-444-53630-3.00011-7 
  37. Michalska KJ, Kinzler KD, Decety J. Age-related sex differences in explicit measures of empathy do not predict brain responses across childhood and adolescence. Dev Cogn Neurosci. 2013;3:22-32. https://doi.org/10.1016/j.dcn.2012.08.001 
  38. Karniol R, Gabay R, Ochion Y, Harari Y. Is gender or gender-role orientation a better predictor of empathy in adolescence? Sex Roles. 1998;39(1):45-59. https://doi.org/10.1023/A:1018825732154 
  39. Decety J. The neural pathways, development and functions of empathy. Curr Opin Behav Sci. 2015;3:1-6. https://doi.org/10.1016/j.cobeha.2014.12.001 
  40. Pagnin D, de Queiroz V. Comparison of quality of life between medical students and young general populations. Educ Health (Abingdon). 2015;28(3):209-12. https://doi.org/10.4103/1357-6283.178599 
  41. Paro HB, Morales NM, Silva CH, Rezende CH, Pinto RM, Morales RR, et al. Health-related quality of life of medical students. Med Educ. 2010;44(3):227-35. https://doi.org/10.1111/j.1365-2923.2009.03587.x 
  42. MacLean L, Booza J, Balon R. The impact of medical school on student mental health. Acad Psychiatry. 2016;40(1):89-91. https://doi.org/10.1007/s40596-015-0301-5
  43. Thomas MR, Dyrbye LN, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al. How do distress and well-being relate to medical student empathy?: a multicenter study. J Gen Intern Med. 2007;22(2):177-83. https://doi.org/10.1007/s11606-006-0039-6 
  44. Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-91. https://doi.org/10.1097/ACM.0b013e3181b17e55 
  45. Chen D, Lew R, Hershman W, Orlander J. A cross-sectional measurement of medical student empathy. J Gen Intern Med. 2007;22(10):1434-8. https://doi.org/10.1007/s11606-007-0298-x 
  46. Neumann M, Edelhauser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996-1009. https://doi.org/10.1097/ACM.0b013e318221e615 
  47. Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Med Educ. 2005;39(6):594-604. https://doi.org/10.1111/j.1365-2929.2005.02176.x 
  48. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-41. https://doi.org/10.7326/0003-4819-149-5-200809020-00008 
  49. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82-5. https://doi.org/10.1097/00001888-200601000-00020 
  50. Wurm W, Vogel K, Holl A, Ebner C, Bayer D, Morkl S, et al. Depression-burnout overlap in physicians. PLoS One. 2016;11(3):e0149913. https://doi.org/10.1371/journal.pone.0149913 
  51. Folkman S, Lazarus RS. An analysis of coping in a middle-aged community sample. J Health Soc Behav. 1980;21(3):219-39. 
  52. Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. J Pers Assess. 1990;55(3-4):610-7. https://doi.org/10.1080/00223891.1990.9674095 
  53. Cohen S, Mermelstein R, Kamarck T, Hoberman HM. Measuring the functional components of social support. In: Sarason IG, Sarason BR, editor. Social support: theory, research and applications. The Hague: Springer; 1985. p. 73-94. 
  54. Schiller JH, Stansfield RB, Belmonte DC, Purkiss JA, Reddy RM, House JB, et al. Medical students' use of different coping strategies and relationship with academic performance in preclinical and clinical years. Teach Learn Med. 2018;30(1):15-21. https://doi.org/10.1080/10401334.2017.1347046 
  55. Steiner-Hofbauer V, Holzinger A. How to cope with the challenges of medical education?: stress, depression, and coping in undergraduate medical students. Acad Psychiatry. 2020;44(4):380-7. https://doi.org/10.1007/s40596-020-01193-1 
  56. Chawla K, Sachdeva V. Domains of stress and coping strategies used by 1st year medical students. Natl J Physiol Pharm Pharm. 2018;8(3):366-9. https://doi.org/10.5455/njppp.2017.7.1040623102017 
  57. Thompson G, McBride RB, Hosford CC, Halaas G. Resilience among medical students: the role of coping style and social support. Teach Learn Med. 2016;28(2):174-82. https://doi.org/10.1080/10401334.2016.1146611 
  58. Yamada Y, Klugar M, Ivanova K , Oborna I. Psychological distress and academic self-perception among international medical students: the role of peer social support. BMC Med Educ. 2014;14:256. https://doi.org/10.1186/s12909-014-0256-3 
  59. Yu TC, Wilson NC, Singh PP, Lemanu DP, Hawken SJ, Hill AG. Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract. 2011;2:157-72. https://doi.org/10.2147/AMEP.S14383 
