Shaping medical students' empathy, reflection and moral judgement : the effects of undergraduate medical education

Background: “The Art of Doctoring” or what is referred to as "professionalism" consists of not only skills and knowledge but also, attitudes and behaviours which include; competence, caring, compassion, altruism, self-regulation, and devotion to the collegial nature of the profession and to the public good. These can be achieved through basic qualities such as empathy, reflection and moral judgement. Medical education, specifically the hidden curriculum, can have major influences on these qualities. Aim: The purpose of this study was to investigate the effect of undergraduate medical education on important personal qualities that are necessary in medical students in order to graduate doctors that have satisfactory levels of professionalism. I selected three important qualities that create a foundation for professional behaviour. These qualities were: (1) empathy, (2) reflection-ability and (3) moral judgment. I studied the effect of medical education on those qualities in an attempt to understand how we can enhance them, or prevent their decline, in our medical students so that the end product is an empathic and reflective medical graduate with superior moral reasoning skills. Method: I investigated the above qualities in three separate, yet interrelated, studies. In a cross-sectional study, the Jefferson Scale of Physician Empathy (JSPE), Groningen Reflection Ability Scale (GRAS), and Moral Judgement Test (MJT) were employed to measure the levels of empathy, reflection and moral judgement, respectively, in undergraduate medical students (years one to five). The scales were administered to all medical students enrolled at the University of Western Sydney in 2011. Attached to the scales was a survey containing questions on demographics, stage of medical education, previous education, and level of completion of particular programmes that aim at promoting personal and professional development (PPD). For verification reasons, the MJT was readministered to all students enrolled at the University in 2012. Results: The results showed that empathy and reflection were maintained during medical education, contrary to other research studies, while moral judgement competence declined significantly in the later stages of medical education. This decline in moral judgement competence was found to be due to a decrease in moral reasoning of one of the two dilemmas in the MJT (i.e. the doctor’s dilemma) hence was referred to as “moral segmentation”. Approximately half of the students showed this phenomenon. Discussion: Preservation of empathy and reflection during medical education may be due to appropriate selection processes as well as educational efforts that aim to sensitize, raise awareness and force critical reflection e.g.; courses in medical ethics, the humanities, reflection, etc. Moral segmentation may be due to students predominantly employing cognitive processes in the doctor’s dilemma (compared to the worker’s dilemma). Approximately half of the population in this study did not show moral segmentation. These students may have reached a level of self-authorship rendering them resilient and providing them with an ability to defy moral segmentation. Conclusion: Moral judgment needs to include a utilitarian component (purely cognitive) as well as a deontological (ethical/emotional) one. In medical school, most of the teaching is arduous science requiring the use of the brain’s dominant hemisphere. There is very little opportunity to employ and train the non-dominant hemisphere which is responsible for our creative and emotional characteristics. It is necessary for medical students to develop and practice their moral reasoning through different scenarios otherwise the utilitarian component may take precedence over the deontological component resulting in compromised moral judgement

Empathy Levels in Medical Students: Do They Really Change Over Time?

There is conceptual ambiguity in defining empathy, which is further amplified when trying to define clinical empathy. The construct of empathy has been an ongoing debate: sometimes being interpreted as a cognitive attribute, other times as an emotional state of mind. Our preferred definition is moral, emotive, cognitive and behavioural dimensions working in harmony to benefit the patient. Understanding the feelings, attitudes and experiences of a patient is the first step towards a potent and effective interview and, thereby, therapeutic agreement. Thus, clinical empathy may be the most powerful tool for a successful collaboration between the patient and the doctor. This chapter discusses the history of clinical empathy starting with Sir William Osler’s definition of ‘neutral empathy’ where he argues that physicians need to neutralise their emotions so that they can ‘see into’ and, thereby, be able to ‘study’ the patient’s ‘inner life’, to Halpern’s insightful observations about the power of empathy, which ‘lies in its ability to help us cross the divide between clinicians and patients created by their very different circumstances’. This is followed by a summary of the literature deliberating the increasing concern among medical educators and medical professionals regarding the decline in medical students’ empathy during medical school, which brings us to our research question: are there significant changes in empathy levels over time in undergraduate medical education? This body of work reports on a cross-sectional study of all medical students enrolled at an Australian medical school, known for its cultural, social and religious diversity, in 2011. The research instrument used consisted of a survey encompassing questions on demographics in addition to the Jefferson Scale of Physician Empathy, Student version (JSPE-S). Empathy levels were compared while controlling for effects of age, gender, marital status, religious belief, ethnicity/cultural background, year of medical training, previous education and level of completion of programmes promoting altruism in an attempt to identify their effect on the levels of empathy. A total of 404 students participated in the study. The scores of the JSPE-S ranged from 34 to 135 with a mean score of 109.07 ± 14.937. This is considered moderate to high when compared to reported scores in previous studies on medical students. Female medical students had significantly higher empathy scores compared to their male counterparts in total and in individual years. Contrary to the literature, there were no significant differences in empathy scores in relation to the stage of medical training. Findings suggest that there is a gender difference in the levels of empathy, favouring female medical students, and that empathy levels may be preserved in medical school despite prior evidence that a decline is pervasive

