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Medical Students’ Empathy for Vulnerable Groups: Results From a Survey and Reflective Writing Assignment

Wellbery, Caroline MD; Saunders, Pamela A. PhD; Kureshi, Sarah MD, MPH; Visconti, Adam MD, MPH

doi: 10.1097/ACM.0000000000001953
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Purpose As medical education curricula increasingly acknowledge the contributions of the social determinants of health to individual health, new methods of engaging students in the care of vulnerable groups are needed. Empathy is one way to connect students with patients, but little is known about how to nurture students’ empathy on behalf of populations. This study examined the relationship between individual and social empathy as groundwork for cultivating students’ empathy for vulnerable groups.

Method In 2014–2015, first-year medical students completed the Social Empathy Index at the start and end of a two-semester population health course, and they completed a reflective writing assignment exploring the challenges of caring for vulnerable patients. Pre- and posttest mean survey scores were compared, and reflective writing assignments were analyzed for themes concerning social empathy.

Results Data from 130 students were analyzed. Scores for the contextual understanding of systemic barriers domain increased significantly. There was a trend toward increased cumulative social empathy scores that did not reach statistical significance. Students’ essays revealed three themes relating to individual empathy as the foundation for social empathy; civic and moral obligations; and the role of institutional practices in caring for vulnerable groups.

Conclusions This study extends understanding of empathy beyond care for the individual to include care for vulnerable groups. Thus, social empathy may function as a valuable concept in developing curricula to support students’ commitment to care for the underserved. Educators first need to address the many barriers students cited that impede both individual and social empathy.

Supplemental Digital Content is available in the text.

C. Wellbery is professor, Department of Family Medicine, Georgetown University Medical Center, Washington, DC.

P.A. Saunders is associate professor, Department of Neurology, Georgetown University Medical Center, Washington, DC.

S. Kureshi is assistant professor, Department of Family Medicine, Georgetown University Medical Center, Washington, DC.

A. Visconti is assistant professor, Department of Family and Community Medicine, University of Maryland Medical Center, Baltimore, Maryland.

Funding/Support: The Dean of Medical Education’s Curricular Innovation, Research, and Creativity in the Learning Environment (CIRCLE) program at Georgetown University School of Medicine provided funding for this project.

Other disclosures: None reported.

Ethical approval: The Georgetown University institutional review board approved this study.

Previous presentations: This work was presented at the Association for Prevention Teaching and Research meeting on March 15, 2016, in Albuquerque, New Mexico.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A488.

Correspondence should be addressed to Caroline Wellbery, Georgetown University School of Medicine, 3900 Reservoir Rd. NW, Pre-Clinical Science Building, Room GB-01B, Washington, DC 20007; telephone: (202) 687-8647; e-mail: wellberc@georgetown.edu.

Paul Bloom1 in his book, Against Empathy: The Case for Rational Compassion, argued that empathy focuses our attention on distressed individuals while doing nothing to help the social groups and populations they represent. Bloom stated that: “Empathy is limited … in that it focuses on specific individuals.… It doesn’t resonate properly to the effects of our actions on groups of people.”1 Bloom echoes other scholars’ concerns about the all-too-parochial and human tendencies of emotion-based empathy.2 These critiques have become relevant to medical education, which has increasingly expanded its scope beyond the care of individual patients to include public health precepts with greater focus on advocacy, policy, and social institutions.3–6 To what extent, then, do medical educators need to recontextualize their empathic relationships with individual patients to apply them to social groups?

To understand how the shift from individual to social empathy might occur, it’s important to recognize the many nuances in the evolving definition of empathy.2,7,8 Current thinking about empathy accepts the notion that hermeneutic understanding of a person’s world fuses cognitive elements with emotional receptivity.9,10 Less defined, however, is the relationship between empathy and moral action. It is unclear whether emotional empathy requires supplemental inculcation of moral principles or whether these principles are somehow integral to empathy as a kind of prosocial precursor—that is, as a way of priming the individual to think and act morally.11,12 Only an inclusive approach to empathy that takes into account emotion, understanding, and moral standards can successfully clarify the connection between individual and social empathy.13

We thought it was important to know if and how emotional and cognitive aspects of empathy extend to representative populations, and how these aspects of empathy might preface moral action in a medical education setting. Social empathy, as defined by Segal and colleagues, is “the ability to understand people by perceiving or experiencing their life situations and as a result gain insight into structural inequalities and disparities.”14–16 We hypothesized that our first-year course on the social determinants of health could improve medical students’ social empathy and that, consonant with discussions of empathy as an impetus to moral action, individual empathy could lead to social empathy. Given Bloom’s argument, we also were interested in any expressions of empathy in students that revealed a counterproductive interaction between individual and social empathy.

