​A physician’s ability to empathise may decline as they get more burnt out. How can we effectively manage it, particularly in our trainees? Gerald Sng, a medical student from Yong Loo Lin School of Medicine, discusses findings of his study.

  • Empathy is important to holistic patient care, and is affected by an individual’s burnout
  • Residents in Singapore that we surveyed have low empathy and high burnout compared to their international peers
  • While the most important factors contributing to burnout are ultimately structural, they can also be tackled by the individual themselves
Empathy is one of the core competencies of the ideal physician. The ability to understand a patient’s perspectives and feelings, to communicate effectively, and to effect helpful actions based on these, should lead to better and more holistic care for patients.

Indeed, studies have shown that physicians judged to be more empathetic are more effective in delivering positive outcomes for their patients, ranging from patient satisfaction, to HbA1c control, to even the duration of recovery from the common cold.

To be able to care for others, though, we first need to care for ourselves. Various personal and social factors come into play in forming a stable emotional foundation on which we base our capacity to care.

Perhaps the most pertinent of these to medical professionals is burnout, which all doctors will face at some point. It is easy to see how physicians’ ability to empathise declines as they become more burnt out .

And this is a relationship that my peers and I at NUS Yong Loo Lin School of Medicine (YLLSOM) demonstrated in a study for the first time in a resident cohort.

Moreover, it seems intuitive that rates of burnout should increase (and therefore empathy levels decrease) the longer physicians practise, with stressors and the like taking their cumulative toll.

Is this reflected in our residents cohort?

Interestingly, however, we found no significant change in empathy or burnout levels as residents progress through training. Unfortunately, that is not entirely good news. Two points of concern stand out:

Comparing against standardised international cohorts, we found that our residents have a high degree of burnout and lower empathy scores. Also, a fairly significant empathy decline does exist, just not during residency training itself.
Let us consider each in turn.
First, that our residents are perhaps more burnt out and less empathetic than their international peers. Before the despairing hand-wringing starts, it might be useful to acknowledge the very unique context here in Singapore.

Not content with consistently topping world rankings on measures of education and industry, our country also claims a couple of less desirable “firsts” – having the longest working hours in the world, and being the least emotional country in the world (at least according to a 2012 Gallup poll).

This may suggest that we may be less culturally attuned to the concepts of work-life balance and demonstrating compassion, accounting for some of this poor comparative performance.

On the other hand, it is arguable that duty-hour limitations should theoretically mitigate the effect of abnormally long working hours on burnout. There is an empathy deficit and burnout excess in our residents even when possible cultural differences are taken into consideration. This is concerning and bears further study.

Next, a fairly significant decline in empathy occurs during clinical training in medical school.

Integrating data from a previous study in medical students in YLLSOM, we noticed a significant empathy decline when students entered the clinical years of their education (Year 3 in particular). There was no significant difference when we compared Year 4 and final year students to residents, or residents in different Years.

Considering that our medical school espouses a very clinically-oriented curriculum and integrates actual clinical duties and responsibilities, this is a significant observation. We propose that what we observe is simply a left shift of the transition point.

In fact, students may actually give an inordinate amount of empathy, as we are often unable to contribute to patient care in any other way.

As we graduate and begin work, the relative weight of different factors may change, but the level of burnout and low empathy remains the same.

The fact that empathy and burnout bottom out early offers some hope. It suggests that the stresses of training do not inherently add to burnout. More importantly, it invites us to intervene early on in clinical training.

How can we effectively address empathy and burnout?

Admittedly, it is often easier said than done. Residents reported that structural factors such as high workload and frequent patient turnover are the most relevant to empathy level.

These cannot be addressed directly, short of a radical overhaul of the healthcare system. However, we can instead address how we allow these factors to influence our personal psyche and emotional outlook. This should take place on both a personal and group level.

This year’s Association for Medical Education in Europe (AMEE) conference saw a strong push towards behaviours and practices supporting physician self-care. A key strategy that emerged was one of mindfulness.

New evidence, particularly in medical students, suggests that it might be uniquely relevant to the medical community, which has one of the highest rates of depression and substance abuse.

Use of techniques to promote what has been dubbed mindfulness-based stress reduction, from simple exercises like deep breathing, to cognitive exercises similar to Cognitive-Behavioural Therapy, appear to be effective in forestalling progression of burnout, and in some cases reduce it.

It may be worth considering introducing trainees to these skills early on in their training, even during orientation periods.  This will help them to be aware of simple strategies that they can use in managing stress in periods of high-intensity.

On a group level, support systems for the trainee in distress are important.

Structured systems for peer or senior mentoring and discussion of workplace difficulties have been shown to reduce trainee distress and promote greater self-actualisation. Such programmes may be useful, especially on an anonymous and non-coercive basis.

The residency system is uniquely set up for that, as it already has formalised systems of mentorship.

What is most important at the end of the day is that we recognise that empathy and burnout are important issues to consider in the development of trainees. We should not neglect them as “softer” competencies in training the doctors and healthcare leaders of tomorrow.