Empathy in Medical Education: Its Nature and Nurture (2021) - AQA

Medical Science Educator (2021) 31:1941–1950 https://doi.org/10.1007/s40670-021-01430-8 ORIGINAL RESEARCH Empathy in Medical Education: Its Nature and Nurture — a Qualitative Study of the Views of Students and Tutors William F Laughey1 · Jane Atkinson2 · Alison M Craig2 · Laura Douglas1 · Mega...

Medical Science Educator (2021) 31:1941–1950 https://doi.org/10.1007/s40670-021-01430-8 ORIGINAL RESEARCH Empathy in Medical Education: Its Nature and Nurture — a Qualitative Study of the Views of Students and Tutors William F Laughey1 · Jane Atkinson2 · Alison M Craig2 · Laura Douglas1 · Megan EL Brown1 · Jessica L Scott2 · Hugh Alberti2 · Gabrielle M Finn1,3 Accepted: 27 September 2021 / Published online: 15 October 2021 © The Author(s) 2021 Abstract Context Medical education is committed to teaching patient centred communication and empathy. However, quantitative research suggests empathy scores tend to decline as students progress through medical school. In qualitative terms, there is a need to better understand how students and tutors view the practice and teaching of clinical empathy and the phenomenon of empathic erosion. Methods Working within a constructivist paradigm, researchers thematically analysed the individual interview data from a purposive sample of 13 senior students and 9 tutors. Results The four major themes were as follows: (1) ‘the nature of empathy’, including the concept of the innate empathy that students already possess at the beginning of medical school; (2) ‘beyond the formal curriculum’ and the central importance of role modelling; (3) ‘the formal curriculum and the tick-box influence of assessments’; and (4) the ‘durability of empathy’, including ethical erosion and resilience. A garden model of empathy development is proposed — beginning with the innate seeds of empathy that students bring to medical school, the flowering of empathy is a fragile process, subject to both enablers and barriers in the formal, informal, and hidden curricula. Conclusion This study provides insights into empathic erosion in medical school, including the problems of negative role modelling and the limitations of an assessment system that rewards ‘tick-box’ representations of empathy, rather than true acts of compassion. It also identifies factors that should enable the flowering of empathy, such as new pedagogical approaches to resilience and a role for the arts and humanities. Keywords Empathy · Compassion · Communication · Medical education Introduction the ability to ‘understand and share another person’s feel- ings and perspective’, there is a consensus that it must also Empathy is difficult to define, but the ability to empathise is involve a ‘self-other distinction’, whereby an empathiser key to co-existing and co-operating with others. Clini- does not mistake someone else’s feelings for their own. cal empathy requires the physician to align to the thoughts There is a general consensus that empathy includes cog- and feelings of the patient in what has been described as a nitive, affective, action, and moral components, though moment of ‘crossing over’. Although empathy involves researchers disagree as to the relative contributions made by each of the components. These four components act as sensitising concepts for our approach in this study. * William F Laughey [email protected] Given that empathy motivates feelings of compassion and increases an individual’s drive to help , it follows that cul- 1 Health Professions Education Unit, Hull York Medical tivating a sense of empathy within doctors should improve School, York, UK patient care. Research supports this — when patients sense 2 School of Medical Education, Newcastle University Medical empathy from their physician, they report greater satisfac- School, Tyne and Wear, Newcastle upon Tyne, UK tion with the consultation and are likely to enjoy better 3 Division of Medical Education, School of Medical Sciences, health outcomes [6, 7]. Physicians too report greater satis- Faculty of Biology, Medicine and Health, The University faction when consultations are rated as more empathic of Manchester, Manchester, UK 13 Vol.:(0123456789) 1942 Medical Science Educator (2021) 31:1941–1950 Although debate exists regarding whether empathy can be regarding the pedagogical strategies which students and fac- measured, there is a concerning body of research which sug- ulty perceive as acceptable and valuable. gests empathy declines as medical students progress through Recent research has suggested pedagogical strategies their training. Hojat et al. and Newton et al. report which place emphasis on the empathic statement (stock declines in mean empathy scores after the third year of medi- phrases such as ‘I’m sorry to hear that’) can lead students cal school, whilst a recent review of studies that sought to to experience ‘empathic dissonance’, defined as ‘the mental measure empathy changes during medical school