Could undertaking qualitative research serve to develop clinical empathy at undergraduate level?

K Mulligan, M Higgins
UCD School of Medicine and Medical science, Health Sciences Centre, Belfield, Dublin 4

Clinical empathy is essential to the practice of medicine and is inextricably linked to the competence of a physician. It benefits both patient care and physician satisfaction yet the concept is often ill-defined1. Recent studies have also shown that it is ineffectually taught at undergraduate level and suggest that new methods be sought2. Conducting interviews for qualitative research could provide the opportunity for medical students to explore patient experience, develop clinical empathy and compassion as well as gaining research experience. Even the exercise of designing questionnaires for qualitative research could encourage students to engage with clinical empathy.

Clinical empathy appears to have suffered an identity crisis in recent decades. As defined by the US Society for General Internal Medicine clinical empathy is “the act of correctly acknowledging the emotional state of another without experiencing that state oneself“3. This has been further expanded to an operational definition stating that clinical empathy is the ability to “Understand the patient’s situation, perspective, and feelings (and attached meanings), communicate that understanding and check its accuracy, and act on that understanding with the patient in a helpful (therapeutic) way”4. The final part of the expanded definition incorporates the concept of compassion. Acting in a caring way on what has been clinically observed and inferred is the crux of medical practice.

There is a large body of evidence to support the benefits of clinical empathy related to patient satisfaction, compliance and adherence to treatment5. Clinical empathy has also been correlated with increased physician satisfaction and decreased rates of burnout6. With the increasing prevalence of phenomena such as “ethical erosion” and “burnout” it’s more important than ever to explore novel ways of encouraging clinical empathy and compassion at undergraduate level.

Clinical empathy is relatively new to undergraduate curricula, beginning at the end of the 20th Century. Via workshops and formal teaching students are taught to convey empathy to patients with certain “tools”; body language, listening skills and stock phrases like “this must be very difficult”7. While these are all important elements of conducting effective consultations they reduce a concept based on cognition-fuelled emotional intuition to an exercise in basic etiquette.

A recent review concluded that further systematic evidence is required to adequately assess the effectiveness of formally teaching empathy at undergraduate level due to the conflicting results of studies to date8. The authors conducted a longitudinal study involving over 700 students from one medical school and found a significant decline in clinical empathy. A systematic review supported this finding of a decline in empathy throughout the course of undergraduate education, in keeping with the empirically observed phenomenon of “ethical erosion”9. As a result it is recommended that there is a need for “more sophisticated and refined” models of assessing and teaching empathy10. The way in which clinical empathy is taught in the context of medical education is often without practical application.

What if medical students could be allocated time to conduct patient interviews as part of a research project? This could allow the development of clinical empathy as well as contributing to the development of current clinical practice. Undertaking qualitative research allows the interviewer to explore the barriers and beliefs of a group of people. Encouraging students to take on qualitative research could provide the opportunity for medical students to develop their clinical empathy by exploring the beliefs and barriers of patients. As a final year medical student my first experience of qualitative research involved interviewing women with gestational diabetes to explore their attitudes towards diet and exercise. Conducting interviews with these women was an immense privilege. Barriers faced by women in improving habits like diet and exercise are varied and exceptionally personal, especially during pregnancy. I learned how difficult behaviour change was for these women due to the impact of factors such as cost and time. I was made aware that any intervention from a medical professional can present different challenges for different women and that adequate support is essential. More than facilitating an interview, I was having a conversation with these women with the purpose of improving services for women just like them. Many of the women I spoke with were eager to provide advice for other women who find themselves in their position, there were many themes that arose such as guilt surrounding the diagnosis and the overwhelming changes to lifestyle that were highlighted. Having talked to these women, I recognized the value of patient led research and considering the patient perspective in medical consultations.

This is not something that has been considered in the literature however the effect of medical students exploring patients’ “illness experience” on clinical empathy has been assessed with promising results.

In a recent feasibility study, one hundred and fifteen third-year medical students took part small group communication skills teaching followed by assessment in multiple simulated interviews. These involved simulated patients and students were asked to explore the patients’ ‘illness experience’. The study assessed the students’ ability to focus on the patient’s contextual information and perspectives throughout a short interview. Both the study coordinators and the simulated patients evaluated the student’s performance. Significant improvement from baseline was shown in communication skills and patient satisfaction. This course has now been added to the Medical school’s curriculum11.

In the clinical years of undergraduate training there’s so much content to get through that students truly engaging with patients falls down the list of priorities. This experience enforced for me the importance of truly engaging with patients in daily practice. As Atul Gawande said when advising medical students in his memoir Better “Ours is a job of talking to strangers. Why not learn something about them?”. Conducting qualitative research is therefore a unique opportunity to develop the practical application of clinical empathy.

Clinical empathy has been a contentious topic in medical education and practice in recent years. Alternative teaching methods are required and encouraging students to take part in conducting qualitative research should be explored as one of them.

Conflict of interest
The authors have no conflict of interest to declare

Karen Mulligan (UCD final year medical student) UCD School of Medicine and Medical science, Health sciences centre, Belfield, Dublin 4

Email: [email protected]

1. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991
2. Thelma Quince, Pia Thiemann, John Benson, Sarah Hyde, Undergraduate medical students’ empathy: current perspectives, Adv Med Educ Pract. 2016; 7:443–455.
3. Learning objectives for medical student education-guidelines for medical schools: Medical School Objectives Project. Acad Med. 1999;74:13±8.
4. Mercer SW, Reynolds WJ. Empathy and the quality of care. Br J Gen Pract. 2002:52 (Suppl):S9–S13.
5. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004;27:237–51.
6. Stratta E, Riding DM, and Baker P. Ethical erosion in newly qualified doctors: perceptions of empathy decline Int J Med Educ. 2016; 7: 286–292.
7. Coulehan JL, Platt FW, Egener B. “Let me see if I have this right…”: words that help build empathy. Ann Intern Med. 2001;135:221–7.
8. Stepien KA, Baernstein A. Educating for empathy: a review. J Gen Intern Med. 2006;21:524–30.
9. Neumann M, Edlehäuser F, Tauschel D. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009.
10. Quince T, Thiemann P, Benson J, Hyde S. Undergraduate medical students’ empathy: current perspectives Thelma. Adv Med Educ Pract. 2016; 7: 443–455.
11. Ruiz-Moral R, Perula de Torres L, Monge D, Garcia Leonardo C, Caballero F. Teaching medical students to express empathy by exploring patient emotions and experiences in standardized medical encounters. Patient Education and Counseling 100 (2017) 1694–1700