How Empathy Declines in Clerkship

An interesting (albeit far from robust) finding in the literature on medical education is that empathy tends to drop like a rock in the 3rd year of medical school. This is obviously not true for everyone - in particular, those coming in with high empathy tend to maintain their empathy levels better than those starting with lower empathy - but declines can be seen throughout the spectrum.

It's one thing to read about on paper, it's another thing to experience first-hand. Without a doubt, I believe my level of empathy - both internal and expressed - has fallen this year. I'm not happy about it and actively working to develop habits to bring it back up, but I can't deny that it happened. Especially on my final rotation through surgery, I caught myself tolerating or even engaging in behaviours I would have considered unacceptable a year ago. Part of addressing this setback in my ability to be a competent, empathetic physician involves identifying the causes of my decline in empathy. Here's what I've come up with.

1) Role Models

Medicine is hierarchical. We learn from those ahead of us and model our behaviours after our superiors. When the staff and residents we train under fail to show empathy, or when we're simply never around when they do demonstrate it, it conditions us students to de-emphasize empathy in our actions as well. I've seen such a spectrum, from exceedingly empathetic physicians and residents, to exceedingly unempathetic physicians and residents, but most fell somewhere in a neutral area. They'd be empathetic when convenient and when it was obviously useful for their sake, but wouldn't put in the effort when empathy was inconvenient or when the benefit was primarily for the patient's sake.

Monkey see, monkey do.

2) Ain't Nobody Got Time For That!

Medicine is busy and very fast-paced. There is constant pressure to do more with less time. The problem is, empathy takes time. It doesn't have to take a lot of time, especially for practiced individuals, but being unempathetic is undoubtedly faster than, you know, actually connecting with patients. When workflow is not set up to allow for empathetic communication, it becomes the first thing to go. Priorities in evaluation or compensation play into this, as students, residents, and staff are far more likely to benefit by being fast than by being empathetic. Ultimately I think being an empathetic practitioner leads to higher job satisfaction, and there are some small awards in medical school, residency, and practice for consistently demonstrating empathy, but the main external incentives are still in favour of going fast above being a compassionate, empathetic practitioner.

3) Active Discouragement

It's less common than the above examples, but there were times where being empathetic was actively discouraged. There are some practitioners who don't believe in empathy as a useful clinical approach, at least not in all situations. I have experienced a physician essentially yelling at a patient for being overweight. I was once called out for being too empathetic in a situation where my supervisor believed it was unnecessary. In fairness, there are absolutely circumstances where overt empathy needs to be toned down or even eliminated because it ends up being counterproductive. In psychiatry, for example, practitioners do need to be conscious about being too overtly empathetic because it can harm the therapeutic relationship. Yet, I found that about half the instances where empathy was being discouraged, the justification was more about convenience than about what was in the best interests of the patient. I found these pressures against empathy easiest to resist because they were so overt, but it was a pressure nonetheless, and contributed to a culture in some parts of my medical training that clearly did not value empathy in medicine.

4) Exhaustion

The spectre hanging over all of this is the chronic exhaustion inherent in much of medicine, particularly during training. Sleep deprivation distorts people's natural emotions, affecting mood, memory, and overall cognition. One notable effect is to make people irritable. Irritability isn't incompatible with empathy, but it certainly makes it a lot harder. Empathy requires a degree of emotional self-regulation and irritability reduces the degree to which emotional self-regulation is achievable. Sleep deprived practitioners can still keep it together, but that control is not as endless as it is in rested individuals. It does make me understand one of the less-appreciated coping strategies for exhaustion - maintaining calm around patients, but being quick to anger around learners, fellow physicians, and other healthcare professionals - though those actions don't exactly help the culture of medicine overall.

There is a second meaning to the title of this section. Compassion fatigue, the challenge of caring about the 100th patient suffering with a given illness with the same intensity as the 1st, is extremely common among healthcare practitioners. It's difficult to avoid, as we become accustomed to the tragedies of illness we encounter on a daily basis, but which are completely novel for our patients. I find this particularly common with conditions that are merely disruptive, rather than debilitating or fatal. When morbidity and mortality are common experiences, empathy for those who are inconvenienced is hard to muster. A truly empathetic person should be able to cut through this fatigue - after all, empathy doesn't mean feeling the same way as another person, but rather understanding they way they feel, even if you wouldn't having similar emotions in the same circumstance. Nevertheless, empathy is easier when your natural emotions more closely align with those of your patient, and compassion fatigue often causes that alignment of emotions between physicians and patients to slowly widen over time.

Solutions

I have no easy answers for reducing this decline in empathy through clerkship. On a personal level, I try the standard approaches - getting a bit more sleep, spending time with people outside of medicine to ground myself a bit, keeping mindful of my actions, and using reflective techniques like this blog. The medical profession in Canada has started putting an emphasis on physician resiliency and I do believe these efforts can be beneficial in preserving empathy through training.

However, the problem isn't with the people going through medical training - many of my fellow classmates enter medical school as some of the most grounded and resilient people I've met. Falling empathy is a systemic problem and requires a systemic solution. Reforming the medical system to allow for sufficient rest, and then to prioritize empathetic communication, will take hundreds of changes, both large and small. The good news is that if we can make enough change, the positive effects will propagate. Hierarchy in medicine means negative qualities persist from generation to generation, but so do useful qualities. The more empathy supervisors show, the more empathy learners will as well. In the meantime, individual-level interventions will have to suffice.