Kindness in the curriculum

Medical schools across the country have started to offer courses on compassion and caring. Some even use virtual reality to put students in their patients’ shoes.
None

Ashley Chin is a 26-year-old, fourth-year medical student at the University of Illinois College of Medicine. But for a few moments, after donning a virtual reality headset and headphones, she experiences the world as a 74-year-old man with macular degeneration and hearing loss. A dark mass obscuring her central vision and the sound of muffled voices offer her a hint of what it’s like to have these challenging health conditions.

“It brought me into a totally different world,” Chin says. “You diagnose all these medical conditions, but you don’t know how they actually affect the patient just from reading books. It was very eye-opening.”

The virtual reality software program Chin was using is one of several novel methods that medical schools are using to foster a sense of empathy in their students.

Empathy expert Mohammadreza Hojat, PhD, research professor in the department of psychiatry and human behavior at Thomas Jefferson University, calls empathy “the backbone of the patient-physician relationship.”

“When patients are treated with empathy and compassion, they feel cared about, which improves trust and adherence to recommendations,” adds Helen Riess, MD, a psychiatrist and director of the Empathy and Relational Science Program at Massachusetts General Hospital in Boston, Massachusetts. In fact, high levels of physician empathy have been linked to everything from less severe colds to better blood sugar control as well as lower rates of physician burnout.

Hojat’s research shows that empathy tends to erode during medical school and residency, even as changes in health care delivery have doctors spending more time looking at their computer screens than at their patients. But schools are attacking the empathy gap with different initiatives.

“Empathetics” training

Donald Tan, a third-year medical student at the University of California (UC), Irvine, School of Medicine, was initially skeptical of the online empathy course that he was required to take. “I thought, ‘Everybody knows how to be kind, right?’” he says. “But it made me realize that it’s not enough just to say, ‘I am a kind person in real life and that will translate into my practice.’”

“I see even very compassionate doctors become clinical and direct because they’re flooded with feelings. They’re afraid they’re going to show too much emotion so they become very matter-of-fact at a time when a family or patient might really need to feel some deep caring.”

Helen Riess, MD
Director, Empathy and Relational Science Program
Massachusetts General Hospital

The course that Tan took, which was developed by Riess, delivers information on the neuroscience of empathy along with practical techniques for improving the bond with patients. The course is divided into three one-hour segments and includes training in recognizing emotions, such as identifying key facial expressions and being aware of your own emotional responses, which can get in the way of effective communication.

Students also learn specific behaviors that convey empathy — to sit beside a patient instead of standing over them, to pay attention to one’s tone of voice, avoid medical jargon, talk less, and listen. The course emphasizes managing difficult medical interactions. “Many doctors feel pretty comfortable feeling and showing empathy when things are going well,” says Riess. “But, if they get a very intense, demanding, or manipulative patient, they often don't have the skills to manage that.”

Delivering bad news can be especially fraught. “I see even very compassionate doctors become clinical and direct because they’re flooded with feelings,” Riess says. “They’re afraid they’re going to show too much emotion so they become very matter-of-fact at a time when a family or patient might really need to feel some deep caring.”

Although originally designed for residents, Riess’ course is increasingly being offered at medical schools, including the University of South Florida Morsani College of Medicine and the State University of New York (SUNY) Downstate Medical Center College of Medicine. Riess believes that the third and fourth years are the best time for the training, when students have had some clinical experience. Some medical schools choose to implement the course during the psychiatry or primary care clerkships.

Virtual reality platforms

As a caregiver for her mother who had Alzheimer’s disease, Carrie Shaw often felt frustrated. “It really annoyed me that I couldn't understand what my mom was experiencing,” she says. “I thought, what if we could do that, tell people’s stories through their own eyes?”

That was the spark that led Shaw to develop the virtual reality platform Chin and other medical students are using to improve their empathy skills. Other platforms put users in the role of an Alzheimer’s patient and a terminal lung cancer patient at the end of life to give them a better feel for what patients are going through. The platform is being used in a growing number of medical schools, including the UC Irvine School of Medicine, Rush Medical College of Rush University Medical Center, and the University of New England College of Osteopathic Medicine, as well as schools of nursing, schools of physical therapy, and home health companies.

“There’s not always something you can do for patients medically. But there’s always something you can do that validates their fears, empowers them, and shows them that you’re trying to help them in every way.”

Megan Hsu, MD
Johns Hopkins Hospital

Another virtual human technology developed by Frederick Kron, MD, adjunct research investigator at the University of Michigan Medical School, doesn’t simply evoke empathy; it also teaches providers how to express it effectively. The system puts students in simulated situations, such as having to give a patient a difficult diagnosis, and evaluates the user’s facial expressions, body language, and verbal communication, then produces responses from the virtual patient that allow learners to tweak their techniques in real time.

“No matter how sincere you may be, if your body language is poor, say you're leaning backwards or looking away, then the patient will not see that as a friendly or inviting behavior,” says Kron.Sometimes it's as simple as raising your eyebrows at appropriate moments when somebody talks or nodding your head to acknowledge the statement a patient has made.”

The platform also offers simulations of interactions with other health professionals, designed to improve communication among members of a health care team. Additionally, Kron is developing an application that takes aim at providers’ implicit biases, which make it harder to establish a meaningful connection with patients.  

A “kindness curriculum”

On rounds one day during her internal medicine rotation, Megan Hsu, MD, then a medical student at Oakland University William Beaumont School of Medicine (OUWB), encountered a metastatic cancer patient in a wheelchair who was having a bad day. The patient’s disease was progressing and doctors were running out of options.

While the attending physician saw to another patient, Hsu sat with the woman and taught her a meditation technique — one she herself had learned through OUWB’s medical school curriculum. “There’s not always something you can do for patients medically,” says Hsu, who is in her first year of an orthopedic surgery residency at Johns Hopkins Hospital. “But there’s always something you can do that validates their fears, empowers them, and shows them that you’re trying to help them in every way.”

It wasn’t a random act. Empathy and compassion are bedrock principles at the medical school, which was established in 2011 with a deep commitment to the humanistic aspects of patient care. “Empathy is more than a course or how we teach, or inspirational speakers,” says Robert Folberg, MD, the school’s founding dean. “This is our culture.”

The medical school has embraced holistic review, with admissions emphasizing experiences and attributes that predict whether a physician will be altruistic, compassionate, and empathetic. These values are reinforced through an integrated curriculum that offers exposure to patients — and chances to practice empathic responses — starting in the school’s Art and Practice of Medicine course where first-year students take the medical histories of new patients at the bedside.

Students also make “spirituality rounds” with pastoral counseling teams. “We ask our students to do this outside of their faith tradition,” says Folberg. “That way they can learn what patients bring to critical decision-making from their faith.”

The school has graduated four classes so far, and there are indications that graduates are transferring the lessons to the rest of their medical careers. Ashley Guthrie, MD, a 2015 graduate of the school who is now an ENT resident at the New York Eye and Ear Infirmary of Mount Sinai, makes it a practice to be at the bedside when her cancer patients’ bandages are changed. “It’s a frightening and painful process,” says Guthrie, who plans to be a head and neck oncologist. “I like to offer them my hand.”