Is medical school an empathotoxin?

Medical school seems to have a profound negative effect on empathy according to a research review just published in Academic Medicine.

The review of 18 studies found that self-reported emotional understanding declines markedly during medical training. Counter-intuitively, the crucial downturn happens when medical students start seeing patients.

Although the studies are almost completely based on self-report, at the very least they show a decline in being interested in others’ emotional states, even if we can’t be sure that emotional competency is being affected.

Apart from the start of clinical practice phase of training the other major influence in empathy decline was personal distress, which concurs with studies that suggest that people in general report less empathy as they feel worse.

Of course, there may be a number of other factors at work, including the stress of training, an attempt to cope with suffering patients and what the article describes as ‘poor role models’.

What this refers to is the traditional ‘learning through humiliation’ style of medical teaching that seems to be oddly prized by the medical establishment as a form of clinical hazing.

The occasional reply to concerns about physician empathy is usually something along the lines of “what would you prefer, someone who is a good clinician or someone who is a nice person?”.

Despite the false dichotomy, the study make it abundantly clear why empathy is important in medicine, as it is associated with:

• patients’ reporting more about their symptoms and concerns
• physicians’ increased diagnostic accuracy
• patients’ receiving more illness-specific information
• patients’ increased participation and education
• patients’ increased compliance and satisfaction
• patients’ greater enablement
• patients’ reduced emotional distress and increased quality of life

Link to PubMed entry for study.
Link to DOI entry for study.

24 thoughts on “Is medical school an empathotoxin?”

  1. A less empathetic physician may be a more efficient (though I doubt more effective) physician, at least early in training.

    Viewed superficially, empathy may appear expendable. Hospitals and practices necessarily emphasize the bottom line & demand maximal patient volume. Even then, many still lose money each year in today’s climate of low reimbursement by insurance companies.

    I wonder if feeling forced to set empathy aside accounts for some of the profound dissatisfaction many physicians have for their careers.

  2. From my personal experience, I think it is true to some extent but then when empathy becomes part of your job-description, I think, it trivialises the whole idea of it.

  3. Dear readers,I personally note that the younger generation of Med students as well as young and more senior doctors have problems with empathy, The actual act of empathizing is retarded mostly by the use of short messages(SMS) and short form languages used in the act of communication.South East Asians best known for their “culture” of smiles and openess has changed due to the globalization effects of the Handphone and social networking.
    The Med Student and the young doctor do not empathize as we did 20 years ago with our patients then and even now.

  4. Physician treat diseases; nurses take care of patients. Some docs are healers; some are both.
    They are in the minority

  5. I just finished my clinical year at a top 5 medical school. The emotional blunting that occurs is tangible, and I have no doubt that this is a real phenomenon. At the beginning of the year it was not uncommon for classmates to start weeping at the death of a patient, now such an event is often met with a solemn shrug. I think, perhaps, that this emotional change is a necessary response to the near-constant barrage of depressing situations one sees in a trauma bay or ICU. Those classmates and residents who have retained their pre-med school “emotional understanding” are less effective in life-and-death scenarios because their personal emotional responses prevent the kind of dispassionate logical thinking that is necessary for good patient care in emergent circumstances.

    As for the comments about teaching, most medical schools now have classes to teach empathetic patient interviewing and techniques to turn your interaction with a patient into a partnership. These classes produce students that spout off insincere platitudes like, “that must be so difficult for you” or “i can’t imagine what you’re going through,” instead of encouraging real emotional bonds that will promote patient satisfaction. The humiliation style of teaching (we call it pimping) that you decry has produced the best physicians the world has ever known. Being asked a question that you don’t know the answer to in front of 100 of your peers is terrifying at first, but it provides the best motivation to learn the staggering amount of facts and patterns that are necessary for adequate patient care. A person whose psyche cannot endure temporary embarrassment in front of classmates will never be able to be a good in patient doctor where death, pain, and disfigurement are everyday occurrences.

