Perceptions of medical professionals regarding role of present medical education system in developing physician’s empathy-an observational study

Objectives: To detect how the positive and negative determinants of current medical education system during undergraduate and post graduate trainings affect the physicians’ empathy. Material and Methods: This is a questionnaire based cross sectional observational study conducted after taking permission from the institutional ethics committee. All the practicing medical professionals belonging to different specialities were included in the study. For each questionnaire item, they were asked to respond either yes / no. Data was interpreted as percentage of acceptance and rejection. Results: 70% physicians believed that present medical education system is helpful in developing empathy still 80% were in favour of conducting classes on empathy during the medical education. 80% agreed to all the positive determinants of development of empathy while 40 % agreed to all the negative determinants of empathy. Conclusion: In present setup though empathy is not included in medical curriculum but the assumed positive determinants of empathy during the under and post graduate training seems to be cultivating empathy in our socio-responsive physicians.


Introduction
Empathy has important role in the patient care and it has strong positive effect on patient's health outcome. 1 Clinical empathy is poorly defined and also difficult to measure. 2 In medical context empathy means an ability to understand the patients' feelings, situation and perspective and to act on that understanding with the patient in a helpful way. 3 Hence it is an important component of high quality communication in healthcare relationships and a crucial aspect of medical practice. Various studies conducted so far relating physician's empathy and behaviour towards patients and their clinical outcomes have shown multiple positive effects. These studies have shown that clinical empathy enhances patient satisfaction, comfort, and trust. 4,5 In current scenario of medical education empathy is undervalued and under-taught. Recent studies have shown that empathy can be significantly increased by teaching, particularly if focus is embedded in students' experiences with patients. 6,7 Different medical education associations and other professional organisations in several countries agree that empathy is a desirable physician characteristic that should be developed and promoted in the medical education process. 8 Currently, there is not much emphasis and time given to teach the empathic response in undergraduate training, postgraduate training and continuing medical education. With this background this study was planned to relate how the current medical education system during the undergraduate and postgraduate training affects the physicians' empathy.

Material and Methods
This questionnaire based cross sectional observational study was conducted in department of pharmacology at a tertiary care teaching hospital. After taking ethical permission from the institutional ethics committee; data was collected in preformed questionnaire. Questionnaire consisting of few sociodemographic questions and other direct questions to physicians was developed with the help of Ahrweiler et al study 8 and distributed amongst the medical education unit faculty of the college for validation. Validation of questionnaire was completed after lots of discussion and changes. The questionnaire was anonymous and was supposed to be submitted voluntarily. Participants were informed and explained the purpose of the study and asked to submit the filled questionnaire form if they agree to participate. Total one twenty clinicians working in the hospital belonging to different specialities were included in the study. Pre and Para clinical professionals were excluded from the study. For each questionnaire item, they were asked to respond either in affirmative (yes) or negative (no). Data was interpreted as percentage of acceptance and rejection. Data collected in questionnaire was analyzed in Microsoft excel.

Results
Total 120 practicing medical professionals including 72 (60%) males and 48 (40%) females with age varying between 32-62 years were finally recruited in the study. They were from various medical fields with experience varying between 8-32 yrs.
While responding to questions regarding medical education and the speculated positive determinants of empathy, 70% physicians accepted that medical education training was helpful in developing empathy and they were having memory of teaching empathy during undergraduate and postgraduate training. 100% physicians agreed that medical education should aim to develop clinical empathy. 80% accepted that there should be classes on empathy and 95% believed that good teachers and lectures are helpful in developing empathy.
60% medical professionals accepted that skill of communication was taught during under and post graduate trainig. (Table 1) Medical education should aim to develop clinical empathy 100 00 4 Should there be classes on empathy 80 20 5 Skill of communication was taught during the training 60 40 6 Good teachers and lectures are helpful in developing empathy 95 5 Among the various forms of training speculated as positive determinants of empathy, 80% considered history taking, 70% clinical postings, 60% psychiatry teaching (both theoretical and practical) were helpful and 70% accepted that practice based learning was helpful in developing empathy. Group discussions, bed side teaching and learning from one another were helpful for 82% of the physicians. (Table 2) Psychiatry teaching (both theoretical and practical) was helpful 60 40 4 Practice based learning was helpful 70 30 5 Group discussions, bed side teaching and learning from one another were helpful 82. 5 17.5 While answering to questions based on negative determinants of empathy 60% practitioners accepted that most of the training was focused on scientific facts and diagnostic results and psycho-social aspects of patients' characteristics were neglected. Cramming for examinations, being overloaded, time taken by tasks that are away from patients (e.g. documentation), improper time management, exhaustion or general stress during the training period is responsible for lack of empathy was agreed by 95% physicians. 65% physicians agreed that medical training is conducted in hospitals in which there is overwhelming exposure to sickness, suffering and death on one hand and responsibilities on the other. 65 % believe that empathy declines after contact with patients is intensified and for 50% practitioners self-assessed empathy drops after students begin the clinical phase of training. (Table 3) Responding to questions related to medical curriculum and empathy, for 90% practitioners; patient contact on personal level during initial clinical postings are helpful and contact with patient is an informal and hidden curriculum which includes empathy and 100% agreed that lack of empathy in formal medical curriculum is responsible for its underdevelopment. (Table 4). Lack of empathy in formal curriculum is responsible for its underdevelopment. 100 00

