Teaching Empathy

by Kumaran Ramakrishnan, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

To teach the pathophysiology of Parkinson’s, a teacher can use a lecture with a PowerPoint. The lecture can teach the pathophysiology of the disease or the therapeutic guidelines for treating the symptoms.  But how can the student learn empathy for a patient with a debilitating condition like Parkinson’s disease?  Or how to understand and relate to the patient?  Numerous articles have been published stating that empathy increases not only are the patient’s positive perception of the physician but also health outcomes. One study found that patients who’s physicians had high empathy scores were more likely to achieve better disease control as evidence by lower A1c and LDL-C measurements.¹ Similar results have been seen in patients with the other disease states such as the common cold. The Accreditation Council for Pharmacy Education (ACPE) requires schools of pharmacy to include empathy in the curriculum in order to provide high quality health care to patients with diverse backgrounds.

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Unfortunately health professional students become less empathetic as they progress through school. One longitudinal study of medical students found the greatest erosion of empathy was in the third professional year.² This erosion of empathy appears to occur when students focus too much on applying their classroom-based knowledge to real patient situations.  A similar longitudinal study has not been conducted in pharmacy students, but there have been reports that interventions can increase empathy among pharmacy students at different stages in their career. 

One study conducted in the second professional year of pharmacy school, engaged students in simulation activities.  Students were asked to act as though they had lost the use of their dominant hand, vision, and speech. There were small and large group discussions after each activity to engage the students.³ The Jefferson Scale of Empathy-Health Profession (JSE-HPS) was administered before the interventions, seven days, and ninety days after these activities. The JSE is a tool designed to measure empathy in medical students, and JSE-HPS has been adapted for other health professionals.⁴ The tool is widely used in studies to measure empathy for both students and practitioners alike. The results showed that while there was an increase in the scores seven days after the activities, JSE-HPS scores returned to baseline 90 days later. When comparing the scores with a control group, there is little difference in the net increase in empathy scores.³ 

In another study, students watch a play featuring two actors — an elderly patient with a “demanding personality’ and an assistant manager who “cared more about rules and regulations than the elderly person’s concerns.” After the play, students engaged in a discussion about the stimulated encounter and how they would use the information in the future. The JSE was administered before the play, immediately after the play, seven days, and 26 days later. Similar to the previous study, while there was a significant increase between the pre-test and immediate posttest, by day 26, the scores were nearly back to baseline.⁵ 

Several other methods have been employed to teach empathy.  Students have been asked to keep a nutritional diary,⁶ participate in a 7-day active learning assignment about diaetes,⁷ and use community resources for patients with a chronic disease.⁸ All of these studies show short-term increases in empathy but scores return to pre-intervention levels in the long run. This provides a unique challenge as any method used must not only increase empathy but maintain it. A solution might be use interventions throughout the curriculum. Accrediting agencies, such as the Accreditation Council for Pharmacy Education, have incorporated empathy into their standards. The ACPE standards mention empathy has an important component of professional communication, ethical behavior, and professionalism. Since empathy is such an important trait for effective health care professionals to possess, it is essential for teachers to understand how to teach empathy.  The studies have shown that several methods, while effective in the short term, have little effect in the long term.  For students to learn empathy and be effective professionals it is important to integrate empathy exercises throughout the curriculum – not just in one isolated course. 

References:

1. Hojat M, Louis D, Markham F, Wender R, Rabinowitz C, Gonnella J.  Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011;86(3):359-364.
2. Hojat M1, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009 Nov 2009;84(11):1182-91. 
3. Lor K, Trong J, Ip E, Barnett, M. A randomized prospective study onoutcomes of an empathy intervention among second-year student pharmacists . APJE. 2015;79; Article 18. 
   
4. Fjortoft N,Van Winkle L, Mohammadreza H. Measuring empathy in pharmacy students. AJPE 2011;75: Article 109.  
5. Van Winkle L, Fjortoft N, Hojat M. Impact of aworkshop about aging on the empathy scores of pharmacy and medical students. AJPE. 2012 2012;76: Article 9. 
   
6. Whitley H. Active-learning diabetes simulation in an advanced pharmacy practice experience to develop patient empathy. APJE. 2012;76; Article 203. 
   
7. Trujillo J HY. A nutrition journal and diabetesshopping experience to improve pharmacy students’ empathy and cultural competence. APJE. 2009 37; Article 37.
8. Chen JT, LaLopa J, Dang DK. Impact of patient empathy modeling on pharmacy students caring for the underserved. AJPE. 2008,;72: Article 40.

Narrative Evaluation System

by Caroline Kim, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy 

Years ago, I attended elementary school in South Korea. My report card consisted of a letter grade accompanied by a short narrative from my teachers.  These comments stuck with me more than the grades.  They gave me insight into my performance beyond numbers.  They explained areas where I needed to improve — even if I earned a high grade — and areas where I did well despite a poor grade.  The finality of my letter grades was inescapable, but the comments were a source of motivation for further learning.

