Sonia Ijaz Haider  ( Department of Educational Development, Aga Khan University; )
Qamar Riaz  ( Department of Educational Development and Surgery, Aga Khan University; )
Roger Christopher Gill  ( Department of Surgery, Aga Khan University, Karachi, Pakistan )

Abstract

Objective:To explore the reasons for decline in empathy among physicians and to identify strategiesfor fostering empathetic clinical practice.

Methods:The qualitative study was conducted at the Aga Khan University Hospital, Karachi, from February to June 2017, and comprised focus group discussions involving separate sessions with medical students, residents and clinical teachers. Content analysis was used to analyse the verbatim transcripts for identification of codes which led to derivation of themes from the data. Consolidated criteria for reporting qualitative research was used to assess the quality of the study.

Results:Of the 109 subjects, 57(52.3%) were medical students, 30(27.5%) residents and 22(20.2%)clinical teachers. Of the 9 focus group discussions, 4(44.4%) were held with the students, 3(33.3%) with

residents and 2(22.2%) with the teachers. Four themes that generated were delineating empathetic clinical practice, reasons for decline, challenges for promoting empathetic clinical practice, and recommendations for developing and facilitating empathetic clinical practice. All the participants unanimously agreed that there was a decline in empathetic clinical practice. Primary challenges included

increased workload and time constraints inhibiting empathetic practice.

Conclusion:It is essential to teach empathetic clinic practice to students and residents during medical training while continuous professional development should reinforce the significance of empathetic clinical practice among medical practitioners and educators.

Keywords:Empathy, Clinical practice, Focus group discussions, Health professionals, Clinical teachers. (JPMA 70: 116; 2020). https://doi.org/10.5455/JPMA.14408

Introduction

Empathy is a fundamentally a vital characteristic of the physician-patient relationship. Empathy is defined as the ability of the physician to recognise and understand a patient's perspective and experience, combined with the capacity to communicate this understanding to the patient.¹ This generates confidence and trust in the relationship, and promotes physician-patient satisfaction, and patient's ability to cope with stress.²A number of studies have explored empathy using different measurement scales.³Majority of these studies indicate that there is a decline in empathy in medical students and residents as they progress in their clinical years.⁴ One study⁵ examined medical students' empathy and concluded that empathy scores in the pre-clinicalyears were higher than in the clinical years. Another study⁶examined changes in medical students' empathy across different medical years and reported decline in empathetic understanding as students advance in medical school. A subsequent study concluded that a significant decline occurs during the third year in which the focus is more on patient-centred activities.⁷It was reported that 75% of medical students become cynical as they progress through the medical school.⁸ An Iranian study⁹measuring medical students' empathy reported a decline from preclinical to clinical trainees and interns. A study⁵measured mood variation and empathy during internship in medical students and concluded that enthusiasm was present in the beginning of the internship, but it soon turned into depression, anger and fatigue. One study⁴ concluded that frequency of mood changes increased and empathy decreased during clinical years.

These studies have examined empathy using quantitative measures, but none of these studies have explored in depth the reasons for decline in empathy and strategies for improving it. It is imperative to fully understand the causes which inhibit empathy among medical students and residents as they advance in their clinical years, and to explore approaches to enhance empathetic clinical practice. The current study was planned to observe the perceptions of medical students, residents and clinical teachers regarding provision of empathetic clinical practice, to identify factors that hinder such an attitude, and to explore ways of sustaining and promoting empathetic clinical practice.

