Is There Hardening of the Heart During Medical School?

 
NEXT SLIDES
Physician–Patient Relationship

Is There Hardening of the Heart During
Medical School?
Bruce W. Newton, PhD, Laurie Barber, MD, James Clardy, MD, Elton Cleveland, MD,
and Patricia O’Sullivan, EdD

Abstract
Purpose                                                  obstetrics– gynecology, pediatrics,              but the scores of women choosing
To determine whether vicarious empathy                   and psychiatry) or noncore (all other            noncore careers fell below those of the
(i.e., to have a visceral empathic                       specialties).                                    norms by their second year.
response, versus role-playing empathy)
decreases, and whether students                          Results
                                                         Vicarious empathy significantly decreased        Conclusions
choosing specialties with greater patient
                                                         during medical education (P ⬍ .001),             The findings suggest that undergraduate
contact maintain vicarious empathy
                                                         especially after the first and third years.      medical education may be a major
better than do students choosing
specialties with less patient contact.                   Students choosing core careers had               determinant differentially affecting the
                                                         higher empathy than did those choosing           vicarious empathy of students on the
Method                                                   noncore careers. Men choosing core               basis of gender and/or specialty choice.
The Balanced Emotional Empathy Scale                     careers initially had empathy exceeding          The greatest impact occurred in men
was administered at the beginning of                     population norms, but their empathy fell         who chose noncore specialties. The
each academic year at the University of                  to be comparable with that of norms by           significant decrease in vicarious empathy
Arkansas for Medical Sciences for four                   the end of their third year. The empathy         is of concern, because empathy is crucial
classes, 2001–2004. Students also                        of men choosing noncore careers was              for a successful physician–patient
reported their gender and specialty                      comparable with that of norms. Women             relationship.
choice. Specialty choice was classified as               choosing core careers had empathy
core (internal medicine, family medicine,                scores comparable with those of norms,           Acad Med. 2008; 83:244–249.

Medical professionalism is essential                     have shown that medical school can often         individual’s ability to imaginatively take
for maintaining the integrity of the                     have a detrimental effect on certain             the role of another so as to understand
profession, and it includes demonstrating                aspects of students’ professional growth.        and accurately predict that person’s
compassion, caring, and a willingness to                 Negative characteristics such as cynicism        thoughts, feelings and actions.6 The first
put the concerns of patient and society                  may increase, and ethical and moral              definition reflects an innate emotional
above one’s own. Medical education                       development can be stunted.1–3                   response, that is, a “gut reaction,” and is
should promote the development of these                                                                   equivalent to the “empathic concern”
professional qualities. However, studies                 Empathy is one of the most highly                described by Davis7; the second
                                                         desirable professional traits that medical       definition refers to “cognitive” empathy
                                                         education should promote, because                and reflects a learned ability to imagine
Dr. Newton is associate professor of neurobiology        empathic communication skills promote            and intellectualize.7
and developmental sciences, and associate dean for       patient satisfaction and adherence to
undergraduate medical education, University of           treatment plans while decreasing the             Many scales that measure empathy are
Arkansas for Medical Sciences, Little Rock, Arkansas.
                                                         likelihood of malpractice suits.4,5 Patients     investigating cognitive empathy of
Dr. Barber is professor of ophthalmology,                view physicians who possess the quality          individuals to “role-play.”8 Previous data
University of Arkansas for Medical Sciences, Little      of emotional empathy as being better             concerning medical students’ cognitive
Rock, Arkansas.
                                                         caregivers. A physician may possess              empathy are conflicting, indicating either
Dr. Clardy is professor of psychiatry, and associate     competent diagnostic skills, yet be              no changes, decreases, or increases in
dean for graduate medical education, University of
Arkansas for Medical Sciences, Little Rock, Arkansas.
                                                         considered by patients as “ineffective”          empathy during undergraduate medical
                                                         because the physician misses the link            training.9 –13 In our previous cross-
Dr. Cleveland is associate professor of family
medicine and pediatrics, University of Arkansas for
                                                         between patient satisfaction, adherence to       sectional study, we observed a decline in
Medical Sciences, Little Rock, Arkansas.                 medical instructions, and physician              vicarious empathy during medical
                                                         empathy.                                         school.14 There are no known longitudinal
Dr. O’Sullivan is professor of medicine, and
associate director of educational research, University                                                    studies of vicarious empathy. In the
of California at San Francisco, San Francisco,           Sociologists and psychologists have              current study, we examined the
California.                                              divided the concept of empathy into two          longitudinal effect of medical education
Correspondence should be addressed to Dr. Newton,        main definitions or types: vicarious and         on vicarious empathy.
