It has been shown over and over that medical students start losing their "empathy" in the third year of medical school. Once the long hours and the rigors of hospital commence, students often stop seeing patients as people. Instead, Room 432 is now "that Gallbladder" or the "Narcotic Overdose" instead of "Ms. Jenkins" or "Mr. Smith." The need to churn out notes, finish scut work ("trivial, unrewarding, tedious, dirty, and disagreeable chores"), and the hospital culture can supersede the real needs of the patient. Thus, we try here in Asheville to prevent this "empathy erosion" before it starts. Following individual patients throughout the year and getting to know them as people is part of the idea, but equally imperative is our training in ethics. When else can third year students sit down and wonder, "Why is this patient not taking their blood pressure medication? Is it because they can't afford it? Is it because it labels them as diseased? Or as a provider, am I not adequately explaining the benefits of this therapy?" If we don't ask these questions, we move on without becoming better providers. We forget to question ourselves, failing to perform our own personal quality improvement. There are few simple answers in medicine, but an empathic doctor is more likely to be able to answer them.
This empathy has actually been quantified, even with such a small sample size of students completing this type of curriculum. When students at a similar pilot program at Harvard Medical School (called the "Cambridge Model") were asked about their preparation during third year, they scored higher than their traditional compatriots with respect to confidence in "truly caring" for patients, understanding social complexities surrounding individual patient care, and relating well to a diverse patient population. Using a scale from 1 to 6, when asked if they felt prepared to become a "reflective practitioner," Cambridge Model students ranked their abilities a 5.50. The traditional students scored only a 4.10. And when asked if the students felt ready to deal with the many ethical dilemmas they would face as future physicians, the disparity was even greater: 5.13 vs. 3.70.
And with respect to the "ethical erosion," before the start of third year, Cambridge Model students "ranked psychosocial concerns slightly, but not significantly higher than did the traditional students. However, by the end of the year, [these] students' scores had increased, and those of the traditional students had decreased, suggesting that ethical erosion did not occur in the students participating in the [new model]."
I know these numbers aren't perfect. Nobody knows if preventing the ethical erosion in the third year stops it from occurring throughout residency. But I think of it as similar to "bending the cost curve" in medicine. We may not be able to completely reduce the rising costs of medical care here in the United States, but if we can bend that rising curve downward, we can save ourselves quite a bit of money. If we can stop students from losing their empathy early, hopefully we can keep our doctors from bottoming-out later.
There is also anecdotal evidence that suggests that students in this model not only are more empathic, but are also happier (wait, I thought medical students are not supposed to be happy!). This seems to make quite a bit of sense in my mind. Frankly, happier people have more room to care. I certainly am less grumpy when I get my full 8 hours. So one must ask, if students are performing at the same level or better with respect to tests and on quantitative assessments of medical learning (which they do!), don't we want to have students who are happier, healthier, and more empathic? I certainly do; it seems like a no-brainer. These are the type of people I want treating my family and friends. In my mind, there is a direct correlation...
Getting to know patients as people + asking the tough questions = more empathic and happier future physicians!
So when we think about "bending the empathy cost-curve," the question is not, "Should third and fourth year medical students receive ethics training throughout these clinical years?" The question is, "Why doesn't training in Ethics continue all throughout residency??"
It should. And I hope to make that a part of my own residency training. At least it is something to consider, and we're asking the tough questions.
Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med. 2007;82(4):397-404.
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