suggested discomfort experienced by the act of making expressions of that the overall trend is for empathy scores to decline. empathy that are not sincerely felt’. These same strate- Qualitative data has added depth to this picture. Tavakol gies can also promote ‘fake’ empathy, and are less accept- et al.’s research suggests that students perceive the formal able to students than strategies which emphasise an appro- teaching of empathy to decline in the senior years of medical priate balance of non-verbal communication [30, 31]. school , giving way to a curricula bias which prioritises Acceptance of pedagogical strategy is an important prec- the biomedical aspects of clinical care. In addition to edent to engagement , and so further investigation of this, as students experience the harsh realities of working in student and tutor opinions of empathy teaching may yield busy healthcare settings, they come to recognise that there valuable insight into which strategies are likely to be well- is minimal emotional support for frontline staff and received, and which strategies will best fulfil the empathic witness role models distancing themselves to cope with the needs of students. Further research is also necessary to dis- hardships of the job [15–17] — learnings from what has cern which pedagogical approaches to countering empathic been termed the ‘hidden curriculum of medical education’ decline resonate with the needs of students and staff. As. such, we asked: how do senior medical students and medical Hafferty and Franks argue that the process of social- school faculty conceptualise empathy and the factors which ising students into the cultural norms of medical practice influence it, and how do these views influence perceptions — of which empathic communication is one example — is of empathic pedagogy? only partly driven by the curriculum that a medical school officially lays out through lectures and seminars, other- wise known as the formal curriculum. Instead, values are Methods communicated to students through less structured means, particularly the setting of clinical placement. Here, teach- Research Approach ing and learning occur mostly in the informal curriculum, within which students are exposed to subtle, hidden lessons We adopted a relativist ontology and constructivist epis- which ‘can often be antithetical to the goals and content temology, which highlight the subjectivity of reality and of the courses that are formally offered’. These latent knowledge [33–35]. We reasoned that a relativist, qualita- lessons are part of the hidden curriculum, they operate at tive approach is well suited to answering the how questions the level of stealth, and are more powerful for it. In the that characterise our inquiry, detailed above. We selected hidden curriculum, students witness negative role-model- Braun and Clarke’s approach to reflexive thematic analysis ling and the pressure of time overriding the requirement for to analyse our data [36, 37] given its acknowledgement of compassion — experiences which risk turning them away the influence of the research team in data interpretation. from empathy. With these negative influences from the hidden curricu- Setting and Participants lum and the pressures of getting through medical school, future doctors’ capacity for compassion may be fatiguing Data were collected at Newcastle Medical School and Hull even before they qualify. Several researchers have suggested York Medical School (HYMS), during the academic years this burnout comes hand-in-hand with cynicism, a harden- 2018–2019 and 2019–2020, following institutional ethics ing of the heart, leading to ‘ethical erosion’ [20–22] — a board approval at both sites (6182/2018). Two centres were phenomenon whereby medical students and doctors become selected to improve transferability of results. Most research- less morally sensitive and ethically aware [23, 24]. Strategies ers had clinical backgrounds (JA, AC, HA, LD, MB, BL), which foster a culture of empathy within medical school are, one was a medical student (JS), and one a non-clinical Pro- therefore, of the utmost importance. fessor of Medical Education (GF). Two authors have exten- It is generally agreed that more qualitative inquiry is sive experience and expertise in qualitative research (HA, needed to better understand how empathy is shaped by med- GF). Recruitment was purposive, consisting of senior medi- ical education, and the reasons for empathic decline [25, cal students (years 4 and 5) and also faculty tutors from each 26]. Further, although research suggests that empathy can of the medical schools. Tutors were all qualified doctors. be taught [27, 28], there has been relatively little research When recruiting students, we limited recruitment to years 4 13 Medical Science Educator (2021) 31:1941–1950 1943 and 5, which are the final two years of medical school in the empathy and compassion, agreeing on a broad view of UK. These students have more placement experience