College of Medicine, Academic Affairs, #603,             imaginative. Vicarious empathy is “an
University of Arkansas for Medical Sciences, 4301 W.     individual’s vicarious emotional response        Previous studies suggest that certain
Markham St., Little Rock, AR 72205; telephone:
(501) 686-7407; fax: (501) 686-8160; e-mail:             to perceived emotional experiences of            measures of a medical student’s
(newtonbrucew@uams.edu).                                 others” and imaginative empathy is “an           personality may predict whether the

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student will enter one of five core              Specialty choice. We classified each          The percentages of men and women who
specialties that are characterized by            student’s specialty choice on the basis of    were nonresponders (75.6%, 87 men, and
continuity of patient care (i.e., family         his or her residency match at the time of     24.4%, 28 women) did not differ greatly
medicine, pediatrics, internal medicine,         graduation. Specialty choice was divided      by gender from the same type of
obstetrics– gynecology, and psychiatry)          into two categories, five core specialties    percentages of the responders (77.8%,
versus noncore specialties, where there is       (i.e., internal medicine, family medicine,    326 men, and 22.2%, 93 women; P ⫽
less interpersonal contact and continuity        pediatrics, obstetrics– gynecology, and       .25). For nonresponders, 53.9% entered
of care (all other specialties, for instance,    psychiatry) and noncore specialties (all      core specialties, which did not differ from
emergency medicine, surgery, radiology,          other choices, for instance, surgery,         the percentage of responders that entered
pathology).10,15 With these possible             pathology, and radiology).                    those specialties (P ⫽ 1.0). The female
personality–specialty connections in                                                           nonresponders did not differ statistically
mind, we designed the present study to           Timing of test administration. Students       in their likelihood of entering core or
determine whether vicarious empathy              completed the questionnaire during            noncore specialties from the female
decreases as students progress through           registration for each academic year.          responders (P ⫽ .82). The same was
medical school, and whether students             Therefore, the M1 classes had no medical      true for men: there was no statistical
choosing specialties with greater patient        training, providing a baseline empathy        difference between responders and
                                                 score.                                        nonresponders in the distribution of
contact maintain vicarious empathy
                                                                                               specialty choice between core and
better than do students choosing
                                                 Analysis of data. Scores for each student     noncore (P ⫽ .63). Therefore, the
specialties with less patient contact.
                                                 were calculated according to BEES             nonresponders do not represent a bias in
                                                 instructions.16 Descriptive statistics were   the data.
                                                 calculated by class, gender, and choice of
Method                                           specialty. As stated earlier, we conducted    There was a significant association
Setting and sample. We gathered this             separate analyses for men and women,          between gender and specialty choice, with
study’s data from a single South-Central         because the BEES is gender specific. For      94 (63.9%) women planning to enter a
U.S. medical school: The University of           each year, we conducted a two-factor          core specialty compared with 134
Arkansas for Medical Sciences. Starting in       repeated-measures ANOVA, using the            (48.9%) men (P ⫽ .004). As anticipated
the 1997, 1998, 1999, and 2000 academic          general linear model procedure from           from the gender-sensitive BEES, the
years, the students in the graduating            SPSS, with the significance level set at      women always had significantly higher
classes of 2001, 2002, 2003, and 2004            P ⬍ .05. The between-subjects factor was      BEES scores than the men (P ⬍ .001).
completed a survey at the beginning of           specialty choice, and the within-subjects
their freshman (M1), sophomore (M2),             factor was time. Significant effects were     Table 1 displays the mean scores by year
junior (M3), and senior (M4) years. With         followed by post hoc tests. We also           (M1–M4) and specialty preference for
approval from our local institutional            performed single-sample tests of means        men and women. Figure 1 shows part of
                                                 to compare our respondents with those         the data in graphic form. Entering male
review board in 2005, we contacted the
                                                 in the normed sample for the BEES.            medical students, regardless of specialty
535 graduates and asked whether they
                                                                                               choice, had empathy scores that were
would allow their data to be used in a
                                                                                               significantly higher than those in the
research study. A total of 419 (78.3%)
                                                 Results                                       normal population (29 ⫾ 28; P ⬍ .001).16
students agreed, 1 student refused, and
                                                                                               The core male medical students stayed
115 students did not reply.                      Among the four classes, with 419              significantly more empathic than the
                                                 students in the study, 25.7% (108; 80.7%      norms (P ⬍ .001) until they finished the
Survey instrument. The survey                    of the class) graduated in 2001, 26.0%        junior year (see the M4 data point in
instrument was the Balanced Emotional            (109; 78.4% of the class) graduated in        Figure 1), when there was no longer a
Empathy Scale (BEES), a well-established         2002, 23.4% (98; 76.5% of the class)          significant difference (P ⫽ .91). In
measure of the vicarious emotional               graduated in 2003, and 24.8% (104;            contrast, after finishing their freshman
qualities of empathy that examines               77.6% of the class) graduated in 2004.        year, noncore male BEES scores (see the
the emotional “primitive” level of               Our overall sample had 272 men                M2 data point in Figure 1) dropped to
interpersonal interactions.8,16 The BEES         (64.9%) and 147 women (35.1%). For            where they were no longer significantly
coefficient alpha is 0.87. The BEES              comparison, the entire graduating             different from norm population scores.