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Method

Our study included a quantitative survey and a qualitative analysis of first-year medical students’ essays, all of which were completed during a two-semester course on the social determinants of health at the Georgetown University School of Medicine called “Patients, Populations, and Policy” (P3) (see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A488 for a list of the course objectives). Our aim was to examine both the quantitative self-reported survey results and the qualitative findings from an analysis of the written reflective essays to better inform our understanding of medical students’ reflections on social empathy.17

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Tools

Using a code to deidentify the survey responses while maintaining the ability to link pre- and posttest responses, we administered Segal and colleagues’ Social Empathy Index (SEI) survey on the first day of class in October 2014 (pretest) and again at the end of the course in March 2015 (posttest). This instrument, which is used in the social work field, has been validated to measure self-reported social empathy.18 The SEI survey includes 40 Likert-scale-type questions with six ordinal response choices (never to always) and encompasses five domains measuring individual empathy and two domains measuring social empathy.

In addition, we created a reflective writing prompt based on Frank Huyler’s19 essay “The Woman in the Mirror” (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A488 for the complete prompt). Students were asked to read Huyler’s essay and write a one-page reflection, drawing if possible on their personal experiences. This assignment was administered toward the end of the P3 course.

While we did not collect demographic data from individual students, we obtained matriculation data from the Office of Admissions. The Georgetown University institutional review board approved this study.

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Analysis of the SEI survey results

As noted in Figure 1, 198 first-year medical students were eligible to participate. Seven completed the initial SEI survey but declined to consent to participate in the study. An additional 34 students either did not complete the posttest survey or did not provide a second consent to include their posttest survey results in our analysis. Finally, 27 students were not included in our final analysis because the self-reported identifiers we used did not provide adequate specificity, resulting in duplicate identifiers. As a result, a total of 130 students were included in our final analysis. The data were exported to Excel (Microsoft, Redmond, Washington) and analyzed using STATA Version 11.2 (StataCorp, College Station, Texas). The results were verified by separate calculations by a team member (A.V.) and an independent statistician.

Figure 1

Figure 1

We conducted our analyses from the summer of 2015 through February 2017. Mean scores were calculated within each of the five domains measuring individual empathy and the two domains measuring social empathy (see List 1 for the seven SEI survey domains). Cumulative scores where the student failed to complete a question were dropped from the analysis. All observations were included in the mean calculations. We conducted Shapiro–Wilk tests with an alpha of 0.05 to test whether the data followed a normal distribution. Then we conducted paired t tests on normally distributed data and sign tests on nonnormally distributed data. For both tests, a P < .05 was determined to have statistical significance.

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List 1Social Empathy Index18 Domains Used in a Study of Medical Students’ Empathy for Vulnerable Groups, Georgetown University School of Medicine, 2014–2015

Individual empathy domains
  • 1. Affective response: Hard-wired emotional response, setting the stage for experientially connecting to another person
  • 2. Affective mentalizing: Pictorial representation of an experience triggering an affective or physiological response
  • 3. Self-other awareness: Recognition of the difference between the experiences of another person and one’s own; moves empathic response into a cognitive or conscious arena
  • 4. Perspective-taking: Cognitively processing what it might be like to personally experience the experiences of another
  • 5. Emotion regulation: Ability to sense another’s feelings without becoming overwhelmed by the intensity of that person’s experience
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Social empathy domains
  • 6. Contextual understanding of systemic barriers: Understanding the life experiences of groups different from oneself, including their historical exposure to, and the impact of, barriers built into the social, political, and economic systems of society
  • 7. Macro self-other awareness/perspective-taking: Using insight into the social, political, and economic context, stepping more fully into the lives of others who are different from oneself and cognitively processing what it might be like to live as a member of another group
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Coding and thematic analysis of the reflective writing assignments

