Introducing the Humanities into physiotherapy education

This post has been modified and published on The Conversation: Africa as Physiotherapy students have much to learn from the humanities.

Selection_018I’m increasingly drawn to the idea of integrating some aspect of the Humanities into undergraduate physiotherapy education. We focus (almost) all of the curriculum on the basic sciences and then the clinical sciences, which has a certain pragmatic appeal but ignores the fact that a person is more than an assemblage of body parts. We spend a lot of time time teaching anatomy and biomechanics (i.e. bodies as machines), and then exploring what we can do to bodies in order to “fix” them. While we pay lip service to the holistic management of the patient, there is little in our curriculum that signals to the student that this is something that we really care about.

“Science is the foundation of an excellent medical education, but a well-rounded humanist is best suited to make the most of that education.”

Empathy is critical to the development of professionalism in medical students, and the humanities – particularly literature – have been touted as an effective tool for increasing student empathy. In addition, there is some evidence that training in the Humanities and liberal arts results in health professionals with improved professionalism and self-care. In other words, health professionals who are exposed to the arts as part of their undergraduate education may demonstrate an increased ability to manage themselves and their patients with more care.

Hilary Allen_Artist in Residence 2015_1000

The relationship between emotion and learning has also been explored, with findings from multiple disciplines supporting the idea that emotion is intimately and inseparably intertwined with cognition in guiding learning, behaviour and decision making. The introduction of the Humanities in health professions education therefore has another potential impact; by using the arts to develop an awareness of emotional response, educators and students may find that exposure to the Humanities might lead to improvements in learning.

As I started looking into these ideas in a bit more detail, I realised that there are several examples of how art and literature are being explored formally by some very prominent medical schools.

dancingwheelsI was disappointed – although not surprised – not to find any good examples of physiotherapy departments who have formally integrated the Humanities into their curricula. However, I did find several papers (all by the same author with various colleagues) that describe a process of integrating these concepts into an undergraduate physiotherapy programme over a period of time, and these are listed in the references below.

avery_hosp_ward_low_resOver the past year or so, I’ve tried to bring some of these ideas into my Professional Ethics module, using the assignments for students to explore the Humanities (art, literature, theatre, music, dance, etc.) as a process of developing a sense of awareness of empathy in the context of clinical education. They can interpret the assignment in any way they want, for example, by writing a poem, drawing a picture, taking a photo, or re-interpreting a song. However, the important part is the reflection that they attach to the piece. Here are some examples of previous student work in this module, without the more personal reflections that accompany them.

  • Eleven hundred hours – poem by a student
  • The mind of the innocent – poem by a student
  • I’ve had two students provide videos of interpretive dance sessions used as methods to try and present an embodied experience of what it might be like to live with a disability.
  • Photovoice assignments (see below for examples): in these assignments students took photos of people and places and then reflected on how those experiences had informed their personal and professional development as ethical practitioners.

Selection_016

Selection_017

I’m hoping to get some experience with this process as part of these little experiments I’m running in the classroom, and that over time we can start building something more formal into the curriculum. Watch this space.

Additional readings

Developing empathy in clinical education

This post was originally written for the Clinical Teacher iPad app, and can be downloaded there as well.

Introduction

Empathy is the ability to understand the emotional context of other people and respond to them appropriately. It has been identified as the cornerstone of the clinician-patient relationship and is recognised as one of the most important characteristics of health care professionals that influence the patient’s outcomes and levels of satisfaction. However, even though it is clear that empathy is an essential aspect of clinical practice, there is evidence that empathy actually decreases as a result of medical education and clinical training. In fact, the greatest decrease in empathy seems to coincide with introduction of patient contact into the curriculum. If empathy really is valued in health care professionals, what changes need to take place in the health care curriculum in order to maintain the caring attitudes that students bring with them into their undergraduate training? How should clinical educators respond to the decline in empathy that seems to be a direct result of the clinical education process? This article explores the role of empathy in health care professional practice, as well as briefly identifies some strategies to further develop and maintain a caring attitude towards patients.

What is empathy?

Empathy is the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts and experiences of another human being, without having those feelings, thoughts and experiences communicated in an explicit manner. It is the capacity to share and understand another’s emotional state of mind and is often described as the ability to “put yourself into another’s shoes” (Ioannidou & Konstantikaki, 2008). In essence, empathy is the ability to understand the emotional makeup of other people and respond to them appropriately.

