If empathy for patients declines in the course of a doctor’s training, can creative practice help redress the balance? Felicity James, Marianne Scahill-Pape, Lauren Gurr and Anna Hennessey report from a pilot study for fifth-year medical students.
The gallery is full of movement, colour, light. Deep blue, ochre, curving and swirling. This is Traces, an exhibition of wheelchair printing and giant mark making created by children and young people from Ash Field Academy school in Leicester, on show at Attenborough Arts Centre. Their large-scale artworks, installed alongside the work of contemporary artists, show how art can move beyond the perceived limitations of disability. These are works of pure pleasure in the creative process, which open art beyond access barriers.
We are responding to these works as junior doctors and creative teachers, asking what such art works might tell us about the doctor-patient relationship. At the Stoneygate Centre for Empathic Healthcare at the University of Leicester we have been exploring imaginative approaches to teaching empathy, and supporting young doctors to explore a range of creative practice. There is widespread agreement that empathy is a vital skill for young doctors, and it is now listed as an outcome for graduates in the requirements set out by the GMC (GMC 2018). But there is little consensus as to how it might be delivered within the curriculum, and a need to identify ‘the most appropriate pedagogical approaches or educational tools to nurture therapeutic empathy’ (Winter et al. 2023). There is also an uncomfortable awareness of its decline among medical students over the course of their studies (Howick et al. 2023; see also Neumann et al. 2011; Hojat et al. 2009). How can we not only nurture, but also seek to maintain, empathy?
Developing a creative curriculum for medical students
Staff from Attenborough Arts Centre, the Centre for New Writing at the University of Leicester, and the Stoneygate Centre for Empathic Healthcare, set out to understand what approaches and art-forms might be most effective both in helping students understand the experience of the patient, and in encouraging students towards developing and expressing their own creativity. We co-devised a six-week student-selected component (SSC) for fifth-year medical students at the University of Leicester, which ran as a pilot in summer 2024. Our curriculum included reading fiction and memoir, writing exercises ranging from haiku to short fiction, studio time, and experiments with different art forms: painting, sculpture and life-drawing. Alongside this, community placements allowed the students to participate in activities with patients as artists in a range of therapeutic settings, and the course culminated in a pop-up exhibition and creative anthology.
Each week had a different theme: ‘Hidden Stories’ included a placement at Headway, a charity which supports people living with brain injuries to engage with the arts; during our week on ‘Mental Health’, we read the work of authors ranging from John Clare to Stephen Bernard alongside a placement with Bright Sparks Arts in Mental Health Group at the Bradgate Mental Health Unit, and created our own literary and visual self-portraits. We considered different models of vicarious empathy, for example wearing an ageing suit; alongside this we engaged with patients in day therapy at Loros Hospice, using the arts therapeutically. We explored issues of ‘Access and Inclusion’ with a visit to Leicester General Hospital Geriatrics ward to take part in a Dose of Dance workshop with Helen Stirland and Sallie Varnam, which allowed patients in bed to participate in the benefits of dance and movement. Alongside these practical placements, we read poems by Dorothy Wordsworth (‘Thoughts on my Sickbed’ (1832)) and the activist Bethany Handley (‘I’m not advocating for all beauty spots to be tarmacked’ (2024)). Visiting the Traces exhibition, and creating our own response to this, allowed another insight into the experience of the wheelchair rider.
Creativity as an entry point into patient experience
Those dynamic wheelchair paintings are a good way into our central question of how we might communicate and empathise across boundaries. Empathy is often defined as learning how to ‘walk a mile in another’s shoes’. Yet this phrase in itself contains an aspect of othering. Indeed, this othering impulse has been identified as a key barrier to empathy (Shildrick 2000). What does it mean to walk a mile in someone else’s shoes when they may have complex access needs?
Part of the answer, we feel, might lie in the joy of creativity. The creative space is a place which allows medical students to access the patient experience in a different way. Encountering the non-verbal child through art, or meeting patients as poets in the hospice setting, resets the dynamics of the doctor-patient encounter. This fits with the findings of current research that ‘to truly enhance students’ empathy, medical education will require complementary ways of reflecting and teaching that creatively explore and challenge the nebulous and often frightening borderland between patient and physician’ (Shapiro 2008). The students reported that exercises such as writing creatively about specific clinical encounters had a deep impact on them and had enhanced their empathy. When asked to reflect on the course overall, the students reported that the stand-out experience had been taking part in creative practice alongside patients and encountering them as artists rather than in a clinical setting. They reported being deeply struck by seeing patients actively using poetry for therapeutic purposes, especially in the context of day therapy at the Loros Hospice. Creativity therefore seems to be an important pathway to empathy, most effective when, as Mercer and Reynolds advise, it is ‘embedded in the student’s actual experiences with patients’ (Mercer and Reynolds 2002).