We were interested in statements of empathy and the themes that emerged around them. We used a traditional coding process as outlined by experts in qualitative analysis.17 Our research team (C.W., P.A.S., S.K.) did an initial read-through of the 153 essays written by the students who completed the assignment and consented to participate. We divided the essays into segments of multisentence and/or short paragraph length. Through a process of open coding, we started to label these segments with initial codes related to empathy. During the next stage, we developed an initial set of codes, which we then used to code the full data set. When identified, discrepancies were discussed and coding definitions were modified to achieve agreement across coders. Our final stage was to collapse these codes into themes aimed to capture the nuances of empathy, including the distinction between affective and cognitive statements and the respective challenges to each. To establish internal validity, we analyzed all the coded segments for interrater reliability resulting in a Krippendorf alpha score of 0.6 indicating moderate agreement. In addition, we asked several faculty during the coding process to read through the essays and codes for accuracy and transferability of our coding categories.

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Results

Of the 198 first-year medical students in the P3 course in 2014–2015, 103 (52%) were female, 137 (69%) were Caucasian, 32 (16%) were Asian, 12 (6%) were African American, 10 (5%) were Hispanic, and 28 (14%) were classified as other. The age range was 20 to 34 years old, with an average age of 24 years old.

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SEI survey results

We compared mean pretest and posttest survey scores across the seven SEI domains. Of the two social empathy domains, only mean scores for the contextual understanding of systemic barriers domain (i.e., “I believe people born into poverty have more barriers to achieving economic well-being than people who were not born into poverty”) significantly increased between the pretest and posttest surveys (see Table 1). There was a trend toward increased cumulative social empathy scores (which combined the scores for the two social empathy domains); however, it did not reach a level of statistical significance. See Supplemental Digital Appendix 3 at http://links.lww.com/ACADMED/A488 for all raw cumulative and mean scores.

Table 1

Table 1

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Reflective writing assignment findings

The essays provided a multifaceted look at what social empathy might mean to first-year medical students. We coded a total of 153 essays and 748 excerpts. Our analysis revealed three themes: (1) Individual empathy can lay the foundation for empathy for vulnerable groups; (2) civic or moral obligations contribute to social empathy by transcending personal comforts and preferences; and (3) institutional practices that prevent the cultivation of social empathy include curricular, professional, and institutional systems (see Supplemental Digital Appendix 4 at http://links.lww.com/ACADMED/A488 for examples of these themes).

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Theme 1.

Individual empathy can lay the foundation for empathy for vulnerable groups. Students frequently invoked a continuum connecting individual patients to their broader social context. Some statements expressed this continuity in terms of abstractions; for example, one student wrote, “Doctors see the world as their patient, and they treat the whole patient.” Others anchored their emotional engagement with social issues in individual patient encounters. For example, another student wrote, “The story of one particular patient truly brought the issue closer to home and emphasized the multifaceted realities of the problem.”

This sense of continuity between empathy for individuals and empathy for groups in the context of their social predicament often was rooted in the student’s experience. This experience could be deeply intimate, such as minority students’ experiences of discrimination; related to previous volunteer or work experiences; or related to exposure to societal challenges in various courses. Regardless, the ability to identify with others through the self seemed to be an important, occasionally essential, component in mediating empathy for vulnerable groups. Imagining the self in someone else’s shoes is a frequently cited definition of empathy20 and is thought to help counter the sense of abstraction often associated with someone who is different or alien (i.e., other). One student wrote:

One thing that I currently try to do and will continue to do in the future, is to think of each patient as someone in my own family, or even myself, and to try to imagine all the factors that would come into play if that person was dealing with this particular situation.

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Theme 2.

Civic or moral obligations contribute to social empathy by transcending personal comforts and preferences. Students responded to Huyler’s moral challenge that doctors show commitment to people from all walks of life. Some students expressed direct empathy toward social groups, using emotional language that addressed unfair conditions, discrimination, or other obstacles faced by vulnerable groups. One student wrote:

Unfairness to a child cannot be rationalized. Oblivious toddlers, profane kindergartners, empathetic grade-schoolers, confused middle-schoolers, pregnant teens—so young, so bright, so disadvantaged, so unfairly. My heart goes out. I want to help. I want to find a way to break the cycle.