than these concepts, to include affective, cognitive, moral, and early-stage students, and so more opportunity to observe behavioural components. All of these formed the sensitis- empathy in practice. Participation was voluntary. Recruit- ing concepts around which we conceived our interview ment occurred via email, social media, and word of mouth. questions and data analysis. Data Collection and Analysis Results Researchers (JA, AC, LD, MB, WL) conducted one-to-one, semi-structured interviews with participants. Researchers The demographics of the 22 participants are outlined in followed a question stem but were open to exploring any Table 1; notably, there was a female preponderance (17 new lines of inquiry prompted by the interview discussion. female, 5 male). We identified four major themes and 14 The approach was iterative, with new questions being added sub-themes from the data, as outlined in Table 2. There were as data were analysed. Interviews were mainly face-to-face, very few areas where it was possible to discern significant or in two cases via online video or telephone (depending differences in the opinions of senior students and tutors, on participant preference). Interviews were audio recorded where present these are noted in the results. and transcribed verbatim by an independent professional company. Braun and Clarke’s six steps of thematic analysis The Nature of Empathy were adhered to Familiarisation, Generating initial codes, Searching for themes, Reviewing themes, Empathy Versus Compassion Defining and naming themes, and Producing a report. Within Step 1, to enhance data familiarity, all research- There was little agreement on the distinction between empa- ers read and re-read at least one transcript, making notes in thy and compassion. Several participants believed compas- the margins of possible codes. Two researchers from each sion had more of an action component to it than empathy. site read and re-read all transcripts from their site, fostering …compassion takes it further because you are trying familiarity with local data. Anonymised data were shared to do something that is actually a loving act. across sites, and those leading analysis at each site (JA, AC, Tutor WL) also familiarised themselves with the other site’s data set. Within step 2, all researchers formally coded at least Limits to Sharing and Understanding one transcript, and all transcripts were independently coded by at least two researchers, aided by the sharing of coding Participants believed empathy was about putting yourself in documents via Google Drive. Within step 3, analysis of the someone else’s shoes. It involved emotional resonance, but pooled, coded data was conducted by multiple researchers ultimately it was not necessary to fully share patient emotions (JA, HA, LD, MB, WL, GF) and facilitated through regu- to adequately express empathy. Students also recognised that lar online video discussions between researchers. Similar if empathy required an authentic understanding of patient con- codes were collated into early sub-themes, and sub-themes text, then expressing empathy in situations for which they had reviewed alongside one another to discern connections no personal frame of reference was bound to be ‘disingenuous’. within the data. Within step 4, team discussions facilitated review of early proposed themes and themes were defined Empathy is not necessarily sharing but understanding and named as a group (step 5). WL produced a narrative and recognising someone’s emotions report of results which was discussed by all authors synchro- Student nously and asynchronously until a final report was agreed So, I think it’s a bit disingenuous to say you can always upon (step 6). have empathy for someone in the sense of really under- Regular discussions also allowed researchers to judge standing their situation. when theoretical sufficiency occurred — the point at which Student the sample size was deemed sufficient to answer the study research question. Table 1  Demographics Reflexive Considerations Tutors Students Newcastle 6 (3 female, 3 male) 6 (5 female 1 male) Our approach was inductive, but most researchers were HYMS 3 (3 female) 7 (6 female, 1 male) already familiar with the empathy literature. Through Total 9 (6 female, 3 male) 13 (11 female, 2 male) reflexive conversations, we shared our own thoughts about 13 1944 Medical Science Educator (2021) 31:1941–1950 Table 2  Major themes and sub themes Major themes The nature of empathy Beyond the formal The formal curriculum and the ‘tick box’ Durability of empathy curriculum influence of assessment Sub themes Empathy vs compassion Professionalism Tick-box empathy — the impact of assessment Ethical erosion Innate empathy Continuity Faking-it Resilience Head vs heart empathy Role-modelling Simulated teaching Limits to sharing and Arts and the humanities understanding Is empathy teachable? Innate Empathy The participants understanding of empathy and compas- sion linked closely with