#KeyLIMEPodcast 236: Getting to the heart of the matter

Reference

Krishnasamy et. al., How does medical education affect empathy and compassion in medical students? A meta-ethnography: BEME Guide No. 57. 2019 Med Teach. 2019 Aug 7:1-12.

Reviewer

Lara Varpio (@LaraVarpio)

Background

• Paper focuses on two important qualities for all clinicians to embrace and embody in their clinical work: empathy and compassion
• Authors point out that, especially with empathy, we haven’t reached consensus on what empathy means and the findings around what happens to a learner’s empathy levels during medical education are contradictory. Some research describes how empathy declines during medical training, while others report little to no change.
• As for compassion, despite often being considered a core competency and a sign of quality care, there is an on-going and inconclusive debate about whether compassion is an innate quality or if it can be taught to learners.

Purpose

• The authors set out to review and synthesize the evidence on how medical education affects empathy and compassion in medical students, and how this is perceived by medical students, educators, and patients.

Key Points on the Methods

The authors followed the seven steps for meta-ethnography that were created by Noblit and Hare in 1988.

• First, the researchers need to determine the focus of the research. Here, that focus is to find qualitative studies that discuss the education of medical students with outcomes of empathy and compassion.
• Second, what is relevant literature for achieving the research goals – this is about inclusion and exclusion criteria development. Here, some of those criteria were to include only manuscripts published in English, between 2007 and 2017, using designs like phenomenology, grounded theory, ethnography, etc.
• Three is reading the studies, noting metaphors, concepts or themes. Here, each paper that was included in the review was read and analyzed by two reviewers. The author team created a data extraction tool, piloted that tool, revised that tool, and then used it to pull data from each paper. Those data included design of the educational intervention, where the study was conducted, and descriptions of the experiences, attitudes, and perceptions of empathy and compassion from the participants AND from the analysis done by the authors. Two authors did these pulls for each paper, and resolved differences via discussion until consensus was achieved. They also appraised the quality of each manuscript using the CASP checklist – the critical appraisal skills program checklist for qualitative research.
• Step four of the method: determining how the studies are related by comparing concepts and metaphors to see similarities and differences. For this, each manuscript was read by 3 different members of the research team. They studied the key concepts and ideas across the papers, they looked at the verbatim quotes across papers, and they looked at the interpretations of the data offered by the authors of each paper.
• Step five had the authors translating studies into one another by comparing concept and metaphors to see how they relate to each other across manuscripts. In this step, the researchers started to develop their own insights and interpretations.
• In Step six, the synthesizing translations step, the authors created a line-of-argument synthesis which involves building up a picture of the whole data set by studying each of its parts. The authors used line-of-argument synthesis to integrate the similarities and differences among the studies to produce a new conceptual model that illustrates their interpretation of the findings.
• Step seven is conveying the findings of the synthesis – that’s the paper and the model the team developed.

Key Outcomes

In terms of what affects empathy and compassion in medical students, the authors identified 4 main themes.

• First, to show empathy and compassion to patients, medical students need to develop and maintain the ability to see patients as people. Medical students are encouraged to have empathy and compassion when they avoided depersonalizing patients into objects, cases, or a disease.
• The second theme: appreciating the elements of empathy and compassion themselves as phenomena. This encompassed moments when medical students were present, carefully listening and attending to the patients. It involved understanding the patient’s emotions and experiences of the care processes, and understanding the experience of the disease or medical issue. It also involved assuring and comforting patients. And responding with empathy to patients which enabled the patients to reciprocate and be empathetic and compassionate towards the learner.
• The third theme was navigating the training environment itself. This theme addressed how time pressures constrained empathy and compassion, how the medical culture itself with its emphasis on scientific and medical knowledge and its resistance to show emotion, how role models and the clinical atmosphere itself could impede the demonstration of empathy and compassion.
• Finally, medical students’ compassion and empathy are guided by their own ideals. The underlying and intrinsic thoughts, motivations, and ideals of each individual learner influences their identity and their ability to be compassionate and empathetic.

Key Conclusions

The discussion largely reviews and summarizes the findings. But right at the end of the discussion the authors highlight that empathy and compassion are relational, they exist in the relationship between the learner and the patient. So to encourage compassion and empathy, learners need opportunities to interact with patients of different types and in different settings. Learners need to be encouraged to be genuinely interested in the patients as people, to engage in dialogue with patients.

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