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Better, not broken: pursuing empathy during medical training

From the April ACP Internist, copyright © 2014 by the American College of Physicians

By Joshua M. Liao, MD, ACP Resident/Fellow Member

“Wait, she brought what?” I said, looking up from my papers.

The attending turned from his screen to emphasize his point. “Nail clippers.”

I stared silently at the desk as he continued, trying to digest what I was hearing. The doctor he was speaking about was one of my colleagues, a newly minted MD and medicine intern. As her supervising resident, I had assigned her to the care of an unfortunate patient, a young woman who had lived a vibrant life until a catastrophic car accident several years ago left her without the use of her limbs. Paralyzed from her neck down, the patient could hardly eat safely on her own, much less clean or care for herself. In addition to being dejected, she was now slowly dying.

But while our entire team felt the weight of the patient’s prognosis, my intern had become particularly affected by it. She had spent extended time with the patient, learning about her life and keeping her company. She had asked the patient about her past and hopes for the immediate future. And, as I was now learning from my attending, she had resolved to do whatever she could to improve the patient’s condition, including bringing in her own nail clippers, staying late one day, and helping a dying woman trim her toenails.

As a junior resident tasked with supervising interns, I have frequently had the fortune of witnessing their strong displays of clinical acumen. I have often benefited from their efficiency, knowledge and industry. But in this intern and the story of her nail clippers, I was reminded of something that, despite being rare amid busy clinical work and graduate medical training, is absolutely indispensable to doctoring: empathy.

A recent Health Affairs blog post highlights empathy as a crucial element to good care and improved patient outcomes. This isn’t exactly surprising. Within the medical community, and particularly among educators, there has long been an explicit appreciation for humanism and compassion. There has also been a tacit understanding of its importance to doctoring: Empathy is the core quality that every medical applicant tries to convey, the one that admissions committees attempt to identify in candidates.

If the data are to be believed, however, medical education doesn’t always promote empathy, despite all of the recognition of its importance. Reports show that medical students lose measures of empathy as they transition from classroom teaching to clinical clerkships, and other data showing that students can quickly acclimate to unprofessional clinical cultures and behaviors without even recognizing them as such. Reports and anecdotal evidence suggest that this process is likely to continue, or even accelerate, in residency training. Between what we are teaching through explicit didactics and the “hidden curriculum,” the collective messages we transmit to learners in everyday words, actions and behaviors, we may be losing our grip on a sacred professional value and significant gains in our patients’ health outcomes, due to a lack of empathy.

Medical schools and residency programs are actively addressing this problem. Many are working on better ways to teach empathy, including through avenues like standardized patients, video recordings, and role-playing. But while these modalities are likely to be helpful in different ways, truly compassionate care demands more. There is only so much to be gained through feedback and guidance around hand placement, head nods, facial expressions, and word choice. There is a stark difference between what empathy looks like and what its fundamental expression feels like.

While existing efforts are commendable, then, empathy requires more than what can be taught didactically. It requires repeated, firsthand encounters with suffering, along with the courage to let suffering affect us. In fact, it is good to engage with this kind of pain because, as David Watts has noted in the New England Journal of Medicine, “we are not destroyed when patients suffer or die, but rather deepened, becoming better able to open ourselves to the complex lives of the distressed and infirm the next time around.” Empathy is an exercise in entering into the uncertainty of another’s condition, confident we will emerge from it better, not broken.

We must show trainees that their patients’ suffering is not to be feared, and that every illness is marked as much by fundamental distress as by corresponding pathophysiology.

There’s no easy path to this lesson. But we should do this in part by placing our trainees squarely in trying situations and actively role-modeling empathetic behavior and lauding examples of empathy that we see in others. Only then can we pass on what I sensed in my intern’s actions and demeanor toward our patient, in the way her concern bled into gesture and expression, coloring them, every head nod, facial expression and word choice, with unmistakable compassion.

Joshua M. Liao, MD, is an ACP Resident/Fellow Member, the Northeastern Region representative on the ACP Council for Resident/Fellow Members, and an internal medicine resident at Brigham and Women’s Hospital in Boston. Find him on Twitter (@JoshuaLiaoMD) or at his website.

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