their perceptions of its role with Participants described the notion of innate empathy. There was professionalism as described within the next theme. an awareness of a natural empathy continuum, with some indi- viduals entering medical school with more inherent empathy. Beyond the Formal Curriculum I think it’s very evident that some people innately are Professionalism able to have an extra layer of either sensitivity or, emo- tionally, awareness and others do lack that. Controlling one’s emotions was linked to professionalism. Tutor Participants were aware of the professional need to display ‘appropriate’ empathy without overstepping the mark. Head Versus Heart Empathy I think people can empathise too much to a point they’re overstepping a boundary… Participants described how empathy starts in the ‘heart’ as Tutor an affective emotion. As students progress through medi- cal training, they learn to control their emotions, noted as Operationalising compassion as ‘part of the job’ helped important to wellbeing. In doing so, they learn to balance participants keep professionalism in mind. their emotions cognitively, and their empathy is balanced or …you’ve got to be very aware that compassion is part modulated by their ‘head’. of our job, on a day-to-day basis Heart empathy risks burnout Tutor Student I think compassionate people tend to go into medicine Continuity and you’ve kind of got that quality you possess, that quality of compassion, and then it's about managing Empathy was seen as easier to give if a clinician knew a it and getting that balance right … I do think it starts patient well: the establishment of long-standing rapport facil- in the heart itated a more natural connection. Unfortunately, continuity Tutor was perceived as increasingly lacking in clinical practice. Sincerity was held to be important. As such, becoming Continuity has been eroded in every area, so you more cognitive was a source of conflict for participants, who haven’t got that trust, continuity or relationship… felt genuine empathy should come from the heart. when it does come to the moment when empathy is needed, then maybe it’s more forced because you don’t I think ideally [heart] but I would recognise there are actually know them very well. situations where that’s not possible or it’s difficult Tutor Student Cognitive empathy was used by some as a distancing tool Role‑modelling to maintain professional boundaries. Participants felt positive role-modelling was the best way to …[if] it was just from the heart, it might make you learn compassion and empathy in clinical practice. make unwise decisions because there are professional boundaries and you do have to be slightly careful My GP… gave her a double slot, and just stopped and Tutor just listened, and kind of just sat there not really say- 13 Medical Science Educator (2021) 31:1941–1950 1945 ing anything, just letting her speak, and it just kind of I think you have to be careful not to have stock phrases really resonated how much he cared, and she obviously that they then stick to… I've told them that they kind appreciated that as well. of need to find what feels right for them… I suppose, Student heartfelt. Tutor Students also described consultations lacking in empathy and doctors speaking disparagingly about patients following a consultation. Both students and tutors reflected that these Simulated Teaching interactions could, paradoxically, strengthen the resolve to be compassionate, because students saw a kind of doctor Participants noted simulated patients (SPs) provided an they did not want to be. However, negative role modelling opportunity for students to learn in a safe environment. also risked leading students away from compassionate care. However, it was acknowledged that role-play provides an You come across other people who are more senior artificial environment which could contribute to the prob- to you that become a bit more off-hand about things, lem of tick-box empathy. Not all students felt comfortable and I think we are taught a lot as medical students to with the performance aspect of simulation. copy the practice that we see, and sometimes I don’t It is a false situation, and it depends on how comfort- think we are skilled enough to know what’s good able you are with acting in front of people. I’m cer- practice and what’s bad practice at that moment. tainly not that comfortable. Student Student Tutors recognised the power of positive role modelling, but felt the pressure of time and other stresses could hinder The Role of Arts and Humanities their own efforts to be such role models. Participants highlighted the potential for integrating arts and humanities into the formal curriculum. There was per- The Formal Curriculum and the ‘Tick Box’ Influence ceived value in utilising stories as a mechanism by which of Assessment to facilitate meaningful discussion and explore the lived experiences of others. Tick Box Empathy These discussions and understanding these different