Other students distinguished between their personal emotional inclinations and a broader sense of altruism, even to patients with whom they could not identify personally. This moral obligation to help brings up the possibility of acting empathically even when one does not feel empathy.21 One student wrote:

The more I think about it, the more I realize how desperately these people need our help, regardless of their repulsive behavior or nature. The core of the spirit of medicine is to deliver care to all. We promised that when we took the Hippocratic Oath. We promised we would do everything we can to help, and to be respectful and humble and kind when we are incapable or fall short of expectations. We can’t take these concepts lightly, because they are the defining factors of our value as health care providers.

Students who emphasized duty or moral obligation often recognized differences between the self and others, rather than focusing on their continuity. One student wrote: “As individuals who are given the privilege of higher education and the opportunity to achieve a stable income, we have an obligation to fix these health care disparities at their source.” Some students described the potential of empathy to provide a false, paternal reassurance that we understand others’ circumstances.22 As one student wrote: “While medicine does stress empathizing with patients, sometimes it is impossible to understand what some people have gone through and who am I to judge?” Thus, students often identified with patients on a micro and macro level but also acknowledged that a physician’s responsibility rests in a nonjudgmental acceptance of difference.

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Theme 3.

Institution-level practices that prevent the cultivation of social empathy include curricular, professional, and institutional systems. Students identified many ways in which medical education, physicians, and the health care system fail to promote empathy in the care of vulnerable groups. For example, students seemed aware of the erosion of student empathy over time. One student wrote:

With the enormous amount of purely medical knowledge that students must learn in medical school, it is not surprising that students and doctors sometimes lose sight of the patient. In fact, it has been shown that students lose empathy during their medical education.

Others mentioned medicine’s focus on skills training rather than on solving every problem burdening a patient: “When a patient’s heart is on the verge of failure, her social history and environmental well-being have to take a side seat.” Further reflecting the skills-based focus of medical education, many students discussed concerns about discomfort with uncertainty, a frequently cited obstacle associated with difficult emotions: “Valuable questions will not always have an easy or direct answer, but they should still be examined. Our society has a tendency to avoid difficult questions and to direct our attention away from things that are unpleasant.”

Finally, students mentioned culturally or institutionally embedded barriers, including elements of the hidden curriculum—ranging from implicit expectations associated with being a doctor to observing callous behaviors—as reinforcing providers’ focus on the self and their indifference to others. One student confessed that he was encouraged “to study medicine in large part for the status, prestige, job security, and financial comfort. I honestly do not believe I would be here if those things were not available to me.” Others frequently mentioned observing the maltreatment of patients from underserved groups: “I remember when a nurse remarked that homeless individuals stole her time away from people who had ‘a real chance at recovery.’” An emphasis on grades, the view that medicine is a trade with a focus on specialization rather than on the humanities, the limiting focus of evidence-based medicine, the prestige of the profession, and physician-centered cultural mores were all mentioned as institutionally reinforced barriers to instilling, cultivating, and consolidating social empathy.

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Discussion

The recent emphasis on population health in medical school curricula raises the question of if, and how, the concept of individual empathy can inform empathy for socially and economically vulnerable groups.23–25 As we hypothesized, our analysis of students’ essays showed that they did indeed connect individual empathy and social empathy. Consonant with previous recommendations to advance individual empathy, our study strongly supports efforts to link empathy to personal experience, as exposure to individual patients and their stories is a powerful means of conveying broader societal influences on health and disease. This exposure does not, as Bloom claims, favor the one at the expense of the many. On the contrary, as one student wrote, “The poverty I experienced is unfathomable to someone who has not experienced it firsthand.” This finding is consistent with research suggesting that experiential exposure to the underserved increases students’ likelihood of continuing to care for this population after training.26–28

At the same time, our study did not support our hypothesis that the P3 course improved empathy.

