2013

2013; 35: 69–70

PERSONAL VIEW

A call for reflection: Medical student driveneffort to foster empathy and compassion

ANIRUDH RAMESH

Johns Hopkins School of Medicine, USA

On my first day of clinical medicine, a newly anointed ‘‘MS3,’’

I heard a thud and a crumple, followed by a woman’s

anguished wail. I turned around and saw a middle-aged man

collapsed on the floor and a woman crouched on her knees

pleading life into him. I was standing in the heart of the

hospital, the cafeteria, around midday. Yet, the area was

devoid of the familiar din of shuffling feet and gentle

conversation, filled instead by one woman’s panic.

I stood paralyzed for a moment, mustering the courage to

overcome fear and uncertainty. The woman’s shrill shrieks

snapped me to action and I ran over to see what had

happened. I looked down at a middle-aged man, maybe 50,

with a gaunt face and sunken eyes. I knelt beside him, my first

patient, and felt another rush of fear. ‘‘Sir, are you okay? Please

wake up.’’ I squeaked. His eyelids remained suspended

between open and closed revealing a gleaming sliver of

sclera, a piercing reminder of my inadequacy.

From that point on, time flew by. I stood aside as physicians

and nurses came pouring to the scene to help the patient.

Neurologists examined the pupils and reflexes, internists

assessed the patient’s heart and lungs. Several people took

the woman aside, trying their best to console her. Despite their

best efforts, the patient yelled out through her tears, ‘‘Why is

nobody helping? Doctor, Doctor, DO SOMETHING!’’

The code team arrived, quickly assessing the scene, giving

oxygen, slapping on a monitor, placing an IV, and getting a

blood sugar measurement. They worked diligently to secure

the man’s neck and move him to a stretcher as security staff

blocked off the hallway. Within minutes, the patient was being

whisked away to the ED.

I walked away from the disintegrating scene, shell-shocked

at what I had just witnessed. I had not gone more than a few

feet when the reality of the situation struck me. He was on the

brink of a cliff, engaged in a tug-of-war against chaos,

randomness, death. There was no explanation, no reason for

any of this. I felt tears welling up in my eyes as I walked

through the hallways. I searched for a quiet room in vain,

ultimately ending up in the ancient auditorium where Grand

Rounds were held. I paced through the pews as tears rolled

down my cheeks, my sobs echoed around the walls.

It is clear that the training arena of future physicians has a

tremendous impact on the kinds of physicians and people they

turn out to be. Studies have enumerated the changes seen in

medical students as they go through their clinical training.

They describe disenchantment, a loss of empathy, and

emotional withdrawal as common occurrences in third-year

medical students (Neumann et al. 2011). Furthermore, studies

have described how structured reflection can be a way to

preserve students’ compassion and integrity through the

tumult of clinical training (Lonka et al. 2001; Thomas &

Goldberg 2007).

Looking back on how I dealt with my emotions of that day,

I realized that what had helped me the most was the

conversations I had with my classmates and with professors.

I made it a priority to explore what had happened and I sought

people out to foster the interaction. However, it took effort on

my part to enable these conversations, and I wondered if there

was not a better way.

During my second year of medical school, I organized a

series of informal reflection seminars to discuss issues

important to our development. Students from the first- and

second-year classes came together every other week to discuss

a theme or topic from a syllabus I had put together. For

example, we discussed why physicians should ask patients

about their spiritual and religious values and how to

ask these questions. We talked about ways to foster the

patient–physician relationship. We shared stories and poems

we had written and reflected on the freedom we find through

fiction.

In all, we met 10 times over the course of several months.

There was a core group of five students who attended almost

every one of the sessions, with a few more who attended

several. Then, we managed to attract certain students who had

a particular passion for the subject of that week’s discussion.

Overall, 30 different students attended with an average

attendance of 10 people per session.

I think our greatest virtues as a group were the diversity of

opinions represented and the comfort we all felt in sharing

them. We disagreed frequently, we digressed often, and we

challenged each other’s assumptions and forced each other to

think critically. But, more than anything else, we all had ideas,

stories, and emotions to share, and we just needed a venue to

come together.

The process of training to be a physician can be extremely

isolating. In the absence of dedicated time to come together

with classmates, I fear that we risk perpetuating the distressing

trends regarding the loss of empathy in our next generation of

physicians.

Correspondence: A. Ramesh, School of Medicine, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA. Tel: 631-235-0484;

fax: 410-614-3368; email: ani@jhmi.edu

ISSN 0142–159X print/ISSN 1466–187X online/13/010069–2 � 2013 Informa UK Ltd. 69DOI: 10.3109/0142159X.2012.731109

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Some medical schools have set aside time for students to

come together during their clinical years to have just these

types of discussions. For example, Stanford School of Medicine

has created a discussion series that runs in parallel with the

clerkship schedule to provide students a brief pause during

each rotation to debrief and explore meaningful issues.

I propose that all medical schools adopt a mechanism to

bring students together during their clinical years. However,

contrasting the curricula that exist at certain schools, including

Johns Hopkins, I suggest that this endeavor be student led. As I

found out during my second year, empowering students to take

charge of their learning experiences can yield unforgettable

discussions and memories. Reflection requires no expertise, but

it does require a stable, nurturing environment. I am confident

that if students are given freedom and space to be creative and

connect with each other, we can foster a happier, more

compassionate, and more humane generation of physicians.

Acknowledgment

The author thanks the students and faculty who participated in

the peer reflection seminar and provided feedback during the

development of this article.

Declaration of interest: The author reports no conflicts of

interest. The author alone is responsible for the content and

writing of this article.

Notes on contributor

ANIRUDH RAMESH, BS, is currently a fourth-year medical student at Johns

Hopkins University School of Medicine. He is interested in pursuing a

combined Internal Medicine and Pediatrics residency program after

graduating medical school.

References

Lonka K, Slotte V, Halttunen M, Kurki T, Tiitinen A, Vaara L, Paavonen J.

2001. Portfolios as a learning tool in obstetrics and gynaecology

undergraduate training. Med Educ 35(12):1125–1130.

Neumann M, Edelhauser F, Tauschel D, Fischer MR, Wirtz M, Woopen C,

Haramati A, Scheffer C. 2011. Empathy decline and its reasons: A

systematic review of studies with medical students and residents. Acad

Med 86(8):996–1009.

Thomas PA, Goldberg H. 2007. Tracking reflective practice-based learning

by medical students during an ambulatory clerkship. J Gen Intern Med

22(11):1583–1586.

A. Ramesh

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