Narratives detailed the unintended consequences of assess- experiences of…literature… is important in itself as ments, such as Objective Structured Clinical Examinations an education for you as a person. And I think medical (OSCEs). Assessments were deemed to lead to a reduction- school misses out on that, because they are so focused ist, or ‘tick box’ approach to empathy. on learning outcomes and content. Student …in an OSCE, you’re just trying to tick a box, aren’t you? And you drop in a statement ‘oh that Is Empathy Teachable? must be really hard?’ and I think there is probably quite a lot of that. But then… everyone is under a Participants questioned whether it was possible to teach empa- lot of stress. thy and compassion to students, though aspects of compassion Student — such as behavioural aspects — were thought to be teachable. Alternatives to assessing empathy in OSCEs were sug- I think compassionate behaviour can be taught, I’m gested, including more continual forms of assessment during not sure compassion can…that’s what you feel. What placements. your teaching is how to act in a compassionate manner Do it as like a longitudinal thing, don’t… take a snap- Tutor shot on a single day Students and tutors also felt that empathy was shaped by Tutor the innate characteristics and life experiences of students, as much as by any teaching that they receive. Ultimately, it is Faking‑It an interaction of these aspects that shapes a student’s matur- ing compassion as they progress through school. The propensity to ‘fake’ empathy was recounted by partici- pants. Fake empathy was particularly linked to rote state- we are not teaching in a vacuum, and this is the great ments of empathy, which can lack sincerity. difficulty 13 1946 Medical Science Educator (2021) 31:1941–1950 Tutor I don’t think there is an erosion of empathy, I think it I do think it is teachable, but then equally it comes matures into something that’s a bit more substantial from so many things, like it comes from life experi- and less introspective and more patient focused. ence, it comes from how you've been brought up, so, Tutor there’s so many factors I think… and how you are with A variety of suggestions emerged from the interviews people. Yeah, you can learn, but sometimes some peo- related to how ethical erosion could be resisted, including ple are good with people, and some people just aren't the need for students to be aware of the phenomenon and Tutor so guard themselves against it, and the need for students to learn how to look after their own emotional wellbeing. Durability of Empathy Resilience Ethical Erosion Both tutors and students reported that when resilience was The general view of participants was that ethical erosion down then the reserves for empathy were also depleted. does occur, though not in all students. It was often character- ised as compassion fatigue, particularly by tutors. Students I think we all probably have those times in our lives cited repeat exposure of difficult circumstances, such as see- when we are the most stressed and working hardest. ing patients with terminal illness, using expressions such as Compassion and empathy becomes something that becoming desensitised, blasé and offhand when faced with instinctively goes. suffering Tutor I think the more you’re exposed to anything the more There was a sense of the need to balance resilience with used to it you become… the more exposed to things how much empathy could be given to patients. In this sense, like death and that kind of thing and I think that can, keeping some emotional distance from patients was seen as yeah I guess that can stop us being as compassionate a protective strategy for avoiding burnout. There was seen Student to be a balance between the needs of patients, who require empathic investment, and the needs of the student or clini- By contrast, tutors were more likely to link empathic ero- cian who require some emotional distance. Losing this bal- sion to high workload, long hours and the general demands ance was seen to risk negative emotional transference. of the job. I’ve had a GP partner who was very compassionate and I don’t think it’s the educational system particularly, gave patients lots of time and was always running late I think perhaps it’s the clinical system that they are and eventually burnt out. pushed out into… if you have to see so many patients Tutor and you’ve got a 12-hour shift … I can imagine you I feel like part of burnout is to do with empathy and might find it more difficult to be empathic with some- kind of having their problems become yours, kind of body than if you were in a system that wasn’t quite as taking it home with you… brutal Student Tutor Being able to switch off was seen as important for bolster- There was a perception that participants needed to limit ing resilience, including taking breaks and holidays. Also their empathic engagement to protect their own emotional helpful was the practice of talking problems