consists of 30 positively or negatively          medical school classes had 65.4%
worded items (15 items in each category)         men and 34.5% women. Among the                Entering female students had empathy
that measure responses to fictional              four classes, there were no significant       scores that were comparable with those of
situations and particular life events.           differences in students’ empathy scores as    the normal female population (60 ⫾ 21)16
Because the BEES is gender sensitive,            they began medical school. Therefore, we      until after completion of the junior year
with men scoring lower than women, the           combined the four cohorts for the             (see the M4 data point in Figure 1), when
students were asked to report their              subsequent analyses. More than half of        they dropped below the norm (P ⫽ .003).
gender. Using the students’ responses to         the students (227; 54.2%) selected a core     When women were classified by core and
the BEES, we analyzed the changes in the         specialty (men ⫽ 133; 58.6%; women ⫽          noncore specialties, core women were
students’ vicarious empathy by gender            94; 41.4%), whereas the remainder             always comparable with the norm (P ⬎
across their first three years of medical        selected noncore specialties (men ⫽ 139;      .05). However, noncore women started
school.                                          72.4%; women ⫽ 53; 27.6%).                    comparable with the norm (P ⫽ .14) but

Academic Medicine, Vol. 83, No. 3 / March 2008                                                                                         245
Physician–Patient Relationship

                                                                                                                                                                                                                either gender, total BEES scores drop
 Table 1                                                                                                                                                                                                        significantly from initial enrollment to
 Empathy Scores of 419 Medical Students by Year and Specialty Choice,                                                                                                                                           the beginning of the sophomore year.
 2001–2004 Graduating Classes, the University of Arkansas for Medical Sciences*                                                                                                                                 Empathy scores stay level from the
                                                                                                                                                                                                                beginning of that year to the beginning of
 Year of empathy score, by                                                                     Specialty                                           Mean
 students’ gender                                                                              choice†                                            score‡                                          SD            the junior year. After completing the first
                                                                                                                                                                                                                clinical year, BEES scores decline sharply,
 Empathy score 1, start of
 freshman year
                                                                                                                                                                                                                as evidenced by the senior BEES scores.
  .........................................................................................................................................................................................................     Thus, men’s and women’s scores both
      Women                                                                                    Noncore                                               57.13                                    23.22
                                                                                               Core                                                  64.35                                    19.98             have a significant cubic trend (i.e., a line
                                                                                               Total                                                 61.75                                    21.41             with two inflection points and a central
  .........................................................................................................................................................................................................
      Men                                                                                      Noncore                                               35.88                                    23.99             plateau; P ⬍ .001 for men; P ⫽ .023 for
                                                                                               Core                                                  39.95                                    20.53             women).
                                                                                               Total                                                 37.87                                    22.42
  .........................................................................................................................................................................................................
      Total                                                                                    Noncore                                               41.74                                    25.56             For the women, there was no significant
                                                                                               Core                                                  50.05                                    23.57             interaction of year in medical school with
                                                                                               Total                                                 46.25                                    24.82             specialty choice (P ⫽ .22), but there were
 Empathy score 2, start of                                                                                                                                                                                      significant main effects for type of
 sophomore year
  .........................................................................................................................................................................................................
                                                                                                                                                                                                                specialty choice (P ⫽ .001), with core
      Women                                                                                    Noncore                                               50.19                                    22.43             women having both a higher score and
                                                                                               Core                                                  60.71                                    23.06             year of school than did noncore women
                                                                                               Total                                                 56.92                                    23.32             (P ⫽ .001) where, as described above,
  .........................................................................................................................................................................................................
      Men                                                                                      Noncore                                               28.53                                    25.32             empathy scores followed a cubic trend.