From empathy to compassion fatigue : a narrative review of implications in healthcare

Evidence is clear regarding the importance of empathy in the development of effective relationships between healthcare professionals (HCPs) and patients in the delivery of successful healthcare. HCPs have pledged to relieve patient suffering, and they value the satisfaction felt from caring for their patients. However, empathy may lead to negative consequences for the empathiser. If there is a personal identification with the emotions of the distressed person, empathic concern may evolve into personal distress leading to compassion fatigue over time. A narrative review was used to explore the connection between empathy and compassion fatigue. A search of MEDLINE, PsychINFO and CINAHL resulted in 141 articles meeting the inclusion criteria. The results included in this chapter explore the practical implications of empathy in relation to compassion fatigue, examining the impact on HCPs as well as the potential risk factors and effective strategies to reduce compassion fatigue. The negative impact of compassion fatigue can have a severe impact on HCP well-being and can in turn impact the care received by the patient. Nevertheless, and despite existing effective strategies to support and manage those experiencing compassion fatigue, more needs to be done to prevent its development in HCPs

From Empathy to Compassion Fatigue: A Narrative Review of Implications in Healthcare

Evidence is clear regarding the importance of empathy in the development of effective relationships between healthcare professionals (HCPs) and patients in the delivery of successful healthcare. HCPs have pledged to relieve patient suffering, and they value the satisfaction felt from caring for their patients. However, empathy may lead to negative consequences for the empathiser. If there is a personal identification with the emotions of the distressed person, empathic concern may evolve into personal distress leading to compassion fatigue over time. A narrative review was used to explore the connection between empathy and compassion fatigue. A search of MEDLINE, PsychINFO and CINAHL resulted in 141 articles meeting the inclusion criteria. The results included in this chapter explore the practical implications of empathy in relation to compassion fatigue, examining the impact on HCPs as well as the potential risk factors and effective strategies to reduce compassion fatigue. The negative impact of compassion fatigue can have a severe impact on HCP well-being and can in turn impact the care received by the patient. Nevertheless, and despite existing effective strategies to support and manage those experiencing compassion fatigue, more needs to be done to prevent its development in HCPs

Understanding patient expectations of health care : a qualitative study

Understanding and measuring patient expectations of health care is central to improving patient satisfaction and delivering patient-centered care. However, most empiric research in this field has focused on measuring patient expectations for specific diseases only. Patient expectations common to a variety of settings and clinical contexts need to be better understood to design measures with wider utility. We aimed to understand how patients express and conceptualize their expectations of health care across a range of clinical contexts and conditions. Semi-structured interviews were conducted with patients presenting to a major metropolitan hospital, informed by interpretive phenomenological analysis. Sampling continued until thematic saturation. Interview topics explored the illness experience, interactions with clinicians, how patients communicated and conceptualized their expectations of health care, and the nature of these expectations. The 26 participants conceptualized and described their expectations in 3 distinct domains: (1) health outcomes, (2) individual clinicians, and (3) the health-care system. Importantly, these domains were consistent across a variety of clinical contexts, participant demographics, and medical conditions. Despite variation in expectations due to individual patient circumstances, we identified 3 conceptual domains within which expectations consistently lie. When designing measurement tools for patient expectations, we suggest incorporating questions specifically addressing the 3 domains we have identified. With such measures, clinicians and health-care providers can be empowered to provide and monitor patient-centered care with outcomes tailored to what patients desire

Twelve tips for adopting the virtual Nominal Group Technique (vNGT) in medical education research

Nominal Group Technique (NGT) is a structured approach to consensus development and data collection driven by problem-solving, idea inception and prioritisation. Challenges of the coronavirus disease 2019 (COVID-19) pandemic necessitated the development of a virtual (vNGT) model to recruit participants from diverse locations and time zones. Our reflections reveal the opportunities and challenges of using Zoom© for NGT sessions, resulting in more effective engagement and focus with fewer distractions compared to in-person meetings. The 12 tips provide practical suggestions for expanding the versatility of NGT in a virtual environment. These recommendations cover every aspect of the process, including the person, place, and object, from planning the sessions, and utilising technology resources effectively, to ensuring a seamless implementation to desirable outcomes. The paper strives to assist individuals in effectively using the online NGT as a substitute for in-person events, promoting effective management of remote participants even during unprecedented times of quarantine and physical distancing

The development and validation of a questionnaire to explore medical students' learning in a blended learning environment

