Christian Scheffer

Empathy Decline and Its Reasons: A Systematic Review of Studies With Medical Students and Residents

Purpose Empathy is a key element of patient–physician communication; it is relevant to and positively influences patients health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency. Method The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size <30 were excluded. Results Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the “hidden,” “formal,” and “informal” curricula as main reasons for empathy decline. Conclusions The results of the reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.

Identifying and predicting subgroups of information needs among cancer patients: an initial study using latent class analysis

PurposeUnderstanding how the information needs of cancer patients (CaPts) vary is important because met information needs affect health outcomes and CaPts’ satisfaction. The goals of the study were to identify subgroups of CaPts based on self-reported cancer- and treatment-related information needs and to determine whether subgroups could be predicted on the basis of selected sociodemographic, clinical and clinician–patient relationship variables.MethodsThree hundred twenty-three CaPts participated in a survey using the “Cancer Patients Information Needs” scale, which is a new tool for measuring cancer-related information needs. The number of information need subgroups and need profiles within each subgroup was identified using latent class analysis (LCA). Multinomial logistic regression was applied to predict class membership.ResultsLCA identified a model of five subgroups exhibiting differences in type and extent of CaPts’ unmet information needs: a subgroup with “no unmet needs” (31.4% of the sample), two subgroups with “high level of psychosocial unmet information needs” (27.0% and 12.0%), a subgroup with “high level of purely medical unmet information needs” (16.0%) and a subgroup with “high level of medical and psychosocial unmet information needs” (13.6%). An assessment of sociodemographic and clinical characteristics revealed that younger CaPts and CaPts’ requiring psychological support seem to belong to subgroups with a higher level of unmet information needs. However, the most significant predictor for the subgroups with unmet information needs is a good clinician–patient relationship, i.e. subjective perception of high level of trust in and caring attention from nurses together with high degree of physician empathy seems to be predictive for inclusion in the subgroup with no unmet information needs.ConclusionsThe results of our study can be used by oncology nurses and physicians to increase their awareness of the complexity and heterogeneity of information needs among CaPts and of clinically significant subgroups of CaPts. Moreover, regression analyses indicate the following association: Nurses and physicians seem to be able to reduce CaPts’ unmet information needs by establishing a relationship with the patient, which is trusting, caring and empathic.

Physician empathy: Definition, outcome-relevance and its measurement in patient care and medical education

Objective: The present study gives a brief introduction into the definition of physician empathy (PE) and its influence on patients’ health outcomes. Furthermore we present assessment instruments to measure PE from the perspective of the patient and medical student. The latter topic will be explored in detail as we conducted a pilot study on the German versions of two self-assessment instruments of empathy, which are mostly used in medical education research, namely the “Jefferson Scale of Physician Empathy, Student Version” (JSPE-S) and the “Interpersonal Reactivity Index” (IRI). Methods: We first present an overview of the current empirical and theoretical literature on the definition and outcome-relevance of PE. Additionally, we conducted basic psychometric analyses of the German versions of the JSPE-S and the IRI. Data for this analyses is based on a cross-sectional pilot-survey in N=44 medical students and N=63 students of other disciplines from the University of Cologne. Results: PE includes the understanding of the patient as well as verbal and non-verbal communication, which should result in a helpful therapeutic action of the physician. Patients’ health outcomes in different healthcare settings can be improved considerably from a high quality empathic encounter with their clinician. Basic psychometric results of the German JSPE-S and IRI measures show first promising results. Conclusion: PE as an essential and outcome-relevant element in the patient-physician relationship requires more consideration in the education of medical students and, thus, in medical education research. The German versions of the JSPE-S and IRI measures seem to be promising means to evaluate these education aims and to conduct medical education research on empathy.

Determinants of physician empathy during medical education: hypothetical conclusions from an exploratory qualitative survey of practicing physicians

