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Empathy Decline and Its Reasons: A Systematic Review of Studies With Medical Students and Residents; Neumann, M; Edelhäuser, F; et al. Academic Medicine 86(8), August 2011, 996-1009.

Reviewed by Julie Byerley

What was the study question?
How does empathy change during medical education and what factors influence this change?

How was the study done?
This is a systematic review of the literature on empathy decline in medical students and residents. Quantitative and qualitative studies on the topic published 1990- January, 2010 were identified in several databases. Eighteen non-intervention studies were identified, 11 on medical students and 7 on residents. Fifteen of the studies were performed in the United States, one in Poland and two in the United Kingdom. All studies used self-assessment surveys of empathy. Some were longitudinal and others cross sectional in design. Typical systematic review techniques were employed.

What were the results?
All except one study suggested a decline in empathy over time during clinical training with the most significant change in empathy occurring in the clinical years. Not all potential factors of influence were considered. The influence of gender and age on loss of empathy was not consistent over the studies. When medical field was included as part of the study, medical students choosing patient-oriented specialties had higher empathy scores than students choosing more patient-remote fields (radiology and surgery were the examples used as patient-remote). Distress including burnout, low sense of well-being, and depression was identified as a main cause of empathy decline. Attempts were made to identify the causes of medical student distress. Maltreatment of learners by their educators, challenges in continuing relationships with social supports, and high student work load were cited as factors of influence on student distress. In addition, student idealism was perceived as vulnerable when harsh clinical realities were faced, leading to empathy decline. Concurrent with this is the student shift in focus from a pre-medical humanistic style to an educated, more objective one. Additional contributors to empathy loss include lack of continuity with patients, lack of role models in the clinical setting, and challenges faced in the learning environment. These problems are enhanced by feelings of uncertainty, concern for academic failure, and isolation of learners.

The discussion section of the paper also describes some fascinating neurophysiologic studies documenting down-regulation of sensory processing regarding empathy in physician brains and changes in mirror neurons that occur in response to distress.

What are the implications of these findings?
Empathy is an important element of communication and professionalism in clinical encounters and has been shown to contribute positively to health outcomes. To sustain medical student empathy and therefore improve the therapeutic physician patient relationship, educators should work to sustain empathy. Given that medical student distress was the factor most significantly identified as decreasing empathy and that empathy of the physician has been directly related to patient outcomes, it can be concluded that supporting medical student wellness is a key factor in improving patient health. Efforts to address the formal, informal, and hidden curriculum to decrease distress and improve the learning environment should be supported by medical student educators.

Editors note: As Dr. Byerley points out, optimizing student learning requires not only relevant objectives, awesome teaching sessions, and regular feedback. It requires that we assist in decreasing students' distress so that they are able to learn.

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