    Empathy and kindness will win you rewards in patient interactions, but those benefits (e.g., increased patient “enablement”) have the greatest impact in the primary care setting. Empathy will not make the radiologist see more clearly, nor will it make the surgeon’s scalpel sharper. As the medical schools produce fewer and fewer primary care physicians (only 5% of my class will go into primary care), it makes sense that we are trained to operate in the high stress inpatient environment. If we are becoming more emotionally removed, it’s because we need to in order to survive a 30 hour shift in the pediatrics ICU where we have to fill out death certificates for three kids or when we have to tell the pregnant woman that her 7-month old fetus will not survive outside her body. I am not setting up a dichotomy, there are great inpatient doctors who have empathy oozing from every pore in their epidermis, but these are without the doubt the exception. For somebody decrying the lack of empathy in doctors, you don’t seem to have a whole lot for those providers who have to deal with sickness and dying on a daily basis.

    Just as medical doctors and surgeons were once trained separately, I imagine that specialist and primary care docs will be trained separately in the future. This is already starting to happen in the form of physician assistant and nurse practitioner programs, in which non-MDs are providing fantastic primary care. Those going to primary care can have their emotional naivete sheltered from the harsher realities of illness, and they can enjoy greater patient satisfaction. Those who want to take care of seriously ill patients can develop the emotional coping mechanisms necessary to survive in the hospital.

  6. The response from the medical student is quite accurate. I’m a fairly new medical student in one of the newest and “cutting edge” curriculum in North America. It was developed as a direct response to this public concern.

    I can say that after a year of intense education, I don’t feel like I know very much medicine. All we were “taught” was how to be empathetic. The fact of the matter is that medical education and residency programs are increasing in length in order to accommodate the broader depth of knowledge that is in the medical field today.

    This comes on the heels of constant research and advancing technology. Even so, there isn’t enough time to have a full understanding of the material without sacrificing every stitch of personal and family time that you have…interesting seeing as we learn that we should help our patients achieve a true “balance” in life.

    I think that if you were to look closely at any profession, you would find some people that are genuinely empathetic and some people that seem ‘cold’. That’s because it is a personality trait and can rarely be taught to a level that doesn’t seem fake. So, if you want a Doc that is a great listener, you might have to just shop around for one that suits you. But beware of the next generation…we will be self taught because the classroom doesn’t have time to teach the basics as long as the administration is catering to the cries for empathy.

  7. @S. Vickery:

    Thanks for adding some humor to my last day of Step 3 study.

    “I can say that after a year of intense education, I don’t feel like I know very much medicine.”

    That’s because you don’t know very much about medicine. No med student, regardless of era or curriculum, ever has known very much about medicine after a single year of study. You’re just beginning to build a foundation that will underlie & help you to organize everything you learn. Realistically, no one knows that much about medicine after even 4 years of study. Internship will open your eyes to this little pearl.

    I suggest thoroughly digesting as much pathophysiology/basic physiology as you can and honing your pharmacology knowledge — a strong foundation in these areas will come back to help you during training when you have less time to read for extended periods.

    “there isn’t enough time to have a full understanding of the material without sacrificing every stitch of personal and family time that you have”

    Do you honestly think today’s med students are unique in this way? Modern med students, much like many young folks, are so narcissistic. You should have known exactly what you were getting into when you signed up for medical education & training.

    These have always been designed to take every minute of a person’s time and focus, regardless of extent of material to be learned. Residents of yesteryear lived in the hospital and were notoriously underslept even though they had the advantage of caring for many less acutely ill patients with much lower patient turnover. The whole system was marked by inefficiency. Our predecessors also generally suffered more overt emotional abuse from their superiors than we do.

    Few suggest that med students and residents can or even should achieve the “life balance” you cite. It’s balance enough if you can find adequate sleep, food, and a little exercise. For any chance of achieving true balance we would likely need to extend the education and training period because, as you said, there’s a lot to learn. And med school education could certainly be moderately more efficient.

    1. @PGYx:

      True True & True.

      I’m sure my personal opinion and experience will continue to change as I endure the long road ahead of me. I doubt that anyone can convince me that removing anatomy from our education (which has been done at my school) was a good decision. I’m fully aware that I will NEVER feel like an expert in medicine, but I’d like to feel like I can at least peek through a crack in the door.

  8. I have a diagnosis of ME/CFS.

    I had an excellent GP who used to bemoan that many doctors forget (or never get) that medicine is an art as well as a science.

    That’art’ should include ‘treatment’ – the way that one human being (the doctor) treats another (the patient). And an understanding that suffering, whether one can physiologically detect it or not, is, nevertheless real.

