Teaching medical students to express empathy by exploring patient emotions and experiences in standardized medical encounters
Introduction
When patients attend a medical consultation, generally they are conveying to the physician their particular experiences regarding the perceived symptoms. Patients interpret these somatic sensations depending on many different factors including their unique personal and contextual circumstances, generating their own ideas and concerns (emotions) that their illness experience has caused, thereby giving rise to the consultation [1], [2], [3]. Generally, patients expect and value that their doctors attend these personal aspects of their experience [4], [5]. Physician attitudes and skills such as genuine interest, respect, reflective listening and empathy allow this task to be effectively carried out [6], which has been associated not only with a better physician–patient relationship but with improvements in clinical outcomes [7], [8], [9], [10], [11], [12], [13].
However, patients do not always overtly express these experiences, feelings, concerns and ideas. But they often communicate them indirectly through more or less subtle nonverbal or verbal “clues” which nevertheless contain interesting clinical information that can be defined as “clinical or contextual clues” [14], [15], [16] and, insofar as they represent a direct way to understanding the patient's experience, as “empathic opportunities” [17]. Some bodily expressions or sudden body or voice changes, anecdotal comments, questions or indirect expressions (speech clues), personal stories, or expressing reluctance to accept diagnostic or treatment proposals [18], represent good examples of these cues. Several studies have addressed the extent to which these expressions are exposed by patients [17], [19], [20], [21]. These expressions that represent a challenge for those doctors who often overlook them, as clinical information and opportunities to know the patient's world are lost [19], [20], [21], [22], therefore limiting their understanding and thus failing to convey a more genuine empathic behavior.
Empathy is one of the key elements of the communicative process and has been identified as the “core of caring”. It is considered a multidimensional concept, a skill with affective, cognitive and behavioral elements [23], [24], [25] which can be taught [26], [27]. A cognitive-behavioral approach of empathy requires the learner not only to identify feelings but to understand them. This approach is especially useful for teaching because it seems to be more easily systematized and applicable in specific teaching strategies [28], [29]. The affective and intuitive components of empathy are much more elusive [30], [31], [32], [33]. However, both approaches should be considered to develop this behavior genuinely.
Given these premises, we designed a teaching program for medical students in their first year of clinical interaction with patients and just before their clerkships, with the following main objectives: 1) to increase their ability to detect and explore relevant patients’ “contextual and emotional clues” in a medical consultation and 2) to increase their ability to tailor their empathic response depending on the clue. To achieve these objectives, the essential element of the theoretical teaching of the program was the communication process linking the patient’s experience with the empathic recognition of the feeling produced by this experience. The program was based on training with cognitive behavioral and intuitive components.
Section snippets
Course: structure and teaching activities
The course is part of the mandatory training in patient-physician communication for 3rd-year medical students. During six weeks students are deeply involved with patients in clinical encounters in hospital and primary care. Previously to this, they receive basic, specific training in communication skills for developing a “person centered interview”. This course has two modules. The overall objective of the first module was to train students in the use of communication skills to obtain relevant
Main results
The number of students enrolled in the course was 115. Most of them, 84 (73%) were women. All students carried out the first interview and 113 roleplayed the second. After this second interview it was considered that 46 students had achieved the objectives, so finally the third interview was performed by 67 students. Table 1 shows the students’ results in the three encounters for each skill scored by EO. Progressive improvements were observed in all communication skills. For the domain
Discussion
Humanistic attitudes such as empathy decline as students progress through the curriculum of medicine from preclinical to clinical level [38] and especially in the third year [39]. The training program offered here just at this crucial time helps the students to express more empathetic manifestations to the patients, obtaining more clues and carrying out a deeper exploration of patients’ beliefs, fears and expectations. Students develop a better understanding of the specific experiences that
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