  60. Hudson JN, Tonkin AL. Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients. Med Educ. 2008;42(9):901-8. https://doi.org/10.1111/j.1365-2923.2008.03107.x 
  61. Madson L, Burns CM. Jumpstarting team cohesion with team activity debriefings. Med Sci Educ. 2019;30(1):609-15. https://doi.org/10.1007/s40670-019-00843-w 
  62. Chen W, McCollum MA, Bradley EB, Nathan BR , Chen DT, Worden MK . Using instrument-guided team reflection and debriefing to cultivate teamwork knowledge, skills, and attitudes in pre-clerkship learning teams. Med Sci Educ. 2018;29(1):45-50. https://doi.org/10.1007/s40670-018-00669-y 
  63. Rosenbaum ME, Schwabbauer M, Kreiter C, Ferguson KJ. Medical students' perceptions of emerging learning communities at one medical school. Acad Med. 2007;82(5):508-15. https://doi.org/10.1097/ACM.0b013e31803eae29 
  64. Smith S, Shochet R, Keeley M, Fleming A, Moynahan K. The growth of learning communities in undergraduate medical education. Acad Med. 2014;89(6):928-33. https://doi.org/10.1097/ACM.0000000000000239 
  65. Tackett S, Wright S, Colbert-Getz J, Shochet R. Associations between learning community engagement and burnout, quality of life, and empathy among medical students. Int J Med Educ. 2018;9:316-22. https://doi.org/10.5116/ijme.5bef.e834 
  66. Champaloux EP, Keeley MG. The impact of learning communities on interpersonal relationships among medical students. Med Educ Online. 2016;21:32958. https://doi.org/10.3402/meo.v21.32958 
  67. Pohontsch NJ, Stark A, Ehrhardt M, Kotter T, Scherer M. Influences on students' empathy in medical education: an exploratory interview study with medical students in their third and last year. BMC Med Educ. 2018;18(1):231. https://doi.org/10.1186/s12909-018-1335-7 
  68. Ahmadian Yazdi N, Bigdeli S, Soltani Arabshahi SK, Ghaffarifar S. The influence of role-modeling on clinical empathy of medical interns: a qualitative study. J Adv Med Educ Prof. 2019;7(1):35-41. https://doi.org/10.30476/JAMP.2019.41043 
  69. Branch WT Jr, Weil AB, Gilligan MC, Litzelman DK , Hafler JP, Plews-Ogan M, et al. How physicians draw satisfaction and overcome barriers in their practices: "it sustains me". Patient Educ Couns. 2017;100(12):2320-30. https://doi.org/10.1016/j.pec.2017.06.004 
  70. Pedersen R. Empirical research on empathy in medicine: a critical review. Patient Educ Couns. 2009;76(3):307-22. https://doi.org/10.1016/j.pec.2009.06.012
  71. Grosseman S, Novack DH, Duke P, Mennin S, Rosenzweig S, Davis TJ, et al. Residents' and standardized patients' perspectives on empathy: issues of agreement. Patient Educ Couns. 2014;96(1):22-8. https://doi.org/10.1016/j.pec.2014.04.007 
  72. Buffel du Vaure C, Lemogne C, Bunge L, Catu-Pinault A, Hoertel N, Ghasarossian C, et al. Promoting empathy among medical students: a two-site randomized controlled study. J Psychosom Res. 2017;103:102-7. https://doi.org/10.1016/j.jpsychores.2017.10.008 
  73. Mercer SW, Maxwell M, Heaney D, Watt GC. The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract. 2004;21(6):699-705. https://doi.org/10.1093/fampra/cmh621 
  74. Roter D, Larson S. The Roter interaction analysis system (RIAS): utility and flexibility for analysis of medical interactions. Patient Educ Couns. 2002;46(4):243-51. https://doi.org/10.1016/s0738-3991(02)00012-5 
  75. Bylund CL, Makoul G. Empathic communication and gender in the physician-patient encounter. Patient Educ Couns. 2002;48(3):207-16. https://doi.org/10.1016/s0738-3991(02)00173-8 
  76. Bayne HB. Training medical students in empathic communication. J Spec Group Work. 2011;36(4):316-29. https://doi.org/10.1080/01933922.2011.613899 
  77. Foster A, Chaudhary N, Kim T, Waller JL, Wong J, Borish M, et al. Using virtual patients to teach empathy: a randomized controlled study to enhance medical students' empathic communication. Simul Healthc. 2016;11(3):181-9. https://doi.org/10.1097/SIH.0000000000000142 
  78. Gilbert A, Carnell S, Lok B, Miles A. Using virtual patients to support empathy training in health care education: an exploratory study. Simul Healthc. 2023 Aug 28 [Epub]. https://doi.org/10.1097/SIH.0000000000000742 
  79. Kurtz SM, Silverman JD. The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Med Educ. 1996;30(2):83-9. https://doi.org/10.1111/j.1365-2923.1996.tb00724.x