Discussion
An indispensable requisite for quality care of patients is clinical empathy as it results in better patient's contentment, compliance and lesser number of litigations against practitioners. 9 Indeed, many of the criticisms of medical care voiced by patients refer to what they perceive as inadequate interpersonal and communication skills rather than therapeutic part. 10 In this present study we tried to analyse scenario of development of clinical empathy in clinicians in perspective to present medical education system.
The result of this study suggested that for a large number of physicians, medical education training was helpful in developing empathy and they accepted that empathy was taught during both undergraduate and postgraduate courses. There is no clear-cut evidence of teaching clinical empathy as a separate skill. It can be assumed that probably it is communicated through curriculum which includes contact with patients. [10][11][12] Also according to the Shapiro study most clinicians convey clinical empathy through observable communication skills, verbal and non-verbal behaviours, body language and by specific concrete actions to improve condition and reduce suffering of the patient. 13 All the physicians were of the opinion that medical education should aim to develop empathy. Though research regarding influence of empathy on clinical outcomes is lacking 14 but there are researches that show that it improves doctor-patient relationship and their satisfaction and even enhance diagnostic accuracy. This positive empathy also helps in better identification of patients' needs, perceptions, and expectations. [15][16][17] Physicians agreed that there should be classes on empathy. Most of the medical education curriculum does not include empathy. 18 Traditionally empathy is not taught and is not given due consideration. Researches carried out on medical students have proved that empathy can be significantly increased if it is taught and especially if conveyed during patient interactions. 7, 19 Shapiro study says that formal training in empathy can lay a foundation, but that the most important aspects of empathy ''can't be conveyed theoretically.'' 13 In Buckman et al study residents were able to deliver bad news in a better way after a short course on empathy. 10 In present study many clinicians opined that good teachers and lectures are helpful in developing empathy. In one study most of the faculty were of the opinion that role modelling is the most effective way to teach empathy though few said it is unreliable if done without explanation. 13 Wider use can be made of single half-day teaching sessions with didactic presentations, followed by supervised role play using standardized patients and DVD or Web-based examples to help integrate the skills into clinical practice. 10 60% of physician agreed that communication skill was taught to them. Medical students can learn basic communication skills consciously or subconsciously by observing their colleagues and seniors though not adequately. 20 Further, it should be grasped by the students entire period of training and should be practiced so as to apply in future. 21,22 Although the need for training in communication skills is stated as a requirement in the 1997 Graduate Medical Education Regulations of the Medical Council of India, formal training in these skills has been fragmentary and non-uniform in most Indian curricula. The "Vision 2015" document of the Medical Council of India reaffirms the need to include training in communication skills in the MBBS curriculum. 23 According to Medical Council of India-Vision 2015, communication skills are one of the important competencies expected from a MBBS doctor. 24 The doctor has to be a good Communicator with patients, families, colleagues and community.
In agreement to the negative determinants various studies have shown that empathy declines during medical school and further decline during residency period. Moreover according to various studies physicians' stress affects practice habits. 25,26 The Shanafelt et al study demonstrates that quality of care in parallel to empathy is negatively affected by personal distress in residents. 26 Results of Thomas et al study suggest training curriculum alone is not responsible for decline in empathy; moreover students' distress and quality of life also contributes. 27 Many Studies have shown a negative shift in attitudes of the students towards patients when compared between preclinical and clinical years. 28 Apart from these negative determinants other factors may also contribute. A darker aspect may be the fact that all senior physicians are good role models and may display negative role model behaviours. These may be silently acknowledged by the students as a 'hidden curriculum.' 29,30 In our study we found that physicians believed that contact with patient in clinics is helpful and it is an informal and hidden curriculum in which empathy is taught. According to the clinicians the fact that empathy is not included in formal curriculum; is responsible for its underdevelopment. So far we have learnt about negative determinants of empathy and that is taught only as a hidden curriculum. Lack of evidence in modern medicine is suggested by Reynold et al study. 31 So, teaching of communicative skills must be included in their syllabus.
Medical students themselves, and several professional bodies, have acknowledged the need to incorporate communication skills training within the formal curriculum. 32 Recently Medical Council India has also introduced Attitude and Communication (AT-COM) programme through Nodal and Regional training centres to cultivate attitude and communication skills among the faculty and medical students.

Conclusion
The results of present study are suggestive to conclude that the present education system is helpful to an extent to develop physician empathy towards patients. In present setup though empathy is not included in medical curriculum but the assumed positive determinants of empathy during the under and post graduate training seems to be cultivating empathy in our socio-responsive physicians.