title: Empathy decline and its reasons: a systematic review of studies with medical students and residents.
abstract: OBJECTIVE
  Empathy is a key element of patient-physician communication; it is relevant to and positively influences patients' health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency.
  
  
  METHODS
  The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size <30 were excluded.
  
  
  RESULTS
  Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the "hidden," "formal," and "informal" curricula as main reasons for empathy decline.
  
  
  CONCLUSIONS
  The results of the reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.
authors.affiliation: Integrative and Anthroposophic Medicine, Faculty of Health, Department of Medicine, University of Witten/Herdecke, Germany. melanie.neumann@uni-wh.de
authors.forename: Melanie
authors.initials: M
authors.lastname: Neumann
authors.forename: Friedrich
authors.initials: F
authors.lastname: Edelhäuser
authors.forename: Diethard
authors.initials: D
authors.lastname: Tauschel
authors.forename: Martin R
authors.initials: MR
authors.lastname: Fischer
authors.forename: Markus
authors.initials: M
authors.lastname: Wirtz
authors.forename: Christiane
authors.initials: C
authors.lastname: Woopen
authors.forename: Aviad
authors.initials: A
authors.lastname: Haramati
authors.forename: Christian
authors.initials: C
authors.lastname: Scheffer
mesh_terms: D002983:Clinical Competence; D003479:Curriculum; D004645:Empathy; D006801:Humans; D007396:Internship and Residency; D013337:Students, Medical / Q000523:psychology*