Editor’s note: Will Jaffee writes this editorial on behalf of the in-Training Editorial Board.
There is a well studied phenomenon in medical education: student physicians begin to burn out out early. According to several multi-center studies, burnout occurs in roughly 50 percent of students before they even earn their medical degrees.
Personally, this manifests in the fading width of the bright smiles we adorned during our white coat ceremonies while our teeth begin to change to a color that only coffee-executives could be proud of. In short, we begin to care less.
This article briefly summarizes the research about these changes and provides personal insight into the experience with empathy decline and burnout through medical school. While empathy, burnout and ethical erosion can be three distinct topics, we believe they are closely related and thus for the purposes of this article will be discussed as one general phenomenon but distinguished where appropriate.
Neumann et al. provide a comprehensive model for empathy decline during medical training. Their model includes physiologic (decreased mirror neuron response, increased distress), psychological (coping, self-defense, decreased quality of life) and other factors. Bellini and Shae, in a single-center study, showed that residents had a progressive loss of empathy over three years and did not return to baseline, which is consistent with work done by others in similar survey-based longitudinal (through residency), single and multicenter studies. This, by our estimation, is multifactorial owing partly to individual personality variability, but also to inevitable feelings of hopelessness and helplessness given a perceived-unbearable workload.
Further, in multiple studies Cheng et al. have shown that physicians downregulate emotional processing of other people’s pain. That is, physicians’ did not show event-related potentials when observing those being pricked with needles the way the control subjects did, which they hypothesize frees up cognitive resources to help a patient in pain rather than being overtaken with empathy. In this way, it can be suggested that the loss of empathy is itself adaptive in a positive manner for patient care during times of great discomfort.
These few articles represent only a fraction of the research on the topic, and there exist a fraction of the general consensus studies that portend to show that empathy decline is not inevitable for the tired 50 percent of us. They are, however, in the minority.
Empathy decline has been shown to be a multifaceted process involving distress, a decrease in the drive to learn new information, and worse, a decrease in the amount of empathy we feel for those under our care. While the above review of the literature generally shows what we would expect of any job that is demanding emotionally, intellectually and physically, we believe the root cause can also be summed up rather simply. The inverse relationship between workload and empathy is caused by one general phenomenon: the sheer volume of work we are expected to complete and the sheer volume of patients we see in vulnerable situations.
It begins with the Sisyphean task of the basic sciences curriculum, in which students are buried under more information than is either possible to learn or relevant to clinical practice. For a group of students that are used to hard work equating with success, the transition to “average” grades (which by definition is most of us) following longer study hours than ever before is not a pleasant nor rewarding academic exercise. The second year of medical school is capped by the most difficult exam any of us have taken to date, the USMLE Step 1 or COMLEX Level 1, which is fear-mongered to dictate much of our future. The terms “depressed” and “insane” were frequently used in describing our peers’ mental statuses while in the throes of studying for these board exams.
The transition to the clinical rotations is, at least transiently, a very welcome change. Here, however, rather than being met by friendly patients who demonstrate patience with a fumbling medical student, we are often met with significant skepticism, tanking our confidence in the process. Friendly residents and attendings make an important supportive difference. However, progress to confidence occurs in the context of such broad ignorance that at times it is difficult to pat ourselves on the back for taking baby steps in a marathon.
As the responsibilities grow, our speed and efficiency grows, but this most often comes at the expense of personal time with patients. Thus even when we want to spend an extra 10 minutes with a patient, we are often forced into saying “I’m sorry Mr. Smith, but I really have to get going.” This only reinforces their status as not-quite-people who we have to inspect and then leave behind to report to our superiors. Worse are those who are actively in distress, delirious or sedated. The hospital can sometimes feel more like a zoo when there are multiple patients shouting, machines beeping, and your attending is telling you to just continue presenting and ignore the cacophony. Add to this the patients who did not notice the massive skin infection they have, smoked their way into another pneumonia, or ignored a GI bleed for a week, and it becomes difficult to know if your patient will have any self-awareness to begin with.
Medical education often becomes an exercise in patience, in which self-harming organisms are coupled with significant pressure from superiors to consider and list for the team every possible esoteric cause of that self-harming organism’s discomfort. In other words, the whole affair is effectively designed to drive students away from patients and “good bedside manner” and towards efficiency and more time writing notes and researched. This slowly erodes compassion for patients and decreases the time available to actively discuss their disease process with them, and pushes us further towards stabilizing and “turfing” them back to their primary care doctor as soon as we can get them out of the hospital. In some ways, this is an appropriate practice, as hospital care is markedly more expensive than outpatient care and should be reserved for the sickest. In other ways, it obviously continues the dehumanizing work of thinking “not my problem” and sending them back to the nursing home or perhaps home with family.
Lastly, we believe it is important to distinguish between empathy decline and ethical decline. It is fully possible to spend less face time with a patient consoling them, describing their possible outcomes, or even caring about them while also doing what is best for them in the background. For instance, one does not necessarily need to spend much face time with a complicated patient (or, again, feel anything at all about them) to coordinate social services, medical necessities (visiting nursing aids, for example) and follow-up appointments. All of these components work together to provide perfectly holistic, organized care, none of which require feeling any empathy for a patient. They are, simply, the jobs of the intern and the clinical support staff.
Empathy decline may be nearly inevitable for some of us, but it does not have to translate to worse care, and as Cheng et al. have shown, it is not necessarily bad. Given these complicating factors, it is our opinion that the decline in empathy is not definitively worse for patients, and in some circumstances may be of benefit. Ethical erosion may occur secondary to or even independently of one’s decline in empathy, and should be discussed as such.