 

Subjects and Methods

The qualitative study was conducted at the Aga KhanUniversity Hospital, Karachi, from February to June 2017,and comprised focus group discussions (FGDs) involving separate sessions with medical students, residents and clinical teachers. Purposive sampling was used for selecting final year medical students, residents in their final year of training and clinical teachers. The medical students and residents in the last year of training were selected because in the final years of undergraduate and postgraduate programmes, they would have a better understanding of provision of empathetic clinical practice and its related issues. Clinical teachers selected had more than five years of clinical and teaching experience and were also currently involved in clinical practice and teaching. Participants were approached via email. No relationship was established with the participants prior to the commencement of the study. All the participants approached provided informed consent to participate, and there were no dropouts. FGDs were held as they help participants to identify and clarify their views compared to individual interviews.¹⁰The structure for FGDs was developed based on a review of the literature, and the format was semi-structured questions flexible enough to allow for the introduction and discussion of further relevant topics.¹¹All the FGDs were conducted in meeting rooms at the university campus, each with an average duration of 52 minutes (range: 40 - 90 minutes). Sessions were moderated by a researcher who had training in qualitative research and conducting FGDs, and was not a clinical teacher. The facilitator summarised the key findings after every session to gain agreement of the participants. When the researchers felt that the data saturation was reached, data collection was stopped and, therefore, FGDs were notrepeated for the group.All FGD sessions were audio-taped and transcribed verbatim. The transcripts were independently analysed manually for the identification of codes by all the researchers. The coding categories were checked and refined. Two members of the research team were not clinical faculty members and were not involved in their teaching, assessment or evaluations. This eliminated any chance of introducing bias on the basis of pre-conceived ideas. The identified codes resulted in the derivation of themes from the data. Consensus on the themes was reached after discussion among the researchers. The trigger questions served as orientation for coding, and subthemes were identified in an iterative process, which ensured that themes were comparable across groups. The trustworthiness of the data was ensured by memberchecking after each FGD, and independent analysis of the transcripts.¹¹ Also, the consolidated criteria for reporting qualitative research (COREQ) checklist was used to ensure the quality of study (Appendix).¹²

Results

Of the 109 subjects, 57(52.3%) were medical students, 30(27.5%) residents and 22(20.2%) clinical teachers. Of the 9 FGDs, 4(44.4%) were held with the students, 3(33.3%) with residents and 2(22.2%) with the teachers. Each focus group session included a minimum of 7 participants and maximum of 15 participants, in addition to the facilitator and a note-taker. Four distinct themes were generated: empathetic clinical practice, reasons for decline, challenges for promoting empathetic clinical practice, and recommendations for developing and facilitating empathetic clinical practice (Table). There was consistency between the data collectedand the themes that emerged. No other minor theme emerged. Empathetic clinical practice was defined as feeling someone's pain by putting oneself in their shoes. In clinical practice, empathy is about being truly aware of the feelings of others and although most of the time these feelings are of suffering and pain, there are times of happiness and joy also. "The ability to feel that you are in that person's shoes while treating them, to understand in depth what they go through,both physically and psychologically, in that disease state especially the chronic ones."
(Teacher#3) There was a general consensus among all the participants that empathetic clinical practice had declined. Although a number of reasons were responsible for this decline,  increase in workload and time-constraints were identifiedas prime reasons. "We are always pushed with time, as we have to see patients within a specified time. We don't have the time to think and go through what the patient is going through in terms of their emotions, so we just quickly take the history, diagnose, manage and move on."