    To those with ‘difficult’ diagnoses this makes all the difference.

    I understand that there are time limits and that medicine is an incomplete science that can be frustrating if there is not an easy answer.

    A little humility and simply saying ‘I believe you but I don’t know what to do to help you and I am sorry that you are ill’ doesn’t take a great deal of effort.

    Unfortunately my GP has now retired.

    If only there were more like him.

  9. @S Vickery

    Removing anatomy?! Entirely? Even the lecture &/or case-based portions? If so, this is frankly stunning and I’m right there with you in your feelings of impending doom. Too many physicians already have little knowledge of which parts are connected to which, which makes it difficult to accurately assess many common complaints.

    “I’m fully aware that I will NEVER feel like an expert in medicine, but I’d like to feel like I can at least peek through a crack in the door.”

    You have the right attitude. I’m new to the field but have learned enough to say that your humility and determination to build your understanding of medicine will serve you & your patients well. I recommend you not count on being spoon-fed. Now is the time to seek educational & clinical sources that suit your learning style and provide reliable information.

  10. Most medical students are pretty freaked out the first
    time they have to dissect a human cadaver (although they
    don’t always show it), but over time they get used to it
    and eventually don’t mind at all. This is due to
    desensitization, and is essential to allow the students
    to learn physiology properly.

    “The review of 18 studies found that self-reported emotional
    understanding declines markedly during medical training.
    Counter-intuitively, the crucial downturn happens when
    medical students start seeing patients.”

    I think this is another example of desensitization. At
    first the students are horrified by the sadness and suffering
    that many of their patients endure, but after a while it
    just doesn’t bother them as much.

    And yet, some doctors end up much less empathetic than
    others. Probably this is because they started out having
    less empathy even before starting medical school, exposure
    to suffering reduced their already small store or empathy.
    While those with lots of empathy, also end up with less
    empathy, but still have lots of empathy left.

    It would be a worthwhile study to test the empathy levels
    of doctors before and after they take a one year sabbatical.
    I would bet that the sabbatical away from suffering would
    increase their empathy levels.


  11. The article is right.

    It’s impossibly difficult to feel empathy for others when you yourself are wasted, having just completed a 34 hour duty with only few hours of sleep, having barely eaten any real food, and being embarrassed in front of the patients by an almighty specialist.

    Seeing a person die in front of your eyes once is shocking. Getting to see it everyday is…well…routine.

    Unfortunate…but it’s the truth. That’s how it is.

    Still, I try. I have been a patient myself, and have had relatives who needed medical attention. Nothing’s worse than talking with a doctor who doesn’t connect with you on an emotional level.

    However, I think it has it’s merits. Most people would say that it’s easier to decide rationally when you are emotionally detached.

  12. Individually, each medical student and practitioner has a finite capacity to act effectively in challenging clinical situations. For some, the first cadaveric incision leads to symptomatic PTSD. It becomes a toss up between doing what we set out to do (learning how to participate in healing) and fitting in with a culture that elevates us above those we hope to serve. As the author says, “our traditional ‘learning through humiliation’ style of medical teaching” is akin to clinical hazing.

    Empathy is inherent in each of us and the positive effects of it are well documented. While we cannot teach empathy we sure can make an effort to do less to discourage it.

  13. “what would you prefer, someone who is a good clinician or someone who is a nice person?”

    False dichotomy… The question forces the choice but if you ask with the third choice with “AND”, everybody chooses this one, of course.

    This shows the importance to take care about the medical studies.
    The question is : How to avoid natural empathy to diminish during the learning process …and
    the professional practice?

  14. Dear CurrentMedStudent,

    Here’s what you said: “For somebody decrying the lack of empathy in doctors, you don’t seem to have a whole lot for those providers who have to deal with sickness and dying on a daily basis.”

    When did this become about people having empathy for the doctor? This is about *doctors* having empathy for patients. Yes, you work hard and see a lot of tragedy. You knew what you were getting into. Why should we have empathy for you when you are unwilling to strive for empathy, preferring instead to offer a list of things that you think justify your lack of empathy. And with that list, you become just another doctor. Not a great doctor… and clearly not even one who reaches for greatness. Just. Another. Doctor.

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