We concluded that the course had several benefits: engaging imaginatively and creatively with patients allowed new insights into empathic healthcare; it also enhanced students’ communication skills through creative practice in different forms. Finally, it encouraged students to see creativity as a tool of self-care and well-being which they could keep practising in the long term, establishing habits which hopefully will continue through their careers. ‘Teaching empathy,’ as Jodi Halpern puts it, ‘involves not only specific verbal and nonverbal skills, but also, and most importantly, a change in medical culture, from emphasizing premature knowing and certainty toward maintaining curiosity’ (Halpern 2001, 158). Creativity, we suggest, might be an important way to help encourage and maintain that essential curiosity.
About the Authors
Felicity James is Associate Professor of Eighteenth and Nineteenth Century Literature and Creative Writing at the University of Leicester, working between the university’s Centre for New Writing and the Stoneygate Centre for Empathic Healthcare. Her academic specialism is Romantic literature, including the authors William and Dorothy Wordsworth and Charles and Mary Lamb, whose work she is editing for Oxford University Press; she is keenly interested in the ways in which their creativity engages with questions of health and empathy.
Marianne Scahill-Pape is a Creative Medicine Arts Associate, creative producer and gallery learning specialist; she has been working with Medical Students for 12 years as course leader for the SSC Disability and the Arts module for third year medical students at the University of Leicester, engaging with artists, activists and service providers with lived experience of disability. She also leads Learning and Outreach at Attenborough Arts Centre, working with thousands of children and young people, families, teachers and artists every year, and is co-founder and chair of SENsory Atelier – a dynamic programme for nine special schools in Leicester, exploring how the arts can be the language of learning for children with complex needs and disabilities.
Lauren Gurr and Anna Hennessey are students who worked with the Stoneygate Empathic Healthcare Centre as part of their fifth year SSC ‘Creative Medicine and Empathic Healthcare’. They both graduated with their MBChB in July 2024, and are now Foundation Year 1 Doctors at Tunbridge Wells Hospital in Kent.
References
General Medical Council. Outcomes for Graduates 2018. https://www.gmc-uk.org/-/media/documents/outcomes-for-graduates-2020_pdf-84622587.pdf
Halpern, Jodi. 2001. From Detached Concern to Empathy: Humanizing Medical Practice. Oxford University Press.
Hojat, Mohammadreza, Michael Vergare, Kaye Maxwell, et al. 2009. “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School”. Academic Medicine 84 (9): 1182-1191. DOI:10.1097/ACM.0b013e3181b17e55
Howick, Jeremy, Maya Dudko, Shi Nan Feng, et al. 2023. “Why might medical student empathy change throughout medical school? a systematic review and thematic synthesis of qualitative studies”. BMC Med Educ 23 (270). https://doi.org/10.1186/s12909-023-04165-9.
Mercer, Stewart W., and William J. Reynolds. 2002. “Empathy and quality of care.” British Journal of General Practice 52(Suppl): S9–12. Oct-Supp-Mercer-s9-s12.qxd (nih.gov)
Neumann, Melanie, Frederich Edelhauser, Dietrich Tauschel, et al. 2011. “Empathy decline and its reasons: a systematic review of studies with medical students and residents”. Academic Medicine 86 (8): 996-1009. DOI: 10.1097/ACM.0b013e318221e615
Shapiro, Johanna. 2008. “Walking a mile in their patients’ shoes: empathy and othering in medical students’ education”. Philosophy, Ethics, and Humanities in Medicine 3 (10). https://doi.org/10.1186/1747-5341-3-10
Shildrick, Margrit. 2000. “Becoming vulnerable: contagious encounters and the ethics of risk”. Journal of Medical Humanities 21: 215–227. https://doi.org/10.1023/A:1009025125203
Winter, Rachel, Andy Ward, Robert Norman, et al. 2023. “A survey of clinical empathy training at UK medical schools.” BMC Med Educ 23 (40). https://doi.org/10.1186/s12909-022-03993-5
I have taught medical students for many years, in pre-clinical, clinical and postgradaute capacities, and my conclusion about their loss of empathy during medical training is that they become emotionally overwhelmed with the vicarious trauma they witness, and emotionally close down to patients as a means for survival. This process is aided and abetted by more senior doctors who suffered, and continue to suffer, in the same way and who have not developed any other lesss destructive and more functional coping mechanisms. Until/unless addressing this becomes mainstream in medicine and given adequate attention and training in being able to witness suffering and not be traumatised, empathy loss will continue, regardless of these very worthwhile programmes you describe above.