                                                                                               Core                                                  34.71                                    22.83
                                                                                               Total                                                 31.56                                    24.29
                                                                                                                                                                                                                Similar to the women, the men had no
  .........................................................................................................................................................................................................     significant interaction of time with
      Total                                                                                    Noncore                                               34.51                                    26.36
                                                                                               Core                                                  45.48                                    26.23
                                                                                                                                                                                                                specialty choice (P ⫽ .19). BEES scores
                                                                                               Total                                                 40.45                                    26.82             for the men differed significantly for
 Empathy score 3, start of                                                                                                                                                                                      career choice (P ⫽ .006) and year of
 junior year                                                                                                                                                                                                    medical school (P ⬍ .001), as described
  .........................................................................................................................................................................................................
      Women                                                                                    Noncore                                               49.19                                    27.59             above.
                                                                                               Core                                                  61.49                                    25.76
                                                                                               Total                                                 57.05                                    27.00             Women choosing a core specialty had the
  .........................................................................................................................................................................................................
      Men                                                                                      Noncore                                               26.32                                    26.14             smallest M1–M4 decline of all groups at
                                                                                               Core                                                  36.05                                    22.64             13.0%. Men entering a noncore specialty
                                                                                               Total                                                 31.08                                    24.93             had the greatest single-year decline (M1–
  .........................................................................................................................................................................................................
      Total                                                                                    Noncore                                               32.64                                    28.39             M2; 20.5%) compared with all other
                                                                                               Core                                                  46.59                                    27.02             groups. Men choosing a core specialty
                                                                                               Total                                                 40.19                                    28.49             had a 25.8% drop in M1–M4 BEES
 Empathy score 4, start of                                                                                                                                                                                      scores, whereas noncore men had a
 senior year
  .........................................................................................................................................................................................................     38.7% decline. Women entering a
      Women                                                                                    Noncore                                               40.40                                    29.72             noncore specialty had a 29.3% M1–M4
                                                                                               Core                                                  55.98                                    23.75
                                                                                               Total                                                 50.36                                    27.02             decline in BEES scores, with a single
  .........................................................................................................................................................................................................     17.3% drop in empathy after completing
      Men                                                                                      Noncore                                               22.00                                    25.40
                                                                                               Core                                                  29.66                                    26.94             the M3 year.
                                                                                               Total                                                 25.75                                    26.40
  .........................................................................................................................................................................................................     For students choosing a core specialty,
      Total                                                                                    Noncore                                               27.08                                    27.83
                                                                                               Core                                                  40.56                                    28.72             there was a gender difference in the
                                                                                               Total                                                 34.38                                    29.07             degree of decline in M1–M4 scores; the
                                                                                                                                                                                                                men’s decline was essentially twofold
* The table presents mean scores by medical school year, specialty preference, and students’ gender. Scores are
  for students’ vicarious empathy (i.e., to have a visceral empathic response); responses were to a well-established
                                                                                                                                                                                                                greater than the women’s decline. Among
  measure of the various emotional qualities of empathy, administered at the beginning of each medical school                                                                                                   women, the drop in M1–M4 BEES scores
  year. Vicarious empathy significantly decreased during medical education (P ⬍ .001), especially after the first                                                                                               was 2.25-fold greater for those who
  and third years. Students choosing core careers had higher empathy than did those choosing noncore careers.
†                                                                                                                                                                                                               choose noncore versus those who chose
  Core specialties (i.e., family medicine, internal medicine, obstetrics– gynecology, pediatrics, and psychiatry) have
  substantial patient contact and continuity of care, whereas noncore specialties (all others, including                                                                                                        core specialties. For men, the drop in
  anesthesiology, dermatology, and general surgery) have minimal patient contact and continuity of care. Totals in                                                                                              M1–M4 BEES scores was only 1.5-fold
  this column are the combined women and men core or noncore scores for each year of the study.                                                                                                                 greater for the noncore versus core
‡
  Totals in this column are the average women’s, men’s, and combined women’s and men’s scores for all students
  at the start of the freshman, sophomore, junior, or senior year.                                                                                                                                              students. In either gender, the greatest
                                                                                                                                                                                                                declines in M1–M4 BEES scores are
                                                                                                                                                                                                                associated with those students who
 then dropped significantly                                                                                For both men and women, the pattern of                                                               selected a noncore specialty.