The purpose of evaluation in education is to guide student development, promote excellence, aid in defining the successful completion of a program, and provide performance evidence.¹  The traditional grading system might be effective in promoting high standards, but it fails to capture abstract details related to student performance. Traditional grading systems also provide little room for feedback to guide the future learning process.  I would argue that there is a need for a more effective method of evaluation beyond numerical and letter ‘grade’ classification systems.

The Narrative Evaluation System (NES) is a nontraditional grading system, which provides constructive feedback on student’s performance using a narrative format.  In construct, NES draws heavily from Walter Fisher’s narrative paradigm theory. ²  The theory states that narration and storytelling are the basis of all human communication. ²  In the NES system, the evaluator takes into account the objectives of the course when evaluating the strengths and weaknesses of a student’s performance.  Like traditional evaluation models, NES also recognizes noteworthy student performance.  In addition, NES encourages cooperation and collaboration by personalizing descriptions of student performance. ³ This helps to promote closer relationships between students and instructors.

NES does have some drawbacks.  NES requires a larger time commitment from educators. ³  In order to summarize student performance into a narrative, educators are required to keep detailed notes on each performance and provide suggestions on how students can improve in the future.  NES explores more dimensions of the evaluation process and educators must devote more time and energy to constructive criticism.  Simply put, NES is more difficult than  the simple categorization required in traditional grading systems.  Even after providing narrative comments, some institutions force educators to use traditional grading systems — allowing a comparison between students using the same grading scale.  The NES system supplements traditional evaluation.³   Students who have been evaluated using the narrative evaluation system often request letter grades — in one study more than two thirds did so.⁴ The most common reason for requesting letter grades was to understand the narrative evaluation by comparing their performance to grades that they are familiar.⁴ 

Very few studies have analyzed the impact of NES on future success.  One study examined whether graduates from a program that used NES remained competitive when it came to admissions into graduate and professional programs.³ When comparing students who graduated from the University of California at Santa Cruz (UCSC) — which uses a narrative grading system — with other University of California campuses which assign traditional grades, the investigators found that UCSC students generally performed as well if not better in terms of acceptance rates into graduate and professional schools.³ 

In another study, a survey of UCSC students and alumni explored their attitudes towards NES.  The survey respondents indicated they preferred NES because it pointed out strengths and weaknesses, and helped them grow personally and professionally.  They appreciated how NES promoted cooperation, scholarship, and creativity. ⁴ However, 62% of undergraduate students surveyed and 54% of alumni surveyed reported some quibbles with NES.⁴ The problems included the length of time it took to receive the narrative, failure to receive a constructive narrative, or evaluations that were similar to and provided little addition information beyond letter grades. ⁴ Despite these challenges, 82% of undergraduate students and 78% of alumni favored NES over a traditional letter grade.<sup>4 

Figure 1. This table summarizes a surveyed undergraduate and alumni opinions of NES.4</sup>

Survey Questions	Undergraduate (%)		Alumni (%)
	Yes	No	Yes	No
NES influenced decision to attend the school	58	42	48	52
Favored NES over letter grades	82	14	78	18
Requested letter grades	32	68	N/A	N/A
Believed NES worked in their favor	N/A	N/A	62	37
Experienced a problem with NES	62	38	54	46

Another study compared the effect of NES and a conventional grade system on learning and motivation.⁵  During the study students were asked to perform certain learning tasks during 3 distinct teaching sessions.  Students were randomized to receive either narrative or numerical grades when completing the learning tasks in sessions 1 and 2, and then took a post-test after session 3.⁵ Results showed that students who received narrative evaluations had the highest post-test performance.  Moreover, traditional grades depressed creativity and weakened student interests in the subject matter.⁵ 

Currently, at least seventeen colleges and universities in United States and Canada use narrative evaluation (NES).  Some have used this system for over fifty years.  NES can guide students in their learning and help them improve on their weaknesses.  The NES model provides a more complete picture of the student and helps students to distinguish themselves as individuals.  Although it may be time-consuming, educators should consider implementing NES – perhaps in conjunction with traditional grades — to enhance the learning process. 

References

1. Hanson J, Rosenber A, Lane L.Narrative Descriptions should Replace Grades and NumericalRatings for Clinical Performance in Medical Education in the United States. Frontiers in Psychology.  Nov 2013; 4: 1-10.
2. Fisher W. The Narrative Paradigm: In the Beginning. Journal of Communication. Dec 1985;35(4): 74-89.
3. Affirmation of Accreditation Self-Study Report. University of California at Santa Cruz. [Internet].  1994 Nov: 22-29. [cited 2015 Mar 8].
4. Wong M. Assessment and Evaluation of Past and Present Student Attitudes toward the UC Santa Cruz Narrative Evaluation System. University of California at Santa Cruz. [Internet]. 1992 Jun. [cited 2015 Mar 9]
5. Butler R,Nisan M. Effects of no Feedback, Task-related Comments, and Grades on Intrinsic Motivation and Performance. Journal of Educational Psychology. Jun 1986; 78(3): 210-216.