BackgroundEmpathy is an outcome-relevant physician characteristic and thus a crucial component of high-quality communication in health care. However, the factors that promote and inhibit the development of empathy during medical education have not been extensively researched. Also, currently there is no explicit research on the perspective of practicing physicians on the subject. Therefore the aim of our study was to explore physicians’ views of the positive and negative influences on the development of empathy during their medical education, as well as in their everyday work as physicians.MethodWe administered a written Qualitative Short Survey to 63 physicians in seven specialties. They were able to respond anonymously. Our open-ended question was: “What educational content in the course of your studies and/or your specialist training had a positive or negative effect on your empathy?” We analyzed the data using thematic content analysis following Mayring’s approach.ResultsForty-two physicians took part in our survey. All together, they mentioned 68 specific factors (37 positive, 29 negative, 2 neutral) from which six themes emerged: 1. In general, medical education does not promote the development of empathy. 2. Recognizing the psycho-social dimensions of care fosters empathy. 3. Interactions with patients in medical practice promote empathy. 4. Physicians’ active self-development through reflective practice helps the development of empathy. 5. Interactions with colleagues can both promote and inhibit empathy through their role modeling of empathic and non-empathic behavior. 6. Stress, time pressure, and adverse working conditions are detrimental to empathy development.ConclusionsOur results provide an overview of what might influence the development of clinical empathy, as well as hypothetical conclusions about how to promote it. Reflective practice seems to be lacking in current medical curricula and could be incorporated. Raising physicians’ awareness of the psycho-social dimension of disease, and of the impact of peer influence and role modeling, seems promising in this regard, too. Stress and well-being seem to be closely related to physician empathy, and their modulation must take into account individual, social, and organizational factors. Further research should investigate whether or how these hypothetical conclusions can deepen our understanding of the determinants of physician empathy in order to help its promotion.

Can patient–provider interaction increase the effectiveness of medical treatment or even substitute it?—An exploration on why and how to study the specific effect of the provider

OBJECTIVEnNumerous studies demonstrate the impact of high-quality patient-provider interaction (PPI) on health outcomes. However, transformation of these findings into clinical practice is still a crucial problem. One reason might be that health communication research rarely investigated whether PPI can increase the effectiveness of medical treatment and/or even substitute it. Therefore, our objective was to provide empirical and methodological background of why and how to investigate the specific effect of the provider on patients health outcomes.nnnMETHODSnThis is a debate paper based on a narrative (non-systematic) literature review in Medline and PsycINFO without any year limitation.nnnRESULTSnNeurobiological evidence based on expectation and conditioning theory indicates that PPI is able to increase the effectiveness of medical treatment. Moreover, the use of creative RCT study designs described in this paper enables health communication researchers to investigate whether PPI is able to substitute medical treatment.nnnCONCLUSIONnThis paper exemplifies that there exist an evidence-based knowledge from neurobiology as well as creative RCT designs which enable researcher to investigate the specific effects of PPI.nnnPRACTICE IMPLICATIONSnResearch on the specific effects of PPI requires intense reflection on which patient groups or types of illness are reasonable, suitable, and ethically justifiable for interventions.

Can final year medical students significantly contribute to patient care A pilot study about the perception of patients and clinical staff

Background: Active participation of medical students in patient care has been shown to be important for professional development of learners. Not much is known about the impact of active student participation (ASP) to the quality of patient care. Aims: We established a Clinical Education Ward (CEW) for the final year medical students caring for patients under structured clinical supervision. This study investigates the views of both patients and clinical staff on the impact of ASP on patient care. Methods: The Picker Inpatient Questionnaire (PIQ) was used to survey all the patients admitted to the CEW during the pilot phase. Results concerning the general quality of health care and the patient–physician relationship (PPR) were compared to two matched pair control groups: patients of the same department (CG1) and of internal wards in Germany (CG2). In addition, quantitative and qualitative data were collected from patients and clinical staff members to specify the impact of students on patient care. Results: Out of 111 patients, 64 responded. The PIQ results revealed very minor problems in the assessment of the overall general quality of care and in PPR at the CEW, while significant improvements existed when compared to CG2. Furthermore, 79% of the patients and 95% of the staff members recorded a positive impact of ASP. Qualitative data illustrated and complemented these results. Chances and challenges in programs with high participation of students in clinical care are discussed. Conclusion: ASP may not only be useful for learners but also offers chances and benefits for patient care.

The impact of financial incentives on physician empathy: A study from the perspective of patients with private and statutory health insurance

OBJECTIVEnWe hypothesized that patients ratings of physician empathy (PE) would be higher among those with private health insurance (PHI, referring to financial incentive) than among patients with statutory health insurance (SHI).nnnMETHODSnA postal survey was administered to 710 cancer patients. PE was assessed using the Consultation-and-Relational-Empathy measure. T-tests were conducted to analyse whether PHI and SHI-patients differ in their ratings of PE and variables relating to contact time with the physician. Structural-equation-modelling (SEM) verified mediating effects.nnnRESULTSnPHI-patients rated physician empathy higher. SEM revealed that PHI-status has a strong significant effect on frequency of talking with the physician, which has a strong significant effect (1) on PE and (2) has a moderate effect on patients perception of medical staff stress, thereby also affecting patients ratings of PE.nnnCONCLUSIONSnOur findings suggest that PHI-status is one necessary precondition for physicians spending more time with the patient. Spending more time with the PHI-patient has two major effects: it results in a more positive perception of PE and positively impacts PHI-patients perception of medical staff stress, which in turn, again influences PE.nnnPRACTICAL IMPLICATIONSnHealth policy should discuss these findings in terms of equality in receiving high-quality care.