 lower than the norm (P ⬍ .002) after                                                                      empathy scores (see Figure 1) across the
 completing the freshman year (see the                                                                     four time points (i.e., the first three                                                              A secondary analysis was done to
 M2 data point in Figure 1).                                                                               years of medical school) is similar. For                                                             determine how similar women’s scores

 246                                                                                                                                                                                                          Academic Medicine, Vol. 83, No. 3 / March 2008
Physician–Patient Relationship

 Mean Score                                                                                                   that occurred after completing the
  70                                                                                                          freshman year of medical school may
                                                                                                              have resulted from a high degree of
                                                                                                              student stress and anxiety caused by the
  60                                                                                                          students’ competitiveness and desire to
                                                                                                              overachieve on examinations. Additional
                                                                                                              stressful factors may include the media’s
  50                                                                                                          presentation of doctors as heroes, which
                                                                                                              helps create a skewed image of the ideal
                                                                                                              physician for entering freshmen medical
  40                                                                                                          students. As the students progressed
                                                                                                              through their freshman year, they
                                                                                                              probably realized there is a mismatch
  30                                                                                                          between the media representation and
                                                                                                              reality.19 Additionally, the freshmen likely
                                                                                                              considered themselves to be in a hostile
  20                                                                                                          educational environment that treated
                 M1                       M2                       M3                      M4                 them like children.20 All of these stressors
               Women Core                      Women Total                     Women Non-Core
               Men Core                        Men Total                       Men Non-Core                   induce self-preservation and coping
Figure 1 Mean scores, by medical school year, specialty preference, and students’ gender, for                 behaviors. In our view, some of these
419 men and women in the classes of 2001–2004, the University of Arkansas for Medical                         behaviors, expressed as increased
Sciences. Scores are for students’ vicarious empathy (i.e., to have a visceral empathic response);            cynicism2 and, ostensibly, decreased
responses were to a well-established measure of the various emotional qualities of empathy,                   vicarious empathy, were used by the
administered at the beginning of each medical school year. The figure shows that vicarious                    students to adjust to the stresses and
empathy significantly decreased during medical education (P ⬍ .001), especially after the first and           internal conflicts associated with medical
third years. Students choosing core careers had higher empathy than did those choosing noncore                education.
careers. Core refers to core specialties (i.e., internal medicine, family medicine, obstetrics– gynecology,
pediatrics, and psychiatry, which have greater patient contact), and noncore refers to all other
                                                                                                              The larger drop in the noncore empathy
specialties, where patient contact is less.
                                                                                                              scores of the M2 women versus the core
                                                                                                              empathy scores for the M2 women
were to men’s within specialty type. This               significant decline in the component of               suggest that the aforementioned stressors
analysis was prompted by the finding that               empathy that is essential to patient care,            may have a differential effect on some
women choosing noncore specialties had                  because empathy is one of three core                  women. We believe women choosing
lower BEES scores than did the other                    values needed to establish an effective               core specialties may better maintain their
women when there was no similar                         physician–patient relationship.17                     vicarious empathy, at least partially,
difference for the males. For students                                                                        because the continuity of patient care (a
choosing a core specialty, women                        The results of this study suggest that                characteristic of core specialties) lends
reported significantly higher empathy                   student empathy is affected by medical                itself to attracting a more nurturing
scores than men did across all four time                education. Our study supports the                     individual. Conversely, the marked drop
points (P ⬍ .001). The effect size, as                  findings of Coulehan and Williams,18                  in vicarious empathy of women choosing
measured by a partial eta squared, was                  who described deleterious changes in                  noncore specialties may reflect more of a
0.33. Women choosing noncore                            various humanistic qualities as medical               “survival” or “coping” mechanism.
specialties also had higher scores than                 students became “immunized” against                   Because noncore specialties (e.g.,
men choosing noncore specialties, but                   these values after their matriculation into           orthopedics and surgery) are still
the difference was not as great (P ⫽ .02).              medical school. In the freshman year, the             predominately chosen by men, the
In this instance, the effect size was only              similar M1 BEES scores for all four                   noncore women we studied were
0.045.                                                  classes indicate that the matriculates                adjusting in the same way that the less
                                                        studied were drawn from a homogenous                  empathetic noncore males did.
