by
Rachel Coleman Drury, Pharm.D., PGY2 Ambulatory Care Pharmacy Practice
Resident, University of Maryland School of Pharmacy
Can empathy be taught? Some would argue that empathy is an
inherent personality trait. Others
believe it’s a developed skill. The literature
suggests that empathy can be cultivated.1,2 Many health professional
schools are incorporating fine arts and empathy building exercises into their
curricula to develop well-rounded practitioners. The Accreditation Council for Pharmacy
Education (ACPE) references empathy five times within the Accreditation
Standards and Guidelines for the Doctor of Pharmacy Degree.3 Pharmacy practitioners must be empathetic in
order to competently deliver effective patient care.3
As a pharmacy resident practicing in the ambulatory care
setting, I could not agree with ACPE more.
“They don’t care what you know, until you show them that you care” is
something I frequently say to students on rotation. To achieve optimal health outcomes,
the provider must first understand the patient’s problems from the patient’s
perspective. This is how a trusting relationship is built. Without empathy, a provider cannot make patient-specific
recommendations.
Empathy is a higher-level skill that requires the practitioner
to quickly process information from the patient interaction to make a
purposeful response that conveys understanding. Like empathy, reflective writing requires the
learner to process information and respond. Given these similarities, reflective writing has
often been used as one method to develop empathy. Universities, residency
programs, and even hospital systems have successfully used reflective writing
exercises to develop a practitioner’s empathy.1 At the Cleveland
Clinic, participating physicians attended training sessions that included reflective
writing and small group discussions. Topics included the patient experience of
pain and suffering, empathy across cultural barriers, and empathetic communication.
This study found that facilitated small group sessions, which included sharing
thoughts from reflective writing exercises, was effective in increasing self-reported
empathy.1
The Columbia University College of Physicians and Surgeons
used a similar method of reflective writing to foster empathy development in an
elective course that was structured to allow participants to deeply explore their
personal experiences of illness. Throughout the course, students were asked to
write about the cultural context of the illness as well as how the ill person
was perceived by others. Similar to the Cleveland Clinic exercise, students
were given the opportunity to share and discuss their reflective writing. Students
in the course indicated that they had a better awareness of their own personal
illness and this awareness brought them closer to the experiences of patients.2
Shapiro and colleagues proposed a two-stage conceptual
model that uses reflective writing to cultivate empathy in health professional
students. The first stage is writing and the second is reading and listening. It is during the writing phase that learners think
about the patient’s situation and contemplate their own subjective and personal
reactions to the patient. Learners
should also be aware of their voice (or point of view) in the reflective
writing – is it the voice of the provider or patient? The learners should also
be encouraged to express emotions, use imagination, and think creativity when
writing. In this manner students may begin to see the psychological and
spiritual dimensions of many clinical dilemmas as well as find creative solutions.4 During the writing stage prompts should be
given to guide the learner. Prompts may include: thinking about a time when it
was challenging to be empathic; reflect on an experience that gave you insight
into patient suffering; and reflect on a personal illness.1,2
During the second stage learners read and listen. By reading out load and listening to the
experiences of others, learners have the opportunity to empathize and sympathize
with one another other. Shapiro defines this as witnessing – an act that
creates responsibility in those who hear the testimony of suffering to not turn
away, but rather to accept and acknowledge. Witnessing allows students to
release their own helplessness and fears. Witnessing only occurs through
mindfulness — excluding thoughts of past problems or future obligations and accurately
and attentively listening and observing. Sharing personal experiences often makes
students feel vulnerable — which in turn allows them to understand their
patients’ feeling of vulnerability.4
When students share their reflections, ground rules must be established.
It is important that students feel safe.
Strict confidentially must be established. All participants must listen to each other
without judgment and offer support.4
The scoring of reflective writing can be challenging.
Should student’s reflection be “graded” or should the student be awarded points
merely for completing the assignment? When evaluating reflective writing, it is
important to remember that the exercise is intended to foster and develop empathy.
Therefore, any evaluation should ensure that students are truly growing from
the experience. One validated evaluation rubric is the Reflection Evaluation for
Learners’ Enhanced Competencies Tool (REFLECT). The
rubric examines several elements of the writing process including
spectrum, presence, description of conflict, attending to emotions, and
analysis and meaning. The performance on each element is assessed based the following ratings: habitual
action (nonreflective), thoughtful action or introspection, reflection, and
critical reflection. In addition, the evaluator
rates the narrative as a whole as either transformative reflection and learning
or confirmatory learning.5
Reflective writing is an effective method to teach and
develop empathy in health professional students. These activities can be easily facilitated
and there is a validated grading rubric.
Learners can continue to use reflective writing throughout their
careers. But reflective writing does have some
drawbacks. For learners, reflective writing is difficult and requires
considerable time to reflect and compose ones thoughts. For teachers, there is a lack of evidence confirming its
benefits in terms of actually increasing practitioner empathy applied to
patient care. None-the-less, the literature shows that reflective writing can be
successfully incorporated into any curriculum and formally evaluated.
References:
- Misra-Hebert A, Isaacson JH, Kohn M, et al. Improved empathy of physicians through guided reflective writing. International Journal of Medical Education [Internet]. 2012 Apr 9 [cited 2014 Oct 1]; 3:71-77.
- DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Academic Medicine [Internet]. 2004 Apr [cited 2014 Oct 1]; 79(4):351-356.
- Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree [Internet]. [Chicago]: Accreditation Council for Pharmacy Education; 2011 Jan 2006 [cited 2014 Oct 1]. 35, ix, xxvi, ps.
- Shapiro J, Kasman D, Shafer A. Words and wards: a model of reflective writing and its uses in medical education. Journal of Medical Humanities [Internet]. 2006 Sep 26 [Cited 2014 Sep 29]; 27:231-244.
- Wald HS, Borkan JM, Taylor JS et al. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing. Academic Medicine [Internet]. 2012 Mar [Cited 2014 Oct 4]; 87(3): 355.
- Peterkin A, Roberts M, Havey T. Narrative means to professional ends. Canadian Family Physician [Internet]. 2012 Oct [Cited 2014 Sep 30]; 58(10): e563-e569.
- Wald HS, Reis S. Beyond the margins: reflective writing and development of reflective capacity in medical education. Journal of General Internal Medicine [Internet]. 2010 Jul [Cited 2014 Sep 30]; 25(7): 746-749.
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