Med students learn empathy by practicing communication skills, observing doctors

As a senior medical student, Andrew Mills watched his teacher, an intensive care physician, talk with the family of a 20-year-old man who had tried to hang himself.

"He had hung long enough that he was brain dead (but his body was still functioning)," Mills recalled.

In a private room, the doctor went through every step of what had happened, what it meant, and what exactly would take place if the family chose to donate his organs.

"We were in there, literally, for an hour and a half," Mills said. "I thought the way he handled it was very impressive."

The suicide attempt "came out of the blue," he said. "The family didn't know he was depressed. They were clinging to the idea that maybe he'd come out of it. The doctor explained that there was irreparable damage ..."

"It was very uncomfortable for me," Mills said. "I've never been in a situation like that before. It's one thing to read about these things, but not until you're physically in the room does it become real to you. You go, 'Whoa, this is some pretty intense stuff.' "

In the end, "the family left that room feeling that something good was going to happen out of this ordeal."

The event stands out in his mind as an example of physician empathy and an example of the kind of physician he wants to be.

Mills, son of Lori Witteman of Bottineau, N.D., and Mark Mills of Austin, Minn., is among 55 students participating in the doctor of medicine (M.D.) commencement ceremony on Saturday at UND. This summer, he begins a residency program in reconstructive plastic surgery at Mayo Clinic in Rochester, Minn.

He is generally satisfied with the way he was taught about empathy-what some call "the art of medicine"-during medical school at UND, he said.

"I think (empathy) can be taught to a certain extent, but a person has to be open to it and willing to learn these (communication) techniques."

Communication skills

Empathy is addressed extensively, beginning in the first year of medical school at UND, said Dr. Charles Christianson, associate dean for clinical education.

Empathy is a specific clinical skill, he said. "It shows you are understanding what the person is thinking and feeling. It involves listening not only to what the patient says, but the emotions behind it ... and making empathic statements to show you understand them-or are trying to understand them.

"Something like, 'It sounds like you're really disappointed in the way your life has gone in the last three months,' opens up more conversation. Looking at it that way, empathy definitely can be taught."

Some students are naturally gifted at conveying empathy, Christianson said, "but for the bulk of people, they get better with practice."

Empathy wasn't part of medical curricula decades ago-it was learned by observing other physicians-but it has taken on more importance in the last 20 to 30 years, bolstered by psychology research, said Christianson, who is also a family physician.

"I found I was doing a lot of this. I learned by trial and error, and things went better with my patients when I did this."

"It's a basic human need to be understood," he said. As a patient, "you're looking at someone who's paid attention to you and tried to understand you. That's something that's probably therapeutic in itself."

'Not learned from a book'

Empathy "can be taught, but it can't be learned from a book," said Dr. Ralph Levitt, a UND clinical professor and a cancer specialist who has practiced oncology for more than 35 years.

Levitt and his fellow teachers demonstrate communication skills and techniques that convey the doctor is truly listening, is interested in the patient and understands the patient's situation.

Through lectures, role-playing and simulation, they guide students, for example, on how to give bad news to patients and how to best communicate with the patient.

In interviews with "standardized patients," people who pretend to have a particular illness or health condition, students hone their skills while teachers and other students observe.

"Empathy has to take the form of action," Levitt said. "You have to actually demonstrate that you are empathetic while you're interacting with the patient."

It is conveyed "not only by what you say, but how you say it, (and) by how you perceive the patient's emotions-how the patient is accepting the information and, if there's a level of stress, how to diffuse that," he said.

Non-verbal communication- eye contact with the patient, body language and physical proximity to the patient-is just as important.

But it's not only about what the physician projects, it's what the patient perceives, Levitt emphasized. It's about "whether or not the patient accepts (the communication) as a sincere approach" and understands it as empathy.

Levitt and his colleagues also demonstrate how not to do it, such as avoiding eye contact, acting distracted or not sensing and responding to the patient's emotions, he said.

"Patients perceive if you're distracted or if you're not truthful."

After the exercise, teachers and students discuss what went well and not so well, and students receive feedback on what else could have been done or said to show empathy.

'Innate capacity'

Bethany Kaemingk, a fourth-year medical student who also graduates from UND on Saturday, said, "I think people have an innate capacity to be empathetic ... As a medical student, you're learning with each new patient. The experiences are shaping what it means to be empathetic."

Empathy, she said, "is being able to recognize what sort of emotions the situation has brought up in the individual and being able to react appropriately with kindness, understanding and sensitivity."

During the last two years of medical school, students work and study with doctors in clinics and hospitals throughout the state and elsewhere.

"I think it's just as important to see examples of how you don't want to be, as it is to see examples of how you want to be," said Kaemingk, formerly of Albert Lea, Minn. She begins a pediatric residency program this summer at Mayo Clinic in Rochester.

In those instances where empathy was lacking, "it usually happened when there was a lot going on," she said. "The physician was not truly listening and picking up on (patient) cues. The physician was more concerned with what they had to get done (that) day. It takes more time and effort to be empathetic to patients."

Studies have shown that taking time to be empathetic produces several benefits, including higher patient satisfaction, higher physician satisfaction, and better health outcomes for the patient, Levitt said.

It encourages patients to be more forthcoming with information, which the physician can use to recommend treatment, and increases patient compliance with the treatment plan, he said.

Physicians are more satisfied with their roles because they know they have the confidence and trust of their patients. Such satisfaction decreases physician burnout.

Treating patients with empathy also discourages malpractice claims, Christianson said, most of which stem from doctors "failing to understand the patient's perspective or devaluing the patient's view."

Public demand

As healthcare has become "more corporate, with big clinics and time constraints" on doctors, patient satisfaction has decreased, Levitt said. "There are more and more demands on physicians, and less and less time."

"Medicine has become more technical and advanced scientifically ... In the past, the human element has been somewhat neglected. You can order any type of scan or test, but it's not the same as talking to the patient, touching the patient and listening to the patient."

Greater emphasis on empathy in medical education, Levitt noted, is probably due to the "unfounded perception on the part of the public that medical students become dehumanized in medical school."

The public wants physicians "who bond with patients in a human way," he said. "Doctors need to think objectively and act objectively with the patient but show that they understand what the patient is going through."

Building empathy with a patient "is something (students) can watch and practice to become adept at," he said. "It's really for their benefit, in their careers and for their future patients."

Patients need and want empathy because "they are giving the doctor the most intimate part of their lives," Levitt said. "You don't do that with a stranger, but with someone you trust."