There are three types of empathy (Goleman, 2007):

  • Cognitive: knowing how another person feels and what they might be thinking
  • Emotional: physically feeling what another person is feeling
  • Compassionate: not only understanding a person’s situation and feeling with them, but being moved to help them

We can’t begin being empathetic when another person arrives. We have to already have made a space in our lives where empathy can thrive. And that means being open—truly open—to feeling emotions we may not want to feel. It means allowing another’s experiences to gut us. It means ceding control. Empathy begins with vulnerability. And being vulnerable, especially in our work, is terrifying. – Sara Watchter Boehner

See the video below for a presentation by Joan Halifax, a Buddhist who works with the terminally ill and those on death row, on the link between compassion and empathy.

Development of empathy in children

By the time that children are two years old they normally begin demonstrating empathy by responding emotionally to someone else’s emotional state. At this stage, toddlers will sometimes try to comfort others or show concern for them. Children between the ages of 7 and 12 appear to be naturally inclined to feel empathy for others in pain, a finding that is consistent with functional MRI studies of pain empathy among adults. Researchers have also determined that other areas of the brain were activated when young children saw another person intentionally hurt by another individual, including regions involved in moral reasoning (Goleman, 1995). The evidence seems to be that from a very young age, children are predisposed towards feeling an emotional response when confronted with another person’s suffering. This would seem to suggest that the emergence of empathy is an inherent characteristic of human development and which occurs spontaneously.

Empathy in clinical practice

Empathy, in the context of health care, is the “…ability to communicate an understanding of a client’s world” and is a crucial aspect of all interactions between clinicians and patients (Reynolds, Scott & Jessiman, 1999). It is the clinicians way of saying (Egan, 1986, pg. 99):

I’m with you, I’ve been listening carefully to what you’ve been saying and expressing, and I’m checking if my understanding is accurate.

It is considered to be an appreciation of the patient’s emotions and associated expression of that awareness to the patient. Empathy is also believed to significantly influence patient satisfaction, adherence to medical recommendations, clinical outcomes, and professional satisfaction. In the clinical setting, the common definition of empathy has been expanded to include emotive, moral, cognitive and behavioral dimensions (Stepien & Baernstein, 2006):

  • Emotive: the ability to imagine patients’ emotions and perspectives
  • Moral: the physician’s internal motivation to empathise
  • Cognitive: the intellectual ability to identify and understand patients’ emotions and perspectives
  • Behavioral: the ability to convey an understanding of those emotions and perspectives back to the patient

These additional features of empathy highlight that emotional engagement and not just intellectual understanding is an important aspect of effective empathy. However, some have suggested that the emotional aspect of empathy brings it closer to sympathy. Confusing the two is a conceptual challenge whereby the clinician actually experiences the other person’s emotions, as opposed to simply appreciating that they exist. This is problematic because when clinicians sympathise with patients and share their suffering, it may lead to decreased objectivity, emotional fatigue and subsequent burnout.

During medical education, we first teach the students science, and then we teach them detachment. To these barriers to human understanding, they later add the armor of pride and the fortress of a desk between themselves and their patients. – Howard Spiro

Decline in empathy during medical training

Empathy has been identified as one of the most important characteristics of medical professionals and is routinely screened for among students. However, while the development of empathy seems to be an essential aspect of positive health care relationships, there is some evidence that as medical students move through the curriculum, their scores on tests of empathy drop, with the largest decrease occurring at about the same time that they begin to see patients. Studies show that the empathy scores of students in their preclinical years were higher than in their clinical years. In addition, gender was a significant predictor of empathy, with women having higher scores on tests of empathy than men. Students with high baseline empathy showed a smaller decrease in empathy scores than students with low baseline empathy during medical education. Self-reported empathy for patients, which is potentially a critical factor in good patient-centered care, seems to wane as students progress in their clinical training, particularly among those entering technology-oriented specialties (Chen et al., 2012).

