Developing self-empathy in medical students and physicians to improve patient outcomes

The noble calling of medicine attracts men and women who want to help others, and who are well-aware that they will be faced, from their earliest days of training, with patients’ illness, pain and suffering. Compassion, and what is also sometimes called empathy, is the basis for humanistic, patient-centered care. Today we are experiencing a crisis of burnout among medical students and compassion-fatigue among physicians, which results in emotional exhaustion, and depersonalization, leading to decreased compassion and empathy with diminished quality of care for patients. Studies have shown that a steep decline in empathy, as measured by the Jefferson Scale of Physician Empathy and other instruments, occurs with greatest frequency in the clinical experience years of medical students. What can ensue are feelings of depersonalization, emotional exhaustion and decreased effectiveness that can lead to depression, anxiety, and even an increased risk of suicide. To counter this alarming trend, the authors introduce the concept of self-empathy, which is new in the context of medical education. This is a way to develop empathy for others, thereby improving the well-being of medical students and practitioners, so that they can better care for their patients. It is critical that the study and practice of self-empathy be integrated into medical school curricula and in continuing education for physicians so that it becomes part of their day-to-day life.


Introduction
Burnout is the condition wherein professionals become distressed, and have feelings of emotional exhaustion, depersonalization, and decreased effectiveness. They may feel depressed, anxious, have relationship issues, and in the most extreme cases, feel suicidal. Health care professionals may be particularly prone to developing burnout, with about 50% of medical school students experiencing the condition. Studies have shown that, tragically, the rate Rajput V, Rosenberger R MedEdPublish https://doi.org/10.15694/mep.2017.000151 Page | 2 of suicide among physicians is 40% higher than the general population for males and 130% higher for females (Dyrbye et al. 2008).There are several interventions described and used can help to prevent burnout or alleviate it among medical students and physicians. There is a strategy called self-care for the caregiver (Mills and Chapman 2016) and is based on the idea that one cannot be caring, compassionate or empathetic for another, for a patient, without first having such feelings for oneself. Medical educators who exhibit negative attitudes, berating themselves for errors, being unsympathetic and critical, present very poor role models for their students and may not be credible when advising patients about health.
Many frontline medical specialties require a greater capacity to deal with trauma and tragedy, but hasn't this always been the case? Why is it that so many medical students and doctors experience higher rates of burnout today? Some of the factors contributing to this escalation may be elevated stress due to financial burdens, increased workload, diminishing amount of time to spend with patients, and poor work/life balance and overall poor quality of life. The key to conquering burnout by doctors-in-training and physicians in practice, is achieving a greater sense of wellbeing through the construct called self-compassion (Mills and Chapman 2016;McKee and Wiens 2017;Sinclair et al. 2014;Neff 2003;Germer and Neff 2013). Self-compassion is a pre-requisite for feeling compassion for another person. This has been called the butterfly effect; whatever you do for yourself will affect others (Gustin and Wagner 2012). Simply stated, it is like the safety warning given to airplane passengers before every flight: put on your own oxygen mask before attempting to help anyone else with theirs.

Defining Empathy, Compassion, Self-Compassion and Self-Empathy
What is self-compassion, and how does it relate to compassion for others, empathy, sympathy, and caring? Most people would be hard-pressed to define and differentiate the words compassion and empathy. There is a difference, though it is subtle. Compassion is a deep awareness of another's suffering and the wish to alleviate it. Empathy is the capacity to feel what another person is feeling, to feel another's pain, sadness, suffering, in a kind of vicarious experience.
Researchers who study these concepts in connection with medical professionals use the terms interchangeably at times, and sometime point out that precise definitions are lacking. Empathy has been described as "compassion in action" meaning that a person who feels empathy goes on to act on the concern for another person (McKee and Wiens 2017). Other researchers define the terms in the opposite way, with compassion meaning concern together with a desire to do something about it (Mills and Chapman 2016). Further confusing the terminology around this topic is the fact that there have been instruments developed to score both compassion and empathy, i.e. compassion scales and empathy scales.
Kristin Neff defined the construct of self-compassion and developed a scale on which to score it (Neff 2003). Selfcompassion includes three components: self-kindness, which means treating oneself non-judgmentally, as one would a friend who may have made an error; feeling one with common humanity, that is connecting with people and accepting that we are all human and imperfect; and mindfulness, an approach to psychological well-being and stressreduction. She stated that, "Self-compassion is an emotionally positive self-attitude that should protect against the negative consequences of self-judgment, isolation, and rumination (such as depression) (Neff 2003)." Practicing self-compassion has been shown to reduce stress and anxiety (Germer and Neff 2013) without negative consequences such as a diminished sense of accountability or motivation. To minimize the confusion resulting from the use of these terms and to stress the need for the deepest understanding of oneself without judgement, in order to treat patients with empathy, the term self-empathy is hereby introduced in the context of medical education.

Combatting Compassion Fatigue, Cultivating Self-Compassion and Self-Empathy
Compassion fatigue among medical practitioners, another term for burnout, is the condition of becoming desensitized to patients' pain and suffering, and has been shown to increase with years of experience, resulting in distress for the doctor and a lower standard of care for the patient (Gleichgerrcht and Decety 2014;Raab 2014). In fact, empathy begins to erode in medical school, unless it is maintained by means of an educational intervention (Rosenthal et al. 2011;Neumann et al. 2011). Self-empathy can enable deep feelings of understanding the emotions and pain of others, and wishing to alleviate the suffering (Riess 2017).Physician empathy, in and of itself, has been shown to have a therapeutic effect on patients (Neumann et al. 2011).Medical schools can do more to incorporate training in compassion and self-compassion into the curriculum (Mills and Chapman; Sinclair et al.) as with journaling and reflective practice, for example. Role modelling and empathetic clinical communication are two important skills that need to be taught. These include such factors as role-playing, using empathic phrases, and using non-verbal empathic gestures. (Figure 1) "Educators should consider using the practice of relationship-centered care as the fundamental building block for their educational interventions to teach empathy (Bat-Rawden et al. 2013p. 1175."

Conclusion
Burnout and compassion fatigue among medical students and physicians are at an epidemic level and their patients may also be at-risk for lower-quality care and poorer outcomes.
Self-empathy training can be integrated into medical training to help generate well-being, compassion, and empathy, resulting in improved patient-centered care.

Take Home Messages
Burnout and compassion fatigue among medical students and physicians are at an epidemic level and their patients may also be at-risk for lower-quality care and poorer outcomes.