(Teacher# 8) A misconception that was highlighted during the discussion was that empathy is a trait which requires separate time. "Empathy requires time and we don't have it." (Teacher# 8) However, participants recognised that this concept was misleading and that empathy is a "feeling" which is assumed to be taught and practised during medical training and expected to be ingrained into clinical practice. Decline in students and residents empathetic behavior was also attributed to diverse background, culture andschooling. It was identified that empathetic practice variedacross individuals and disciplines. "It is a trait which varies from individual to individual and in some specialties is practised more compared to the others."
(Resident# 11) Participants indicated that gradual sustained exposure to critical patients and maintaining composed attitude also promotes desensitisation. "Since the beginning of the year, we get to see sick patients and get desensitiszed. We are dealing with very serious patients all the time and we don't have the time to empathise with each patient."
(Student #14) It was recognised that lack of reflection and settingunrealistic objectives induces stress which in turn makes the individual more robotic and this behaviour is learned by residents and students as well. "We are becoming more robots than human beings, and the decline in students is because they don't see empathy happening." (Teacher#14) In terms of challenges for promoting empathetic clinical practice, one of the primary challenges identified was increased workload followed by time-constraints for implementing empatheticclinical practice . "As far as faculty is concerned, patient load is a huge constraint. For residents, because we are expecting them to develop full competencies, some of which require hours of practice and work, adding empathy as an attribute would be a challenge, again because of the time and the load that they have in terms of teaching and learning. For students, curricular constraint will be there to add it in as a separate thing."
 (Teacher # 20) Students were of the opinion that empathy is there butdue to the nature of the environment, workload and timeconstraints it cannot be practised. "Over time it is not empathetic but sympathetic as it becomes more of a routine. For example suturing for the first time will be different while now for us it is a very casual task." (Student #37) "You want to practise it, but somehow it gets lost amidst the chaos of time and patients."
(Student# 11) It was also indicated that seeking agreement and commitment from everyone that empathetic practice should be followed would be a paramount challenge. "It's difficult to make everyone agree that empathetic clinical practice is important. It would be a challenge that this initiative is taken as a positive one."
(Resident #27) When it came to recommendations for developing and facilitating empathetic clinical practice, some of the respondents believed that empathy is an innate trait which cannot be developed, while others suggested that it can be developed. It was further suggested that empathy is a cognitive trait with emotions comprising behavioural science and psychological components. "I think the cognitive part is to be taught and emotional part is inherent. You can teach people to work around their deficiency but you cannot give it to them. So empathy is not to feel; it is more to understand."
( Teacher #12) Developing positive role models and supportive institutional policies were considered essential for medical students, residents and junior clinical teachers. "This has to be adopted as a culture, it has to be a part of organisational culture, not only should the directors be doing it but the organisational policies and culture should be aligned with it."
(Teacher #15) To sensitise about empathy and prevent its decline amonghealth professionals, it was suggested to have workshops,training sessions and inspirational talks to reinforce this attribute. Other suggestions were increasing the number of doctors, ensuring availability of time for rounds and clinics, increasing the number of theatres and beds, decrease workload, and register a specific number of patients only. It was also proposed to be included as a reflective practice among teachers, students and residents. It was recommended that empathy should be formally taught during medical school training.