                                                        population, and that the undergraduate
Discussion                                              education of the matriculates,                        The sophomore year, which is an
Our study is unique in at least two                     predominated by basic science courses,                additional year of basic science courses
aspects. It is the first longitudinal study to          did not decrease vicarious empathy                    similar to the freshman experience,
follow four cohorts of undergraduate                    below the established norm. Indeed, the               maintained stable BEES scores. This may
medical students. Second, it is the first               entering male medical students had BEES               be explained by the students’ acclimating
study to examine vicarious empathy (i.e.,               scores that were significantly higher than            to the academic rigors of basic science
to have a visceral response) instead                    the norm. For both the men and the                    courses. The junior clinical year, where
of cognitive empathy (i.e., to, in                      women, the M1 BEES scores were not                    all students participate in standard
imagination, take the role of another) in               significantly different between core and              rotations, produced another dramatic
medical students. We believe that the                   noncore groups.                                       drop in BEES scores for both the men
decrease in BEES scores revealed in this                                                                      and the women. This drop substantiates
study represents a loss of vicarious                    For all the students studied, the                     findings from the literature that suggest
empathy. If so, this study reveals a                    significant decrease in vicarious empathy             that the first clinical year of medical

Academic Medicine, Vol. 83, No. 3 / March 2008                                                                                                        247
Physician–Patient Relationship

school is demanding and challenging.21        The “intended” medical curriculum,                four-year curriculum.2,9,33,34 Some
The large drop in M3 students’                which is the formally offered and                 residency programs, aware of the
vicarious empathy occurred while the          endorsed curriculum, often falls short of         reduction in humanitarian traits in
students were seeing patients they had,       student expectations because of the               medical graduates, have developed
presumably, looked forward to helping. It     “informal” and the “hidden” curricula.28          intensive workshops devoted to teaching
is interesting to note that a recent study    The informal curriculum, as defined               and enhancing physician–patient
showed that a similar drop in empathy         by Hafferty,28 “is an unscripted,                 interactions, yet studies show that even
occurred after dental students began          predominantly ad hoc, highly                      with such courses, idealism and empathy
seeing patients.22 In university tertiary     interpersonal form of teaching that takes         decrease and cynicism increases in as
care centers, empathy is hard to direct       place among and between faculty and               little as five months after the start
toward the challenging patients when the      students” (e.g., in the hallway, lounge, or       of the intern year.35–37 We maintain
treatment emphasis is on technology.23        on-call room), whereas the hidden                 that the attempted maintenance of
Immense cultural differences between          curriculum “is a set of influences that           professionalism should be part of the
physicians-in-training and patients may       function at the level of organizational           medical school curriculum that is
also make it more difficult to achieve        structure and culture” (e.g., advertising         combined with the reinstatement of
adequate empathy. Physicians who are          the amount of National Institutes of              effective bedside teaching. However, our
role models should work more closely          Health dollars the institution garners or         study findings suggest that the loss of
with medical students to develop an           espousing the need for basic science              innate, vicarious empathy could make it
empathic relationship with such               rather than humanities courses when               difficult to effectively teach medical
patients.24 Our own findings suggest that     applying to medical school). These latter         students, interns, and residents to
this could be particularly important for      two curricula contribute to insidious             consistently role-play empathic concern.
women who enter a noncore specialty,          declines in desirable professional traits,
because their drop in vicarious empathy       because students easily recognize that            This study was of a single four-year
scores more closely emulated the              campus policies and resource allocations          medical school in the mid-South.
naturally lower empathy scores of the         and “what’s really important to learn”            Therefore, the findings may not be
men than the scores of their female           often conflict with the stated institutional      directly applicable to other medical
colleagues who selected a core specialty.     educational mission.1,28 Instead, the             institutions in the United States. During
                                              mandate that should be implicit within            the period of this longitudinal study, the
Studies show that clinicians consider an      the informal and hidden curricula should          curriculum at the institution remained
empathic physician–patient relationship       be the societal obligation of medical             fairly stable and can be described as
as one of the most important aspects of       schools to provide and/or train better            “traditional.” Therefore, differences in
professionalism5 and that professionalism     physician role models who can aid                 empathy scores from year to year, or
and physician–patient interactions are        students in overcoming losses in empathy          between graduating classes, were not
best demonstrated by clinician role           and other professional characteristics.26         influenced by large-scale curricular
models at the bedside in hospitals or,25 as                                                     changes. The students voluntarily took
suggested by Benbassat and Baumal,24 in       The most frequently offered solutions to          the BEES four times. As with any
primary and chronic care clinics and/or       ameliorate the loss of professionalism at         repeated measure, there are concerns that
hospice facilities. Other studies reveal a    the undergraduate medical level involve           familiarity with the survey may affect