through with wellbeing and get through medical school exams. colleagues, though the culture of not admitting weakness in when you go to medical school, you kind of learn how medicine makes this difficult. to build a wall: like, it’s professional empathy, it’s a bit I have a tendency, if I’ve got a lot on, just to kind of like a wall actually. It’s like a separator from patients… close myself away and just keep on working. Whereas It’s like I’m parking my empathy, for now, while I con- I know that actually just doesn’t work, and I need to centrate on other things. just stop and take a break. Tutor Student However, not all participants thought empathy declined There’s a lot of show and bravado in medicine, so, with progression through medical school, with one arguing the I don’t know that it’s… openly talked about enough. change in empathy was more about maturation than erosion. Tutor 13 Medical Science Educator (2021) 31:1941–1950 1947 Students reported receiving little in the way of teach- opposing concepts – for example, emotional giving and self- ing about resilience and would welcome such an initia- preservation. Given this balance can be difficult to strike, tive, including teaching focussed on the ability to deal empathy is seen to be fragile, like the flower in our horti- with the strong emotions that empathic engagement can cultural analogy. trigger. Part of this question of balance is the extent to which clinical empathy should be cognitive (centred on under- We’ve been taught about other aspects of emotion, for standing), or affective (centred on feeling). These data example breaking bad news and things like that, but we suggest that without a level of feeling, there is the danger haven’t been taught how to deal with it emotionally in that purely cognitive empathy will seem insincere, espe- yourself if you are distressed by a situation. cially in the case of rote statements of empathy. This ech- Student oes the findings of other qualitative studies [30, 31] which outline the limitations of purely cognitive empathy, sug- gesting rote statements can be used as insincere substitutes Discussion for authentic empathic engagement. Although previously the model for the professional We began this research by asking how we conceptualise delivery of empathy centred on ‘detached concern’ , clinical empathy and how empathy is influenced by the more recently Halpern has suggested the idea that teaching and practice of medicine. Our data suggest that doctors can put their feelings entirely to one side is neither empathy often involves finding a delicate balance between likely, nor desirable (Fig. 1). Instead, Halpern advocates Fig. 1  The empathy garden. Empathy is represented by a flower. support, students can become more resilient (the stake). Resilience is All students start their developmental journey with innate empa- tested by stress-inducing factors (the lightening), such as the stress thy, demonstrated by the seeds. The growth of the seeds to a flower of recurring examinations and NHS pressures, including long-hours occurs as students navigate the formal (blue) and other than formal and high workload. Over time, or without support, with exposure curricula (green) and their constituent parts (the leaves). Central to to negative contextual factors (the wind) including negative-role how these curricula experiences intersect is the stem, depicting the modelling and the cynicism that accompanies the practice of fak- hidden curriculum. Empathy is nurtured by positive relationships ing empathy, there is an ethical erosion and decline in empathy — and role-modelling, including positive consultations with patients, symbolised by the falling petals. The growth and erosion of empathy continuity, and support from peers and tutors — represented by the occurs through the process of socialisation — this includes exposure watering can and droplets. If provided with the right tool-kit (spade), to role-models, patients, tutors, or tacit and implied experiences from through formal teaching, positive role-modelling, and peer and tutor the hidden curriculum 13 1948 Medical Science Educator (2021) 31:1941–1950 emotional resonance and ‘compassionate curiosity’ for the used reflection to strengthen their resolve that they them- patient’s circumstances, ideals which require a measure of selves would never want to practice in a way that seems so affective empathy. Our data suggest that a barrier to lacking in empathy. Other researchers have also reported achieving this is the perception that any emotional invest- how students can take positive reflections from negative ment in the patient’s predicament could be detrimental to experiences and educators should consider promoting the student or doctor. Both students and tutors report that the use of reflective practice to help combat the adverse they do not feel equipped to deal with the strong emotions influences less than compassionate role models. linked to sincere empathic engagement and worry