To the Editor:

Empathy is a frequently discussed concept in the medical literature. Much focus has been on finding a fitting description, identifying appropriate quantification tools, and hypothesizing reasons for measured declines in student empathy [1,2,3,4,5]. Despite the existing literature on empathy, little has been done to examine students’ own interpretations of their empathy education [6,7,8]. The following pilot study uses qualitative methods to examine the influence of a student-run free clinic on empathy development, particularly as it compares to formal curricular interventions.

Student-run free clinics are an optimal context for the cultivation of empathy for several reasons. Students are exposed to many patients who are often stigmatized in other contexts, such as patients with legal involvement or those who are unemployed or homeless, and the student-run free clinic provides students with the opportunity to hear these patient’s stories and provide care. Students may develop relationships over time with patients, which could encourage empathy as students work to address healthcare challenges and learn how patients’ lives develop. Furthermore, in the student-run free clinic, students often feel more autonomy or ownership over patients, as they have the ability to see patients for follow-up, perform procedures, and make clinical recommendations directly to faculty members. This autonomy, combined with the time spent with patients to complete procedures and develop a plan, may encourage students to empathize with patients, particularly since this is outside of the pressures of clinical evaluation.

This study utilized semi-structured interviews that were designed following participant observation and review of the curriculum relevant to empathy. Participant observation was undertaken, with collection of detailed field notes, twice weekly from June 5, 2012 through September 6, 2012 at St. Vincent’s Student-Run Clinic (SVC), which delivers pro-bono healthcare services to indigent patients in Galveston, Texas, through the volunteer work of health professions students and faculty preceptors from the University of Texas Medical Branch (UTMB) in Galveston, Texas. The participant observation was conducted in the student lounge areas of the clinic as students waited to present their findings from patient examinations to faculty members.

Lecture materials and course syllabi were analyzed from the Practice of Medicine (POM) One and Two courses, which teach interviewing and physical exam skills to first and second-year medical students at UTMB. Participant observation was also conducted once per week at sessions of the Humanities, Ethics, and Professionalism class that is part of the POM Two course. This class uses readings from the social sciences and literature to explore topics such as empathy, patient autonomy, and paternalism.

Based on the participant observation and review of the curriculum, a semi-structured interview was constructed that explored the students’ experiences of their empathy education. Students at SVC who had volunteered at the clinic more than five times were recruited and all agreed to be interviewed. Five second-year students and five third-year students were interviewed. All interviews were recorded.

This study used a grounded theory approach, in which themes are considered to arise from data that consists of field notes and interviews [9]. Excerpts that represent examples of the themes were noted and coded under certain categories. The study was approved by the Institutional Review Board at UTMB.

Three themes regarding the role of the student-run free clinic in empathy cultivation were identified: (1) volunteering in a student-run free clinic cultivated empathy (2) role modeling, as opposed to more formal curricular approaches, was important for empathy development, and (3) longer appointment times, with the ability to hear patients’ stories, positively contributed to empathy cultivation.

All ten student volunteers felt the student-run free clinic could be helpful in cultivating empathy. In particular, the students noted the additional clinical experiences as important for their empathy development. One third-year medical student said, “Sometimes in your clerkship, you don’t really get a ton of patient contact. It’s hard to work on that (empathy) when you’re just standing there (during a clerkship), and you are just being told to do this, do that every now and then. The rest of the time, you are just standing in the sidelines. So, this (St. Vincent’s) is direct patient encounters. You really do have time to talk to them [the patients] and just figure out what kind of role you want to have when you are in the clinic.”

Some students felt that the setting was helpful for broadening their empathy for patients that they would not ordinarily see on the wards. For example, one second-year medical student explained, “It (volunteering) kind of broadens the spectrum that you are able to show [empathy] for ‘cause the people [who] go there for care are people [who] usually don’t have insurance.”

While their formal empathy education sometimes provides medical students with specific techniques or tools, the students emphasized the importance of role modeling in their cultivation of empathy. This distinction between role modeling and lessons learned through classwork was found in eight of the ten students’ interviews. One student said, “I’m sure we’ve been taught about it (empathy) in Practice of Medicine class, but it doesn’t really stick. I think it’s one of those things that is very inherent, but the most important thing is having a good role model where you see somebody being empathetic and with good bedside manner, and that’s where you get it.” Another student explained, “I tend to get annoyed at it (lessons in class) frequently ‘cause it’s taking time away from things that I think are more important. I feel like you could learn so much just by going (to St. Vincent’s) and seeing how [the] doctors that are volunteering their time [there] interact with patients.”

Another prominent theme that arose was students’ perception that empathizing with patients was easier when less pressured by time. This theme appeared in seven of the ten student interviews. One student explained, “Sometimes I think it’s actually easier in St. Vincent’s (to empathize) than other hospitals ‘cause (when) you are in a real hospital, you are pressured by time and when you’re in a rush it’s hard to remind yourself to do that (empathize). But at St. Vincent’s, there’s so much time, including waiting for the attending. I try to think about, if I were here, what would I want people [to do with] me, and that’s easier to do ‘cause you have more time.”

Another student also emphasized differences in time allotment per patient: “In clinic [during the clerkships, I empathize] a little bit less because I have less time. I spend a long time with my patients at St. Vincent’s.”

This study represents an attempt to understand how students make meaning of their empathy education, particularly the role of the student-run free clinic. The research revealed three themes of the role of the student-run free clinic in empathy cultivation. We believe there is potential value in educators at other institutions conducting their own inquiries into how their students understand their own empathic development, with particular attention to the values of role modeling and the obstacles of time pressure within required rotations, compared with volunteer clinics.