This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the American University of the Caribbean, the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine. Nor does any of this represent any position of the Northeast Georgia Medical Center or Northeast Georgia Health System.

Tuesday, September 27, 2011


A recent study Rosenthal, et al (1) in the journal Academic Medicine, studied the Jefferson Empathy Scale in medical students at the Robert Wood Johnson Medical School . This study was born out of a committee that included medical students, residents, and faculty. Their purpose was to design a curricular intervention that could be done in the third year of medical school that would help to preserve empathy throughout the year. 

The purpose of the study was "to evaluate JSPE-MS scores of two consecutive medical school classes in order to assess the impact of an empathy-preserving curricular innovation". At RWJ Med school they believed that there is a decrease in empathy across the third year of medical school. Anecdotally, I think that most medical educators know this to be true.

Wiggleton and colleagues (2) found moral distress, burnout, and depression in third year students. In this study, the authors described 50 potentially distressing situations which medical students might encounter in clinical rotations. Situations included: a patient had very advanced disease because they faced barriers to accessing care; a member of the team was disrespectful to someone below them in team ranking; optimal care was not provided as a result of alcoholism, drug use or homelessness; and our team provided care that only prolonged a patient's suffering. Over half of these situations had been experienced at least once. 35% of the situations caused mild to moderate distress.  

Diseker and Michielutte (3) found that empathy decreased before and after clinical experiences in the third year. The author's administered the Hogan empathy scale to all medical students. They found the empathy scale to be negatively correlated to MCAT scores. (see my previous blog about the MCAT). And they found that there was a significant decline in the empathy score from the beginning of medical school to the end.

Hojat and colleagues (4) found empathy significantly declined across the third year of medical school. They found that empathy did not really change that much in the first and second year, but the decline during the third year persisted until graduation. Interestingly, 27% of the students did not have any decline in empathy.

So, in this study the authors designed a curricular intervention that was given in the clinical year. Their intervention was six interactive sessions that were given during each of the required third-year clerkships. The sessions were one hour long and included time for debriefing on intense experiences, reflective essays/blogs,  and discussions of role models, patient care, morally distressing events, and the students' reactions.

This intervention seems fairly simple and similar to a longitudinal experience that our school has in the third year of medical school. The authors were able to document a lack of change in empathy across the third year. There was no statistically significant change in pretest/posttest empathy scores (pre = 115.4, post = 113.9, p =.135). One interesting fact was that student who entered family medicine, internal medicine and pediatrics had significantly higher empathy scores than those entering other specialties such as surgery, urology, otolaryngology, and anesthesiology.

Hopefully, there will be more interventions designed to help our students during the third year. It is hard. They are vulnerable and are often treated like crap. Dr. Steven Kanter (5) in his opening editorial in the March issue of Academic Medicine, reminds us that we need to think with our head as well as our heart to provide the best patient care. If we damage our students they will no longer have the ability to think with their heart, to care for their patients.  OK, I will get off the soap box for a while.

(1) Rosenthal S, et al Humanism at Heart: Preserving Empathy in Third-Year Medical Students. Acad Med 2011;86(3):350-358.
(2) Wiggleton C, et al. Medical students' experiences of moral distress. Acad Med 2010; 85:111-117.
(3) Diseker RA, Michielutte R. An analysis of empathy in medical students before and following clinical experiences. J Med Educ. 1981;56:1004–1010.
(4) Hojat M, 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.
(5) Kanter S. Think With Your Head and With Your Heart. Acad Med  2011;86(3):273.

Sunday, September 18, 2011

Professional dress: does it matter any more?

Sorry, I have been absent for a couple of weeks.

We started a new class of students off on their medical journey last month. The first year students arrive on campus bright-eyed and bushy tailed as it were. At our school most are fresh out of college. They have spent the last four or five years as Biology or Chemistry majors. They went to class or maybe they didn't. Most college courses don't have attendance requirements. They are generally allowed to dress however they want, this time of year shorts, flip flops and ball caps are the norm.

In 2005, there was a big flap (or should I say flip/flap) when the national championship women's Lacrosse team from Northwestern University was invited to the White House to meet President George Bush.  The scandal began when several people noticed that a picture taken of the ladies showed four of the nine players in the front row wearing flip flops.  Now these ladies were dressed up in skirts and nice clothes. After all they were meeting the President, but dressing up apparently did not include changing shoes.
So here we are with another class of new medical students. I am the co-director of the first module so I am sitting there in class most every day. The students are polite, they almost always address me as Dr Delzell, and so far I have not seen any rude behavior in class. But at least half the class is wearing flip flops. T-shirts are the norm. Many extolling their undergraduate school or their fraternity/sorority. Many of the guys wear ball caps. 

Now don't get me wrong, I like to dress casual. As soon as I get home from work I put on shorts and a t-shirt. I love to wear flip flops. I would love to have a job at a medical school that is located on the beach so I could wear casual Hawaiian-style shirts and flip flops every day.  But I don't.  And neither do our students. 

I know that there are some schools that require professional dress whenever the students are on campus. Dr. David Steele, Senior Associate Dean for Medical Education at the Paul L Foster Texas Tech School of Medicine in El Paso has told me that at their new medical school the faculty decided to require students to dress professionally every day. Even during the basic science lectures. And last year, we were invited to be visiting professors at the Yerevan State Medical University in Yerevan Armenia. We visited the campus and toured one of their large lecture halls that would hold about 600 first year medical students. It had hard wooden benches and no air conditioning and the students were required to dress up (suit and tie for the men) each day for lecture.

I don't know if it makes a difference. We talk all the time about how Millennials-Generation Y is different from past generations. I am sure that in the sixties when the hippies started their first day of medical school, they were wearing bell bottoms and tie-dye shirts. I am sure the professors were concerned about the lack of professionalism that those students displayed.  This is to some extent a generational issue that is seen every year. But where is the line?  When is it a generational issue-where the younger generation have a different set of internal rules and values that guide them in different ways than a previous generation? And when is it a maturation issue-where you need to learn behavior from those that are your teachers and mentors?