The lack of significant change in SEI scores overall may be explained by a ceiling effect with regard to the initial scores as well as the short time between the pre- and posttest surveys. It may not be reasonable to expect students’ notions of empathy to change over six months. Our finding that social empathy scores significantly increased only in one domain (i.e., contextual understanding of systemic barriers) should raise concerns, especially because the students’ essays also highlighted the formidable effects of a wide range of perceived obstacles to enacting both individual and social empathy, along with the elements of the hidden curriculum that aggravate these barriers.29–32 In sum, the P3 course may have succeeded in identifying the problems involved in caring for vulnerable groups without providing adequate solutions.33

The survey results suggest that a short course on the social determinants of health has a limited impact on nurturing social empathy. The themes in students’ reflective writing assignments, however, may offer ideas for enhancing such a course, for example, by including self-care, experiential learning, reflection on interpersonal communication, and an examination of students’ values. Students’ responses also supported the relevance to social empathy of Donald Schön’s34 concept of reflection-on-action, which assigns reciprocal roles to hands-on experience and articulate awareness.

While our study did not provide a mechanism for determining what influence the reflective writing assignment had on the posttest survey results, our analysis of students’ essays did highlight the importance of institutional culture in nurturing empathy at the micro and macro levels. Student well-being has long been recognized as a stepping stone to providing compassionate care.35,36 Nuanced use in students’ essays of the self as a reference point for individual and social empathy, in conjunction with their misgivings about the institution’s effects on their personal health and integrity, reinforces the need for educators to address the continuum between self and other.37

Further study is needed to determine whether subjective engagement, through such activities as the reflective writing assignment as a component of social empathy, is important in motivating or eliciting socially engaged behaviors (for which we found encouraging signs in students’ passionate responses to our prompt).38 Some students explicitly made a connection between the reflective writing assignment and social empathy; for example, one student wrote, “I, personally, after this reflection will be more cognizant of treatment plans and health care access logistics among vulnerable populations in my future practice.” A study that more closely correlates quantitative and qualitative measurements of empathy, for example, by using Segal’s SEI to document changes in empathy in response to exposure to narratives, might provide further insight into the impact of reflective writing on social empathy.

A major strength of our study was our use of complementary data sources. In broadening our lens using established individual empathy-focused reflective writing frameworks,39–44 we hope to have parsed the elements that might lead to a deeper understanding of the underlying mechanisms of clinician empathy as they apply to social groups.37

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Limitations

The limitations of our study include the absence of a control group in the pre- and posttest survey design and the short time period between the pre- and posttest surveys. As students’ essays demonstrated, empathy is high in first-year medical students, potentially resulting in an undetectable change from the start to the end of the P3 course. In addition, there are many other factors in students’ lives for which we could not control in our study, which may have influenced a notable lack of change in social empathy, including the medical school experience itself. We plan to readminister the SEI survey to our student cohort in their fourth year in the fall of 2017 to see whether their empathy scores have changed.

More important perhaps is the fact that we could not gauge the impact of the reflective writing assignment on students’ posttest survey scores. The negative feelings and acknowledgment of barriers within and outside the medical school that were described in the essays seem tied to our survey finding of increased contextual understanding of systemic barriers. However, exposition of these barriers also was a focus of the P3 course, so we cannot be sure of the effect the reflective writing assignment specifically had on students. We can only assume that the course content and the social and institutional challenges articulated in Huyler’s essay reinforced each other, perhaps to the detriment of other aspects of students’ individual and social empathy.

Finally, like most studies on empathy, ours did not address patient outcomes. More specifically, it did not determine whether the cultivation of social empathy through course work or reflective writing led to moral or socially meaningful action. However, it did lay the groundwork for medical education interventions that emphasize solution-oriented experiential learning and promote a medical culture that “walks the talk” of empathic social engagement.

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Conclusions

While social and individual empathy share many features, this study extended our understanding and assessment of empathy beyond care of the individual to include care for vulnerable groups. As a result, we believe that social empathy is a valuable concept to consider when developing population health curricula. Social empathy could be taught by offering relevant clinical experiences, while fostering an institutional culture of fairness and justice. Reflection and writing about social aspects of clinical medicine are also valuable tools for engaging students in discussions of social empathy. Further, assessing social empathy may guide medical educators to better understand students’ needs, including stress and burnout. To achieve change, however, educators first need to explicitly address the many barriers students cited that get in the way of both individual and social empathy.

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Acknowledgments:

The authors thank the Georgetown University Medical Center Dean of Medical Education for funding this project. They also thank Stephen Fernandez and Sameer Desale for their assistance with the statistical analysis and Hedy Wald for her supervision of the reflective writing assignment. Finally, they thank Andrea Cammack for her administrative assistance.

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