What we need in medical schools is not to teach empathy, as much as to preserve it – the process of learning huge volumes of information about disease, of learning a specialised language, can ironically make one lose sight of the patient one came to serve; empathy can be replaced by cynicism – Abraham Verghese

There are good reasons for the decrease in empathy, including the fact that students work in high-stress environments that place significant pressure on them with heavy workloads, intense time pressures and a diminished sense of autonomy in the healthcare system. In many health systems productivity is valued and rewarded financially and doctors who don’t see as many patients as their peers are sometimes seen as slow and inefficient.The stress of studying and working in the clinical environment may eventually take its toll on students and clinicians in terms of their time, and physical and emotional well-being, all of which make it difficult for them to be empathic. The focus on science and rationality during medical training tends to emphasise detachment and objective clinical neutrality, and prioritises the technologic over the humanistic. Trying to find the right balance can be tricky (Lim, 2013).

In addition, the focus of medical education seems to devalue the patient as a human being. We often talk about the “case” rather than the person. The style of writing is “objective” and impersonal, where that which can be seen is given more importance than that which can be heard. Often the patient is seen as a model, a body to be treated, or a good “teaching case” that illustrates a point (Shapiro, 1992). If we accept that decreased empathy as a direct result of participation in the medical curriculum is undesirable, we need to ask how we can address the problem.

We start with students who are very caring but have no diagnostic skills, and end up with physicians with great diagnostics skill but who don’t care. – Richard Frankel

Developing empathy in clinical education

It seems that empathy can be developed and it should therefore be possible to design a curriculum aimed at maintaining empathy during the third year of medical school. A curriculum where students are encouraged to discuss their patient reactions and emotional response in a safe environment during their clerkships may contribute to the preservation of empathy. Students can also be introduced to the idea that doctors can be taught that empathy is a skill that can be developed and maintained, as opposed to an inherent, unchangeable personality trait. Another strategy that can affect the development of empathy in students is the introduction of the Longitudinal Integrated Clerkship, which has been shown to have a positive impact on the patient-doctor relationship (Ogur et al., 2007).

An interesting perspective on developing empathy in medical education has also been to introduce modules that incorporate literature, movies, drama and poetry into the medical education curriculum. Some medical schools have gone so far as to integrate studies of the Humanities into their curricula, suggesting that the study of literature can help to achieve the following objectives (Shapiro & Rucker, 2003):

  • Stimulate skills of close observation and careful interpretation of patients’ language and behavior
  • Develop imagination and curiosity about patients’ experiences
  • Enhance empathy for patients’ and family members’ perspectives
  • Encourage relationships and emotional connections with patients
  • Emphasise a whole-person understanding of patients
  • Promote reflection on experience and its meaning

There is evidence that empathy and attitudes toward the Humanities in general improved significantly after participation in a literature-based module. In addition, students’ understanding of the patient’s perspective became more detailed and complex after the intervention. They were also more likely to note the ways in which reading literature might help them to cope with study-related stress (Shapiro et al., 2004).

Other strategies include interventions like role-playing and video analysis to try and preserve empathy during the challenging medical education process. Studies of these interventions, particularly the use of communication skill workshops, indicate that the behavioral dimension of empathy can be influenced through curriculum change (Stepien & Baernstein, 2006). In addition, programmes that aim to validate humanism in medicine (such as the Gold Humanism Honor Society) may reverse the decline in empathy (Rosenthal et al., 2011).

Studying the humanities may also be used to combat a perceived loss of empathy that may occur over the course of medical training. – Schwartz et al., 2009

It should be noted however, that current studies on empathy in medical students are challenged by varying definitions of empathy, small sample sizes, lack of adequate control groups, and variation among existing empathy measurement instruments (Stepien, 2006). Some of the empathy measures available have been assessed for research use among medical students and practising medical doctors. These studies have shown that empathy measures can be used as tools for investigating the role of empathy in medical education and clinical training. However, no empathy measures have been found with sufficient evidence of predictive validity for use as selection tools for entry into medical school (Hemmerdinger, 2007).

In the era of new health care policy and primary care shortages, research on empathy in medical students may have implications for the medical education system and admission policy for training institutions (Chen et al., 2012).

