A 'Hidden Curriculum' in Med School Trains Doctors to Have Less Empathy

A lack of empathy in healthcare can be disastrous. In the UK, between 2005 and 2009, hundreds of avoidable deaths occurred at the Mid Staffordshire NHS Foundation Trust. The Francis report, which investigated the causes of the failings, concluded that a lack of empathy contributed to the catastrophe.

More recently, dozens of tragic, unnecessary infant and maternal deaths occurred at the Shrewsbury and Telford Hospitals. The Ockenden Report, which investigated the causes of these deaths, stated that lack of empathy exacerbated the problem.

Meanwhile, research suggests empathy in doctors may even reduce premature death in patients with type 2 diabetes.

Empathy is a core skill that medical students require. The General Medical Council, which sets the standards and outcomes for medical student education and training in the UK, says that empathy is central to their strategy.

However, a "hidden curriculum" in medical school can reduce medical student empathy. A new study, published in BMC Medical Education, is the first to systematically demonstrate why empathy declines during medical training and raises important questions about the priorities of current medical education.

Empathy is known to reduce patient pain and improve their satisfaction with care, and protects against doctor burnout. It's also cost-effective according to a study that compared longer, empathic consultations with standard consultations.

Based on its importance, you might hope that empathy increases throughout medical school. Yet levels of empathy in medical students often decline as their training progresses.

In a recently published systematic review, my colleagues and I analyzed data from 16 qualitative studies and 771 medical students. Our review included any qualitative study that investigated why empathy might change during medical school.

We found that when medical students transition from the first phase of medical school which is mostly lecture-based, to the second phase of medical school which is more clinical and patient-facing, they are met with a "hidden" informal curriculum.

This curriculum includes subtle, non-formal influences over students. For example, there is often an unbalanced focus on the biomedical model of disease, which focuses on the body as a machine, over the "biopsychosocial" model of disease, which includes biological, psychological, and social factors.

But also the way that the curriculum is structured to create a stressful workload, and to promote the influence of role models (who may show little empathy themselves) has an effect.

Students, who are likely to have little experience of what being a patient is like, often adapt to this hidden curriculum by developing cynicism and becoming emotionally distanced and desensitized. This, in turn, lowers empathy.

Like all studies, our review has some limitations. The studies included in the review were small, very few were from outside Europe or North America, and many were of limited quality. However, the remarkable consistency of the identified themes warrants rigorous efforts to reverse the empathy decline.

How to fix the problem

By bringing the cause of empathy decline to light, our study paves the way for educational programs that foster, maintain and even enhance empathy in medical students. These interventions are described briefly below.

1. Having students "walk a mile in patients' shoes", for example by having them spend the night in the emergency room, or wearing age simulation suits. Providing students with the experience of what it is like to be a patient will provide them with a more empathic perspective.
2. Balancing the focus on the biomedical model with education on the more holistic biopsychosocial model of disease. Patients are increasingly complex and come to see their doctors with intertwined physical, psychological and social problems. The biopsychosocial model is better suited to understand and treat these patients.
3. Getting real patients into the classroom when students are learning facts about the body. By combining patient stories with facts about the human body, their subsequent transition from the lecture theatre to clinical placements is less of a shock.
4. Evidence-based and effective empathic communication training. While all medical schools teach communication skills, the effectiveness of the training varies. Empathic communication skills have been shown to be effective and include expressing understanding, non-verbal behavior (nodding, leaning forward) and optimism.
5. Role-model training and peer support. Role models are known to have a strong influence on medical student behavior, yet the extent to which doctors display empathy varies. Enhancing the empathy of the doctors that students meet will therefore promote medical students' empathy.

Implementing these empathy interventions is difficult given the pressures on the tightly packed medical school curriculum. But it is possible. The Stoneygate Centre for Empathic Healthcare at the University of Leicester is currently developing and piloting all of them.

Empathy benefits patients and practitioners, yet it declines throughout medical school. Now that we have identified the causes of its deterioration, medical schools can focus on curriculum interventions that enhance it.

Jeremy Howick, Professor and Director of the Stoneygate Centre for Excellence in Empathic Healthcare, University of Leicester

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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