Response to the 2011 Question of the Year
Nearly every medical school applicant struggles to avoid using the trite phrase “I want to help people” in interviews and essays. While the phrase is overused, it reflects the spirit behind much of the practice of medicine. Yet some aspect of medical training leads to a decline in this altruism and empathy and a concurrent rise in cynicism.1 Undergraduate medical education, while effective in educating students about the Krebs cycle and similar biochemical pathways, promotes a form of learned helplessness. This perceived loss of control makes many trainees feel distanced from the patients and communities they hope to serve. Their loss of empathy affects their patients, as both satisfaction and adherence fall when patients perceive their physicians to be less empathic.2
Trainees' disillusionment may also make them disinclined to advocate for patients outside the exam room. Physicians' efforts to help patients navigate the labyrinthine health care system—by removing barriers to health care access and thus improving outcomes—are just as important as treatment plans. Physicians can effect change locally through initiating patient safety and quality improvement measures like checklists, “bundles,” and standardized sign-outs. Most visibly, physicians can be active on both sides of the health care reform debate.
To empower future physicians to “help people,” the medical education community must accept that advocacy is a central component of its identity and a professional responsibility.3 The ability to advocate—for patients, for self, and for society—is central to improving health. Robust, well-integrated advocacy training could inspire future physicians to improve the overall health of a population and ameliorate medical students' and residents' feelings of helplessness. Providing physicians with the tools they need to engage in defining the health of individuals and populations can combat disillusionment stemming from an inability to realize the initial goal of serving others.
Advocacy training, if incorporated as a core component of medical education, may preserve trainees' commitment to society and, more specifically, to improving the health of society. Advocacy training involves the development of at least three concrete skills: education, grassroots organizing, and policy analysis. In practice, advocacy begins with the identification of an unmet health care need or disparity, which is followed by the development of an educational campaign to influence individuals and then the formation of a grassroots coalition that will build and affect long-term policy. In medical school and residency programs, the focus should be on the development of longitudinal experiences that enhance trainees' understanding of advocacy and its role in their future practice and that equip them with the skills necessary to be successful physician advocates.
To attain competence, trainees must both be exposed to knowledge-building activities and have opportunities to practice their skills on issues they are passionate about as part of a longitudinal, spiral curriculum. Before entering medical school, premedical students should be encouraged to follow a course of study that involves and deepens their understanding of the human condition and to participate in service learning experiences that connect the classroom with the community. Medical students should then focus on building knowledge in areas such as health care quality, access, disparities, and financing. Once that foundation is laid, medical students should be taught relevant skill sets, such as effective education, grassroots organizing, and policy-making tactics. Furthermore, interns and residents should be offered opportunities to identify problems, gaps, or needs in the health care system and to address such problems, cultivating critical-thinking, problem-solving, and advocacy skills in the process. Faculty mentorship and institutional support will play an important role in ensuring that trainees are not only provided such opportunities but also value and engage in them.
Physicians' power to positively shape individual- and population-level health depends on their strong dedication to society and their perceived ability to make a difference. Thus, it is imperative that the medical education community formalize opportunities for trainees to develop as change agents, to ensure they are empowered to fulfill their dream to “help people.”
1 Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182–1191.
2 Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004;27:237–251.
3 Gruen RL, Pearson SD, Brennan TA. Physician-citizens—Public roles and professional obligations. JAMA. 2004;291:94–98.