What we know matters, but who we are matters more. Being rather than knowing requires showing up and letting ourselves be seen. It requires us to dare greatly, to be vulnerable…Vulnerability is the birthplace of love, belonging, joy, courage, empathy, accountability, and authenticity. If we want greater clarity in our purpose or deeper and more meaningful spiritual lives, vulnerability is the path. – Brene Brown

Conclusion

There is clear evidence that empathy is an essential aspect of developing and maintaining effective clinician-patient relationships. However, there is also evidence to suggest that the process of clinical and medical education may actually lead to a decrease in empathy as a direct result of the way that clinical training is structured. Incorporating a range of strategies from the Humanities may help to maintain empathy in health care professional students, including using literature, poetry, art and music as ways for students to explore various aspects of empathic engagement. While it seems that the ability to measure empathy would have a significant influence on curriculum design, current studies of empathy have been criticised for a variety of reasons, indicating that stronger evidence is needed if we are to integrate the teaching and assessment of empathy in clinical education.

References

Chen, D.C., Kirshenbaum, D.S., Yan, J., Kirshenbaum, E. & Aseltine, R.H. (2012). Characterizing changes in student empathy throughout medical school. Medical Teacher, 34(4): 305-11. doi: 10.3109/0142159X.2012.644600.

Chen, D., Lew, R., Hershman, W. & Orlander. J. (2007). A cross-sectional measurement of medical student empathy. Journal of General Internal Medicine, October, 22(10): 1434-1438.

Ducharnme, J. (2013). Medical students diagnosed with low empathy. Boston Magazine.

Egan, G (1986). The skilled helper. Brooks-Cole, Monterey, CA.

Goleman, D. (1995). Emotional intelligence: Why it can matter more than IQ. Bantam Books. ISBN: 055338371X.

Hemmerdinger, J.M., Stoddart, S. & Lilford, R.J. (2007). A systematic review of tests of empathy in medicine. BMC Medical Education, 7:24, doi:10.1186/1472-6920-7-24.

Ioannidou, F., & Konstantikaki, V. (2008). Empathy and emotional intelligence: What is it really about? International Journal of Caring Sciences, 1(3), 118–123.

Lim, J. (2013). Empathy, the real measure of a doctor. Today Magazine.

Ogur, B., Hirsh, D., Krupat, E. & Bor, D. (2007). The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Academic Medicine, April, 82(4): 397-404.

Poncelet, A., Bokser, S., Calton, B., Hauer, K.E., Kirsch, H., Jones, T., Lai, C.J., Mazotti, L., Shore, W., Teherani, A., Tong, L., Wamsley, M. & Robertson, P. (2011). Development of a longitudinal integrated clerkship at an academic medical center. Medical Education Online, 16:10. Published online 2011 April 4. doi: 10.3402/meo.v16i0.5939.

Reynolds, W. J., Scott, B., & Jessiman, W. C. (1999). Empathy has not been measured in clients’ terms or effectively taught: A review of the literature. Journal of advanced nursing, 30(5): 1177–85.

Rosenthal, S., Howard, B., Schlussel, Y.R., Herrigel, D., Smolarz, G., Gable, B., Vasquez, J., Grigo, H. & Kaufman, M. (2011). Preserving empathy in third-year medical students. Academic Medicine, 86(3): 350-358.

Schwartz, A. W., Abramson, J. S., Wojnowich, I., Accordino, R., Ronan, E. J., & Rifkin, M. R. (2009). Evaluating the impact of the humanities in Medical Education. Mount Sinai Journal of Medicine, 76, 372–380. doi:10.1002/MSJ

Spiro, H. (1992). What is empathy and can it be taught? Annals of Internal Medicine, 116(10): 843–6.

Shapiro, J., Duke, A., Boker, J., & Ahearn, C. S. (2005). Just a spoonful of humanities makes the medicine go down: Introducing literature into a family medicine clerkship. Medical Education, 39(6): 605–12. doi:10.1111/j.1365-2929.2005.02178.x

Shapiro, J., Morrison, E., & Boker, J. (2004). Teaching empathy to first year medical students: evaluation of an elective literature and medicine course. Education for Health, 17(1): 73–84. doi:10.1080/13576280310001656196

Shapiro, J., & Rucker, L. (2003). Can poetry make better doctors? Teaching the humanities and arts to medical students and residents at the University of California, Irvine, College of Medicine. Academic medicine. Journal of the Association of American Medical Colleges, 78(10): 953–7.

Stepien, K.A. & Baernstein, A. (2006). Educating for empathy: A review. Journal of General Internal Medicine, 21(5): 524–530. doi: 10.1111/j.1525-1497.2006.00443.x