Flint Wang was eager to start his third year of medical school, when he would finally break free of the classroom and treat patients. But once in the hospital, Wang, like many classmates, felt insecure and discouraged. Doctors don’t hesitate to point out students’ knowledge gaps. And neither do some patients.
Medical training can be so stressful that it is sometimes difficult to connect with those being treated. “Your knowledge is shaky and you walk around the wards frazzled,’’ said Wang, 25, who nonetheless is glad he decided to become a doctor.
The third year of medical school can be particularly bruising. But growing research suggests that something about this formative but punishing experience may harden students toward patients — a transformation that could persist years down the road.
At Boston University School of Medicine, where Wang is now in his fourth year, Dr. Daniel Chen has found in studies that students’ empathy scores fell between the time they started medical school and the time they graduated. The most significant drop occurred in the third year, just as students started caring for their first patients. Other researchers have uncovered similar patterns during residency training, although some physicians question whether the surveys capture the complexity of the issue.
“Empathy is the cornerstone of the doctor-patient relationship,’’ Chen said, so “it’s becoming more and more important to research.’’ He defines empathy as letting patients know the doctor understands their thoughts and feelings — important because studies show that patients of caring doctors may be healthier.
‘Empathy is the cornerstone of the doctor-patient relationship,’ so ‘it’s becoming more and more important to research.’
Diabetics with empathic doctors were more likely to keep their blood sugar and cholesterol controlled than patients whose doctors were not as caring, according to a study published in 2011 in Academic Medicine by Mohammadreza Hojat of Jefferson Medical College in Philadelphia.
Because of the implications for patient health, Boston University and Jefferson are trying to boost students’ sensitivity with role-playing, analyzing movie clips of doctor-patient interactions, and participating in “reflection groups.’’ In one experiment at Jefferson, residents, who are junior doctors in training, assembled rocking chairs in the homes of poor, single new mothers while talking to them about child care. The idea was to enhance the doctor-patient relationship. Empathy scores jumped.
Six Boston University medical students interviewed by the Globe, including Wang, said the studies’ findings are not surprising. Medical students traditionally have been viewed as at the bottom of the hospital hierarchy. They make routine checks on patients then report their findings to the residents. “You are so focused on getting the information you need, the personal interaction can go out the door,’’ said Steven Lin, 28.
Sometimes it’s the patient who puts up the barriers. “You go into a room and the patient says ‘I don’t want to see you, you’re a student. I want to see an attending,’ ’’ said Bill Hammond, 28, who plans to become a surgeon.
In a paper published last year in the journal Medical Teacher, Chen found that women outscored men on a survey designed to measure empathy, but scores for both genders fell during medical school. Students who planned to enter people-oriented specialties like internal medicine and pediatrics were more empathic than those who planned to pursue technical fields such as surgery and radiology. And while empathy fell in both groups during medical school, the drop was greater for technology-minded students.
Chen said students often believe they have to maintain a distance from patients to protect themselves. “It is time-consuming and physically draining to be involved in a very emotional situation,’’ he said.
But Hojat suspects another phenomenon is at work, something he calls the “hidden curriculum.’’
Senior doctors emphasize that medicine is a business. They encourage students and residents to quickly discharge patients to maximize hospital profits and to practice defensive medicine to avoid malpractice claims by angry patients. This “lack of positive role models’’ may lead students to believe that human connection is of little importance, he said.
Hojat wrote and tested the most widely used survey to measure empathy in medical students and residents. It asks participants to rate their level of agreement with about 20 statements, including “I believe that emotion has no place in the treatment of medical illness’’ and “a physician’s sense of humor contributes to a better clinical outcome.’’
Dr. Beth Lown, an internist at Mt. Auburn Medical Center in Cambridge and medical director of the Boston-based Schwartz Center for Compassionate Healthcare, said that one pitfall of the survey is that students and residents are rating themselves, when ultimately empathy may be best judged by the patient.
In one study at Boston University, students interacted with actors portraying patients. Observers rated third-year students as more empathic than second-year students, which may indicate a difference between how students feel and how they act, Chen said.
“Students may select when to turn on their empathy switch and when not. This guy is coming in with a fractured foot and really wants to get out of here. He doesn’t require [empathy], whereas the homeless guy may need a little more understanding because he’s disenfranchised,’’ Chen said. It may be “they are full of empathy but they select when to use it.’’
Wang echoed this point, saying students learn how to be “efficient with their empathy’’ over time. “I’ve done a lot of cancer rotations. A hand on the shoulder or handing a patient a tissue can really help.’’
Chen, who is assistant dean of student affairs at the medical school, helps direct the internal medicine rotation that all medical students complete. He requires third-year medical students to attend weekly reflection groups to talk about difficult experiences in the hospital, such as a patient dying and coping with conflicting feelings of wanting to both talk to and avoid the family, or feeling nothing at all. He hopes these discussions will lead to greater empathy.
Hojat said a number of interventions can increase empathy in students and residents, including an experiment he calls the aging game. Students participate in a play during which they wear earplugs and dirty glasses to simulate how difficult it can be for the elderly to hear and see. But the impact wears off after a month or two, and Hojat is trying to figure out how to make the effect longer-lasting.
“Students come in with a lot of idealism,’’ Lown said. “They want to be of help and service. And then something starts to happen when they are exposed to clinical care. We need better curriculum and education on how to manage those feelings.’’