chronic lack of clinical role models,26 and   teaching students to be empathic or               the students’ responses. For logistical
perhaps a lack of positive role models        “humanitarian” via courses that                   reasons, this study did not examine BEES
could have contributed to the decline in      emphasize empathic communication                  scores after the completion of the senior
empathy scores we observed after the          skills.9,12,29 Evidence suggests that in most     year. It is unknown whether another
completion of the first clinical year of      instances the gains are modest and                significant decrease in vicarious empathy
undergraduate medical education.              temporary,10,30 and some feel that                would have occurred after completion of
                                              empathy and compassion are increasingly           the M4 year or even into residency
In addition to complicated treatment          difficult to teach as an individual               training, but other studies suggest this
regimes and a lack of clinical role models,   matures.20 In contrast to traditional four-       would have been the case.34,35 A number
literature shows that juniors, as student/    year schools, several recent studies have         of students did not respond to our
physicians (i.e., individuals that are        shown that six-year medical schools, or           request to use their BEES data. Therefore,
learning to assume an authoritative role      schools with a problem-based learning             the effect that these purged data would
in providing care while simultaneously        curriculum, have greater opportunities to         have had on our current results cannot
being subservient to their mentors),          integrate humanism and empathy into               be determined. However, we do know
perceive themselves as being abused           their curricula.31,32 Despite some                that for either gender, the numbers of
by their mentor/role models.1,21,27           encouraging initial reports from several          nonresponders who entered core or
This student abuse has been termed            of these nontraditional schools, a large          noncore specialties on graduation did not
“traumatic deidealization” by Kay19 and       cadre feels that medical students possess a       differ significantly from those who did
is another factor possibly contributing to    detrimental inertia, fueled by a frank            permit their data to be used. Thus,
the declines in empathy. Other potential      decline in ethics, morals, empathy, and           nonresponder career choice was not a
factors include fatigue and a lack of         service-oriented attitudes, that cannot be        factor that could have skewed our results.
patient continuity that is exacerbated by     overcome by a concurrent limited
starting a new clinical rotation every four   exposure to the humanities, especially            In conclusion, in our study, the first three
to five weeks.                                when presented in an already crowded              years of medical education significantly

248                                                                                           Academic Medicine, Vol. 83, No. 3 / March 2008
Physician–Patient Relationship

decreased students’ vicarious empathy.               5 Brownell AK, Côté L. Senior residents’ views    21 Silver HK, Glicken AD. Medical student
The decline in empathy occurred in                     on the meaning of professionalism and how            abuse: Incidence, severity and significance.
students who chose core and noncore                    they learn about it. Acad Med. 2001;76:734 –         JAMA. 1990;263:527–532.
                                                       737.                                              22 Sherman JJ, Cramer A. Measurement of
specialties, with significant declines               6 Mehrabian A, Young AL, Sato S. Emotional             changes in empathy during dental school.
occurring during the first basic science               empathy and associated individual                    J Dent Educ. 2005;69:338 –345.
year as well as the initial clinical year              differences. Curr Psychol Res Rev. 1988;8:        23 Griffith CH III, Wilson JF. The loss of student
when students were exposed to patients.                221–240.                                             idealism in the 3rd-year clinical clerkships.
The decrease may constitute a coping or              7 Davis MH. Empathic concern and the                   Eval Health Prof. 2001;24:61–71.
                                                       muscular dystrophy telethon. Empathy as a         24 Benbassat J, Baumal R. What is empathy, and
survival mechanism where empathic                      multidimensional construct. Pers Soc Psychol         how can it be promoted during clinical
feelings are suppressed. Although a                    Bull. 1983;9:223–229.                                clerkships? Acad Med. 2004;79:832– 839.
hardening of the heart may aid physicians            8 Chlopan BE, McCain ML, Carbonell JL,              25 Wright SM, Kern DE, Kolodner K, Howard
coping with patients on a daily basis, this            Hagen RL. Empathy: Review of available               DM, Brancati FL. Attributes of excellent
runs counter to the patient’s need for an              measures. J Pers Soc Psychol. 1985;48:635–           attending-physician role models. N Engl
                                                       653.                                                 J Med. 1998;339:1986 –1993.
empathic caregiver.38 Because of the
                                                     9 Diseker RA, Michielutte R. An analysis of         26 Greganti MA. Where are the clinical role
significant drop in vicarious empathy                  empathy in medical students before and               models? Arch Intern Med. 1990;150:259 –261.
during medical school, we propose that                 following clinical experience. J Med Educ.        27 Brainard AH, Brislen HC. Learning
empathy should be constantly reinforced                1981;56:1004 –1010.                                  professionalism: A view from the trenches.
by the use of role-playing throughout               10 Rezler AG. Attitude changes during medical           Acad Med. 2007;82:1010 –1014.
students’ education and be periodically                school: A review of the literature. J Med Educ.   28 Hafferty FW. Beyond curriculum reform:
                                                       1974;49:1023–1030.                                   Confronting medicine’s hidden curriculum.
reinforced during their residency training          11 Jarski RW, Gjerde CL, Bratton BD, Brown              Acad Med. 1998;73:403– 407.
and practice as physicians.                            DD, Matthes SS. A comparison of four              29 Evans M. Reflections on humanities in
                                                       empathy instruments in simulated patient–            medical education. Med Educ. 2002;36:508 –
                                                       medical student interactions. J Med Educ.            513.