Background: A blended learning environment is multifaceted and widely used in medical education. However, there is no validated instrument for exploring students’ learning in a blended learning environment in medical programs. This study aimed to develop and validate an instrument for exploring how medical students learn in an undergraduate medical program that employs a blended learning approach. Method: Using Artino’s seven step approach, we developed a questionnaire to investigate how medical students learn in a blended learning environment. For pilot testing, 120 students completed this 19-item questionnaire. These 19-items were evaluated for construct and convergent validity across an expert medical education panel. Further item testing was analysed with principal component analysis (PCA) with varimax rotation for item reduction and factor estimation. Hence, validity was thoroughly addressed to ensure the questionnaire was representative of the key focus questions. Cronbach’s Alpha was used for item reliability testing, and Spearman’s Rho was used for the correlation between the questionnaire items and the extensively used MSLQ. Hence, validity and reliability were systematically addressed. Results: Exploratory Factor analysis identified four factors F1 and F3: Resources: Accessibility & Guidance (14-items), F2: Learning behaviours: Social and Contextual (5-items), and F4: Motivational factors: Intrinsic and Extrinsic Motivation (4-items). Internal consistency and reliability tests were satisfactory (Cronbach’s Alpha ranged from 0.764 to 0.770). Conclusions: The resulting Blended Learning Questionnaire (BLQ) was determined to be a reliable instrument to explore undergraduate medical students’ learning in a blended learning environment

Moral judgement development during medical student clinical training

Background: Whereas experience and cognitive maturity drives moral judgement development in most young adults, medical students show slowing, regression, or segmentation in moral development during their clinical years of training. The aim of this study was to explore the moral development of medical students during clinical training. Methods: A cross-sectional sample of medical students from three clinical years of training were interviewed in groups or individually at an Australian medical school in 2018. Thematic analysis identified three themes which were then mapped against the stages and dimensions of Self-authorship Theory. Results: Thirty five medical students from years 3–5 participated in 11 interviews and 6 focus groups. Students shared the impacts of their clinical experiences as they identified with their seniors and increasingly understood the clinical context. Their accounts revealed themes of early confusion followed by defensiveness characterised by desensitization and justification. As students approached graduation, some were planning how they would make moral choices in their future practice. These themes were mapped to the stages of self-authorship: External Formulas, Crossroads and Self-authorship. Conclusions: Medical students recognise, reconcile and understand moral decisions within clinical settings to successfully reach or approach self-authorship. Curriculum and support during clinical training should match and support this progress

Students' social networks are diverse, dynamic and deliberate when transitioning to clinical training

Context: Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training. Methods: Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T0) and then again four months later (T1). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationships impacted their transition. We conducted mixed-methods analysis on this data. Results: At T0, eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1. People from within and beyond the clinical space made up participants’ social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance). Conclusions: This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students’ social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions

Pedagogical interventions and their influences on university-level students learning pharmacology-a realist review

IntroductionThe knowledge complexity and varied delivery formats in pharmacology education can leave students unprepared in essential pharmacotherapy skills. This significantly influences their ways of thinking and working in clinical environments, resulting in a challenging clinical transition. This need demands pedagogical innovations to strengthen pharmacology education and improve learners’ skills and competencies in pharmacotherapy. This evidence-based realist review aimed to examine the contextual factors and program theories or causal mechanisms crucial for effective pedagogical interventions in pharmacology, seeking to answer the question of ‘what works for whom, under what circumstances, how, and why’.MethodThe realist synthesis was initiated after retrieving data from Medline (OVID), Cochrane, EBSCO hosted ERIC, SCOPUS, and Embase (OVID) including other sources for additional records. The preliminary analysis enabled the establishment of context, mechanism, and outcome configurations (CMOC) and formulation and refinement of the initial program theory regarding the pedagogical interventions in pharmacology. Data synthesis iteration helped to identify the relevant context and unravel its relationships with underlying causal mechanisms through which said interventions generate outcomes of interest.ResultsA realist review analyzed 1,217 records and identified 75 articles examining a range of educational interventions from individual efforts to faculty-wide curriculum changes in pharmacology education. The key contexts for pharmacology education were troublesome content, traditional delivery methods, inadequate and limited opportunities for knowledge integration, and application. Active participation in interactive learning, along with enjoyment and motivation, was proposed as a causal mechanism for optimizing cognitive load and achieving positive outcomes. The outcomes of the review include subjective perceptions of improved confidence and satisfaction, objective measurements of high post-test scores.DiscussionPedagogical scaffolding in constructivist learning environments helps students overcome challenges in learning troublesome pharmacology knowledge. Considering the human cognitive system’s processing capacity, these interventions improve learning by effectively using cognitive resources. Innovations that focus on enhancing cognitive load through task construction can also promote positive emotional experiences in students, such as engagement and enjoyment, as explained by flow theory. A constructive learning environment, where the cognitive load is optimized and high flow is achieved, can maximize the impact of pedagogical interventions in pharmacology.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=160441, PROSPERO (CRD42020160441)