that Previous research has cast doubt on the assessment this could leave them more susceptible to burnout. Whilst of empathy, especially in OSCEs [30, 31]. Students in this concern makes intuitive sense, the evidence regarding this study have, once again, raised the issue of ‘tick box’ affective empathy and the risk of burnout is contradictory. assessments, noting that simply making a rote state- Whilst some research supports this link [42, 43], other ment of empathy, regardless of whether it was meant, evidence suggests that doctors who exhibit more affective is enough to secure the marks. The implied message empathy are also those who are at the least risk of burning within the hidden curriculum here is that a performance out. This is an area that would benefit from further of empathy — and OSCEs of course occupy the level of research. ‘show’ in Miller’s Pyramid — is all that is really While based on only two UK medical schools, our data needed. Assessing empathy in a way that rewards rote suggest that resilience is not taught in any systematic empathic statements may ultimately be to the detriment way. Although resilience (like empathy) is difficult to of the teaching of compassionate communication in med- measure, there is some evidence that specific educational ical education. workshops and the techniques of cognitive behavioural therapy (CBT) can improve resilience. Future stud- ies could consider whether these interventions may allow Limitations for greater willingness to engage in affective empathy. Such research could help guide pedagogical strategies and The principal limitation of this study is that it is restricted the future integration of effective resilience teaching into to two UK medical schools. Empathy has cultural aspects, medical school curricula. Currently, the perception that and the findings may have less relevance for schools in students do not feel equipped with strategies to deal with other settings, particularly Eastern schools. For exam- emotional aspects of patient contact, expressed clearly in ple, research on empathic decline suggests it is a Western our data, may be deterring students from being fully open school phenomenon — Eastern schools do not share the to empathic consulting. same decline. Furthermore, there was a preponder- This study underlines of the key role played by the hidden ance of female participants in this study (17 females, 5 curriculum: for example, positive role-modelling, accom- males), which may affect the transferability of results panied by appropriate student reflections, were felt to be given there is evidence to suggest that, on average, females the most direct ways to enhance a student’s appreciation of are more empathic than males [48–50]. empathy, and there is evidence in the wider literature to sup- port this [15–17]. Tutors were aware of this, and to some extent they felt the burden of it, highlighting that stress- ful work environments, coupled with a lack of time, meant Conclusion they could not always live up to the empathic role models they aspired to be. Therefore, whilst desirable, positive role- This qualitative study outlines a number of educational modelling may not always be easy to attain. factors which all have the potential to shape student empa- In common with previous findings [15, 46], our data thy during their time in medical school. We have depicted also suggest that students witness frequent examples of empathy as a flower, emphasising its fragile nature, and negative role-modelling, including hearing doctors make its susceptibility to potential perils that reside mainly in derogatory remarks about patients after displays of seem- the hidden curriculum of medical education. We have also ing empathy and witnessing doctors who communicate described the perceived trade-off between empathy and with minimal empathy in their consultations. Negative resilience, that giving the former reduces the latter. This role modelling risks giving the impression that empathy perception may or may not be correct. However, it remains is unimportant. It is interesting, however, that some stu- significant barrier to empathic engagement and requires dents in this study, witnessing negative role modelling, more research. 13 Medical Science Educator (2021) 31:1941–1950 1949 Based on the findings of this study, we propose a num- 5. Bowen GA. Grounded theory and sensitizing concepts. Int J Qual ber of key points for educators (Box 1). Methods. 2006;5(3):12–23. 6. King A, Hoppe RB. Best practice for patient-centered communica- tion: a narrative review. J Grad Med Educ. 2013;5:385–93. Box 1 Key Points 7. Howick J, Moscrop A, Mebius A, Fanshawe TR, Lewith G, Students arrive at medical school with their innate empathy which Bishop FL, Mistiaen P, Roberts NW, Dieninytė E, Hu XY, is then prone to influence as they commence their socialisation into Aveyard P. Effects of empathic and positive communication in medicine. 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