Acknowledgments                                        1985;60:545–551.                                  30 Kauss DR, Robbins AS, Abrass I, Bakaitis R,
The authors thank the Academic Affairs Office of    12 Stepien KA, Baernstein A. Educating for              Anderson LA. The long-term effectiveness of
the College of Medicine for their assistance in        empathy. J Gen Intern Med. 2006;21:524 –             interpersonal skills training in medical
distributing the questionnaire, and Tom Hart           530.                                                 schools. J Med Educ. 1980;55:595– 601.
and Marilyn Walderns, of the Office of Academic     13 Hojat H, Mangione S, Nasca TJ, et al. An          31 Sirridge M, Welch K. The program in medical
Computing, for collating the data. This study was      empirical study of decline in empathy in             humanities at the University of Missouri–
supported by the UAMS Teaching Scholars                medical school. Med Educ. 2004;38:934 –941.          Kansas City School of Medicine. Acad Med.
Program (funded by the Arkansas Department of       14 Newton BW, Savidge MA, Barber L, et al.              2003;78:973–976.
Higher Education) and Research to Prevent              Differences in medical students’ empathy.         32 Roche WP III, Scheetz AP, Dane FC, Parish
Blindness. Special thanks to John Németh.              Acad Med. 2000;75:1215.                              DC, O’Shea JT. Medical students’ attitudes
                                                    15 Hojat M, Brigham TP, Gottheil E, Xu G,               in a PBL curriculum: Trust, altruism, and
                                                       Glaser K, Veloski JJ. Medical students’              cynicism. Acad Med. 2003;78:398 – 402.
References                                             personal values and their career choices a        33 Pellegrino ED. The metamorphosis of
                                                       quarter-century later. Psychol Rep. 1998;83:         medical ethics. A 30-year retrospective.
 1 Hafferty FW, Franks R. The hidden
   curriculum, ethics teaching, and the structure      243–248.                                             JAMA. 1993;269:1158 –1162.
   of medical education. Acad Med. 194;69:861–      16 Mehrabian A. Manual for the Balanced              34 Rogers J. Being skeptical about the medical
   871.                                                Emotional Empathy Scale (BEES); 1996                 humanities. J Med Humanit. 1995;16:265–
 2 Testerman JK, Morton KR, Loo LK, Worthley           [unpublished; available from Albert                  277.
   JS, Lamberton HH. The natural history of            Mehrabian, 1130 Alta Mesa Road, Monterey,         35 Griffith CH, Wilson JF. The loss of idealism
   cynicism in physicians. Acad Med. 1996;71           CA 93940].                                           throughout internship. Eval Health Prof.
   (10 suppl):S43–S45.                              17 Rogers CR. A Way of Being. Boston, Mass:             2003;26:415– 426.
 3 Branch WT Jr. Supporting the moral                  Houghton Mifflin; 1980.                           36 Bellini LM, Baime M, Shea JA. Variation of
   development of medical students. J Gen           18 Coulehan J, Williams PC. Vanquishing virtue:         mood and empathy during internship. JAMA.
   Intern Med. 2000;15:503–508.                        The impact of medical education. Acad Med.           2002;287:3143–3146.
 4 Levinson W, Roter DL, Mullooly JP,                  2001;76:598 – 605.                                37 Klein EJ, Jackson JC, Kratz L, et al. Teaching
   Dull VT, Frankel RM. Physician–patient           19 Kay J. Traumatic deidealization and the              professionalism to residents. Acad Med. 2003;
   communication. The relationship with                future of medicine. JAMA. 1990;263:572–573.          78:26 –34.
   malpractice claims among primary care            20 Kimball CP. Medical education as a                38 Rosenfield PJ, Jones L. Striking a balance:
   physicians and surgeons. JAMA. 1997;277:            humanizing process. J Med Educ. 1973;48:             Training medical students to provide
   553–559.                                            71–77.                                               empathic care. Med Educ. 2004;38:927–933.

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