When I enter the examining room, Mr. Jones is visibly distressed. His chest heaves as he struggles to catch his breath. I glance at his charts and make note of his chief complaint: chest pain. After a brief introduction, I fire off a barrage of well-rehearsed questions: When did the chest pain first begin? Does it radiate outwards or stay localized in one spot? Is there anything that makes the pain better or worse?
At one point during the interview, Mr. Jones grows teary-eyed as he recalls his father’s death from a sudden heart attack. “I’m really scared, doc. Do you think what happened to my Dad could happen to me, too?” Placing my hand delicately on his knee, I assure him that I will do everything I can to make sure his heart is working fine. For the first time during our brief encounter, Mr. Jones looks relieved.
But despite my warm promises, I don’t return with an EKG machine. I’m not really a doctor, and Mr. Jones is not suffering a likely heart attack. He is a perfectly healthy medical librarian who happens to moonlight as a standardized patient. The scene I have just portrayed is the third-year summative OSCE (Objective Structured Clinical Examination), a familiar milestone along students’ journey to become physicians. The OSCE assesses students’ abilities to clinically examine patients, diagnose medical illness, and demonstrate strong communication skills. For first-timers, the OSCE may feel like a bizarre, yet clinically sacred ritual, an act of “faking doctor” that has become an integral part of most American school medical curricula.
In addition to the more technical aspects of a physical exam-things like generating a differential diagnosis or correctly manipulating the chest and lung, students also receive points for how well they “praise patient for taking steps to improve health,” “use encouraging and supportive gestures,” and “show empathy.”
In other words, students are graded on how good they are at being humans.
And given the widespread concern regarding a loss of empathy in medicine it’s no wonder that so much emphasis has been placed on medical students’ convincing capability for “humanism.”
In recent years, health care reform restrictions favoring shorter, less personal visits and an admissions process that traditionally favors excellent scores over interpersonal skills have largely eroded away at physician empathy. And consequently, patient satisfaction has plummeted. A 2011 survey by the Schwartz Center for Compassionate Care found that only about half of the 800 recently hospitalized patients felt that their physicians were empathic and caring. In a study of videotaped doctor-patient encounters with oncologists and cancer patients, researchers only provide empathic responses 22 percent of the time.
Some health care educators questions blame an admissions process that traditionally favors excellent scores over interpersonal skills, others believe the strenuous nature of training and the uncompromising hours result in dehumanized physicians. Whatever the reason, it’s clear that empathy is a vital part of a physician’s training and when it comes to our education, it’s a part that we’re getting shortchanged on.
During the preclinical years of their training, medical students spend hundreds of hours memorizing biochemical pathways and learning disease etiologies. Yet during these first two years, there is significantly less curriculum time devoted to the softer skills of medicine, attributes like empathy, active listening, reflection and introspection. This disparity translates into a cohort of newly-minted physicians with strong technical skills and a mental encyclopedia of factual knowledge, but deficits in equally important interpersonal skills.
Anecdotally speaking, I can’t tell you how many times a friend or relative has complained to me about their doctor: “They just didn’t listen” or “They don’t really care.” I’d like to think these are exceptions and not the norm. But as a third-year medical student on the floors, I’m beginning to have doubts. I’ve seen residents or attendings dismissed a patient’s pain complaints knowing those complaints could possibly lead to a longer hospital stay. I’ve been in the operating room while an attending compared an overweight patient’s body (sedated on the operating table) to a Thanksgiving turkey. I have heard residents crack jokes about a patient’s mental illness, not take her complaints seriously because she was “crazy.” I won’t pretend to stand on some moral pedestal, even as a naïve and idealistic third-year student, I’ve had my own moments of weakness. There are times when I’ve interrupted patients or cut them off, when I was more concerned with presenting at rounds for my attending than listening to my patient’s needs.
Beyond anecdotal observations, this erosion of empathy has been shown in scientific studies. At Jefferson Medical College, researchers used an “empathy scale” to show the most significant and rapid decline in empathy in medical students occurred during the third year of training. Puzzlingly, this phenomenon occurs during a time when students should be most empathetic, as they have finally ditched the endless P and textbooks for real human interaction. Researchers also point out that these decline in empathy is not transient; it persists through graduation and beyond.
When I leave my OSCE, and my last exam of medical school, I can rest assured that I was convincing enough to pass the empathy litmus test. I surely passed as a human. But, as I near the end of my medical training, I have to wonder, is this enough?