A reflective practice intervention for professional development, reduced stress and improved patient care--a qualitative developmental evaluation.

OBJECTIVEnProfessional capabilities, such as empathy and patient-centeredness, decline during medical education. Reflective practice is advocated for teaching these capabilities. The Clinical Reflection Training (CRT) is a reflective practice intervention using the professional dilemmas faced by medical students during clinical practice. The aim of this study was to evaluate students perceptions of the helpfulness of the CRT and its effects on their medical education.nnnMETHODSnEighteen semi-structured interviews were conducted with medical students who had participated in the CRT. Content analysis was used to analyze the interview data.nnnRESULTSnMedical students did not feel adequately prepared to manage the difficult personal and interpersonal problems frequently encountered in clinical practice. They reported that the CRT reduces stress, improves patient care and serves as a tool for professional development.nnnCONCLUSIONnThe CRT may be a useful tool for developing professionalism during medical education, reducing stress and enhancing the quality of patient care.nnnPRACTICE IMPLICATIONSnProviding students with reflective practice training that draws on their current personal clinical problems in order to improve their clinical work may be a productive investment in personal professional development, physician health, and quality improvement.

Towards non-reductionistic medical anthropology, medical education and practitioner–patient-interaction: The example of Anthroposophic Medicine

OBJECTIVEnTo develop the hypothesis that reductionism in medical anthropology, professional education and health care influences empathy development, communication and patient satisfaction.nnnMETHODnWe identified relevant literature and reviewed the material in a structured essay. We reflected our hypothesis by applying it to Anthroposophic Medicine (AM), an example of holistic theory and practice.nnnRESULTSnReductionism in medical anthropology such as in conventional medicine seems to lead to a less empathetic and less communicative health care culture than holism such as in CAM disciplines. However, reductionism can be transformed into a systemic, multi-perspective holistic view, when the emergent properties of the physical, living, psychic, spiritual and social levels of human existence and the causal relations between them are more carefully accounted for in epistemology, medical anthropology and professional education. This is shown by the example of AM and its possible benefits for communication with and satisfaction of patients.nnnCONCLUSIONnA non-reductionistic understanding of the human being may improve communication with patients and enhance patient benefit and satisfaction.nnnPRACTICE IMPLICATIONSnInterdisciplinary qualitative and quantitative studies are warranted to test this hypothesis and to understand the complex relations between epistemology, medical anthropology, education, health care delivery and benefit for patients.

Integrative medical education: Educational strategies and preliminary evaluation of the Integrated Curriculum for Anthroposophic Medicine (ICURAM)

OBJECTIVESnthe development and preliminary evaluation of a new medical program aimed at educating students in patient-centered integrative care and developing appropriate educational strategies.nnnMETHODSnThe Integrated Curriculum for Anthroposophic Medicine (ICURAM) was developed with modules on anthroposophic medicine integrated into the full 6 years of the regular medical curriculum. The educational strategy is the ESPRI(2)T approach, combining Exploratory learning, Supported participation, Patient-based learning, Reflective practice, Integrated learning, an Integrative approach and Team-based learning. The student participation, assessed based on the number of credit points earned per year (ctp/year) through the ICURAM (1 ctp=30 h workload), served as a preliminary indicator of student interest.nnnRESULTSnOf the 412 55%medical students participated in the program: 16% full participation (≥ 4 ctp/year), 18% partial participation (1-3.99 ctp/year) and 22% occasional participation (0.25-0.99 ctp/year). The amount of additional workload taken on by students was between 7.8h/year for occasional participants, 33 h/year for partial participants and 84 h/year for full participants.nnnCONCLUSIONnMore than half of medical students were willing to invest a significant amount of additional time in the optional program.nnnPRACTICE IMPLICATIONSnAn integrative medical curriculum with a student-centered educational strategy seems to be of interest to most medical students.