"We are not really taught about empathy, we are focussed

on medical knowledge and grades. I think medical schools and residency programmes should focus on empathy. This can be taught with video clips, debates on such topics with facilitators, a guided discovery of this is what we are talking about and once you get it in early years, then it will be there." (Resident #29)

Discussion

The results would be of interest to policy-makers and those in leadership roles who aspire to promulgate empathetic clinical practice among students, residents and clinicians. The conceptual understanding of empathetic clinical practice of realising and putting oneself in others' shoes to feel their pain and suffering was similar among all three groups. This finding is similar to other studies in which empathy was recognised as constituting both cognitive and effective domains.¹³A number of reasons were identified for decline in empathetic clinical practice. A primary factor and persistence challenge identified by teachers and residents was increased workload in terms of administrative, clinical services and teaching responsibilities, and lack of time to address these responsibilities effectively. Existing studieshave identified similar findings.¹⁴ To address this challenge,the present study suggested creating a system where there is balance of responsibilities for clinical teachers i.e., overall workload should be reduced, dedicated time for clinical teaching should be increased, and there should be additional hiring of doctors and related staff to prevent burnout. Existing evidence also supports that organisations can play an important role by designing interventions to facilitate physicians in their responsibilities.¹⁵In the present study, students and residents felt thatcontinued stress to meet academic schedules and deadlines leave little room to think about empathetic clinical practice. Existing evidence also supports that general life stressors in combination with medical school stressors lead to burnout which overall adversely affects their health.¹⁶ Findings from the present study propose reduced workload for students and protected time for academics. Nurturing positive learning environment, focussing on problem-solving, teaching stress management skills and providing social support has been reported by other studies.¹⁷One of the interesting findings of the present study was that continued exposure to patient care fosters desensitisation. This desensitisation stems from the fact that persistent and continuous exposure to patient care renders the doctor habitual. Additionally, more focus is on ensuring patient safety and well-being rather than on delivery of empathetic clinical practice. Existing evidence also indicated similar findings that students excel to be competent doctors, but, during that process, lose their ability to empathise with the patients.¹⁸Findings from the present study indicate that students'background, culture and schooling may influence empathetic clinical practice. This is supported by literature which found that demographic and socio-economic background of medical students influenced their empathy levels.¹⁹ Similarly, another study demonstrated cultural variation in empathic concern and perspective taking across 63 countries.²⁰Another important finding was that promulgation of commercialisation in medical practice is responsible for the overall decline in empathetic clinical practice. Evidence also indicates that commercialisation has led to decline in physician collegiality, promoted de-professionalisation, and endangered medical ethics.²¹This commercialization is not only present at the physician level, but also gradually observed in residents and medical students. Hence, a trickledown effect takes place from the seniors to the juniors, and, therefore, a gradual change towards decline in empathy in the entire healthcare system is observed. One of the possible ways to address this could be to constitute policies which delineate the extent of commercialisation between universities and teaching hospitals, while institutions should put in place stringent policies to foster empathetic clinical practice. Another important finding of the study is that practitioners may agree that empathy is important, but practicing empathetic clinical practice may not be perceived as significant by all practitioners. A study argued that doctors can be competent in their treatment without being empathetic.²² Additionally, evidence indicates that demonstration of empathetic clinical practice varies from people-orientated specialty to technology-orientated specialty, and across gender.²³To address this decline, the present study recommendedintegrating empathy as a longitudinal theme in undergraduate and postgraduate curriculum. Additionally, it was suggested to arrange workshops, seminars and discussions among residents, teachers and students for sustaining empathetic clinical practice. Also, continuous efforts are needed to reinforce the importance and practice of empathy during medical training and continuous professional development. There are commonly available teaching materials also that highlight the importance of empathy. Other studies recommended working with positive role models and doing practical discussions around psychosocial impact of illness to create awareness about empathy.²⁴ Findings from the present study also suggested ensuring repetitive reflective practice among clinicians, residents and students to foster empathetic clinical practice. Evidence also supports the role of reflective practice in facilitating empathy.²⁵Findings from the study also propose to keep evaluation system for sustaining empathetic clinical practice. Providing feedback for continuous improvement of empathetic clinical practice can be managed, but continuous monitoring and later evaluating it for all students, residents and clinicians will be difficult. Empathy is a multi-dimensional concept comprising cognitive and effective domains and when we talk of developing it and breaking it down into observable behaviour, it may be possible to develop thecognitive aspect but to what extent will it be possible to develop the affective domain remains questionable. The strength of the current study is that it explored in depth the reasons for decline in empathy, and identified ways of promoting empathetic clinical practice. Limitationof the study is FGDs which have a tendency to give morespace to the stronger voices that dominate the discussion. However, the current study made every effort to be inclusive and to allow all the participants to express their opinions.

Conclusion

Empathy is an integral component of clinical practice. There is a gradual decline in empathetic clinical practice among practitioners, but this is becoming widespread in medical students and residents. It is essential that during medical training, students and residents should be taught empathetic clinic practice, while continuous professional development should reinforce the significance of empathetic clinical practice among medical practitioners and educators. Empathy is a skill that can be learnt, and is not excessively time-consuming. The students need to be made aware of false beliefs in relation to empathy as well as commonly available teaching materials highlighting the importance of empathy. Institutions need to make concentrated efforts to ensure that empathetic clinical practice is followed.

Acknowledgement:Authors would like to thank Dr. Farzeen Fatima, Dr. Zaiba Shafiq Dawood, and Dr. Sarah Ashraf for their support in data collection, and all the residents and students who participated in the study.

Disclaimer:None.

Conflict of Interest:None.

Source of Funding:None.

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