Can simulations measure empathy? Considerations on how to assess behavioral empathy via simulations

https://doi.org/10.1016/j.pec.2008.01.003Get rights and content

Abstract

Standardized patient simulations have been used as an assessment tool, providing teachers an opportunity to observe learner clinical and communication skills while eliminating the fear of harm to patients. Yet the vices and virtues of these simulations in measuring clinical and communication skills have been deliberated. Based on our standardized patient examination experience, we believe standardized patient simulations can be used to assess certain forms of learners’ empathic behaviors. We advocate that, in properly designed and conducted simulations, the scores and feedback comments from standardized patients to learners regarding their empathic behaviors can identify learners with important deficiencies. We conclude our discussion by recommending that reflective practice, challenging cases, decision moments, and raters training to provide feedback can supplement and enrich the use of standardized patient simulations in evaluating empathy.

Introduction

Simulations in medical education were introduced to provide learners with opportunities to practice and perfect their skills [1]. One of the most frequently used simulations for interactions with patients is standardized patients. These standardized patient simulations provide teachers with an opportunity to observe and assess learner clinical and communication skills while eliminating the fear of harm to patients [1], [2]. The vices and virtues of these simulations in measuring clinical and communication skills have been deliberated. These deliberations are justified as no single assessment in medical education has been or should be used to measure the many different intra- and inter-personal competencies (i.e. skills, knowledge, and attitude) [3]. Wear and Varley [4], along with others [5] challenge us to think about the measurement of empathy during standardized patient simulations. Their concerns are threefold: Do simulations elicit a performance just for “positive evaluations” versus heartfelt empathy and consideration for the patient? Do simulations measure only the most basic manifestations of empathy? And if so, in keeping with the age-old adage that assessment drives teaching and learning, will the assessment of this rudimentary form of empathy perpetuate a minimum standard of empathy in practice?

We acknowledge the concerns expressed by Wear and Varley and endorse that empathy should be measured by more than one assessment method. However, based on our standardized patient examination experience, we believe these exams can be used to assess learners’ empathic behaviors. We advocate that, in properly designed and conducted simulations, the scores and feedback comments from the standardized patient to learners regarding their empathic behaviors can identify learners with important deficiencies. At the crux of our argument is that standardized patients and effective standardized patient training can reproduce a real patient's experience of empathy. Empathic behaviors are intertwined with communication skills [6] and thus in crafting our arguments, we draw from findings in both domains.

Before focusing on our recommendations, we will address two key issues surrounding the measurement of empathy during simulations. The first issue is “test-wiseness.” Test-wiseness is the learner's ability to become acquainted with an exam and use the characteristics and format of the exam to earn a high score [7]. In simulations, it is perceived that what the learner learns is how to act and respond to a patient, without experiencing any feeling for the patients. Perhaps reassuringly, the most experienced learners do not perform better on measures of communication, a skill area related to empathy, on simulations than those with moderate amounts of experience [7], [8]. These findings negate the notion that the learner who has taken the exam enough can simply go through the motions of communication (rather than engaging emotionally with the patient) to score higher.

The second issue is social desirability exhibited in simulations. Learners may modify their behaviors during simulation simply due to being observed. However, in any setting, a learner may say what she/he thinks an observer wants to hear. Thus simulations are not prone to social desirability any more so than other observed assessment situations such as those in the presence of an attending with a real patient.

To move beyond these issues and address how to assess empathic behaviors in simulated encounters, we draw upon three prevailing, closely related theories of empathy. Larson and Yeo [9] view empathy as a form of “emotional labor” requiring surface and/or deep acting. Surface acting is the intentional display of emotions such as care and interest without actually feeling those emotions. Deep acting involves internally altering one's emotions to reflect those of the patient. Because it is not always reasonable to expect physicians to modify their emotions, Larson and Yeo argue that surface acting alone can foster therapeutic relationships by making the patient feel validated. Surface acting is a consistent series of measurable behaviors while deep acting is less outwardly measurable that involves the cognitive and affective aspects of empathy. Similarly, Stepien and Bauerstein identify four forms of empathy [10]. These forms are characterized by the physician's ability to:

  • (1)

    imagine the patient's emotions—emotive empathy;

  • (2)

    empathize with the patient—moral empathy;

  • (3)

    identify the patient's emotions—cognitive empathy;

  • (4)

    convey an understanding of the patient's emotions back to the patient—behavioral empathy.

Surface acting and behavioral empathy are the outward display of empathy. This outward display is critical because it focuses attention on the patient. The physician thus becomes attuned to the patient's perspective and emotions to focus on what is meaningful to the patient [11].

Taken together, these theories suggest that clinical empathy requires display of care and interest, careful listening, and flexibility on the part of the physician to determine patients’ needs and provide care to meet those needs. The overt form of empathy, which is behavioral empathy or surface acting, is a critical step in the provision of care. We contend that simulations, at minimum, can measure behavioral empathy or surface acting. Well crafted simulations can also assess the learner's attunement to the patient and subsequent revelations by the patient, and most importantly, the ability of the physician or learner to acknowledge and address those concerns.

Section snippets

Behavioral empathy and simulations

Simulations can identify learners who reveal the basic skills characterizing behavioral empathy. If during simulations the learner can develop rapport, ask relevant questions clearly, listen and respond carefully and take appropriate clinical actions for the patient [12], then the learner has demonstrated the skills that should be habitual in any clinician's practice and represent behavioral empathy or surface acting. Assessing surface acting is not necessarily assessing minimum (or sufficient)

The role of standardized patients and standardized patient trainers in simulation

In properly designed and conducted simulations the feedback to learners from standardized patients can be valuable. Standardized patients should be trained not only to ensure that the student asks the appropriate history-taking questions and conducts the right physical exam, but also to report on the personal aspects of the encounter from the perspective of the case patient. When doing the latter, standardized patients provide results to the learner that reveal whether the patient's emotions

Enrichment of simulation use

We believe that surface acting is important to assess and carefully crafted simulations can measure multiple forms of empathy. Yet, it remains important to consider how the evaluation of empathy can be enhanced and how other measures of empathy such as the cognitive and emotional can be further developed. Incorporation of other assessments during simulations can augment measurement of individual empathy. Reflective practice, challenging cases, decision moments, and rater training on how to

Discussion and conclusions

Empathy is an essential part of patient care. If educators decide that empathy is not measurable via simulations, then the discovery of ways to assess it during simulations will loose momentum. This nihilism will in turn perpetuate the idea that learners do not need to consider their empathic behaviors during simulations. The measurement of empathy should be pursued during all forms of assessment that include patients. The use of simulations to teach and to measure learner skills is commonplace

Acknowledgement

We gratefully acknowledge our standardized patient trainer, Bernie Miller, whose creativity and relentless energy have provided us with quality standardized patients profoundly aware of the depth of feedback they provide.

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