Shaishav Datta,1 Wafa Khoja,2 Meera Dalal-Burns 3
1Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; 2School of Medicine, Queen’s University, Ontario, Canada; 3St. Michael’s Hospital, Ontario, Canada.
Compassion and empathy are integral qualities in a good physician. Empathy is a multidimensional construct conveyed through verbal and non-verbal expressions, such as sustained eye contact, careful listening, embodied experience, and tactile contact.1 Both the quality of clinical communication with patients and patient wellbeing are improved when patients interact with physicians whom they perceive as empathetic.1,2 Thus, a physician’s ability to build a strong, therapeutic relationship is grounded in their repertoire of non-verbal skills. But how are these skills taught? While the vast majority of our medical curriculum is knowledge-based, clinical conversation skills are developed through practice and experience during clinical skills teaching sessions. Among other challenges raised by the COVID-19 pandemic, pre-clerkship medical students lacked some of their only opportunities to learn the critical nuances of the art of effective communication with patients during the 2020-2021 academic year. While we have established creative ways to take most of our learning online, pre-clerkship medical students may be missing crucial experiences to develop skills at the very core of what makes a good physician.
Now third-year students across the country experienced an abrupt end to in-person clinical skills sessions beginning in March 2020, while many now second-year students had their very first patient interactions over video-conferencing platforms. As we learned the skills of expressing appropriate empathy, it has been difficult in many ways to display these multidimensional emotions through a two-dimensional screen. Even for those of us who have had experience with patient interactions in the past, we have noticed a stark increase in awkwardness in learners as well as Standardized Patients (SPs). Non-verbal actions that display empathy, such as touch, were no longer possible and left many of us unable and untrained on how to express empathy. It was challenging to read the intricacies of body language and create a welcoming and comfortable environment online, particularly when technological difficulties occur.
Below we provide some of our experiences as first- and second-year medical students in Ontario during the 2020-2021 academic year.
During one of our few in-person clinical skills teaching sessions, I recall instinctively placing my hand on the shoulder of the SP while adjusting my stethoscope to listen for the mitral valve. After the examination finished, the SP remarked: “Of all the things you did during this session, I really appreciate you placing your hand on my shoulder during the physical exam. It made me feel comfortable and showed that you care about me.” This taught me a valuable lesson about the importance of touch in providing empathetic care. While it seemed so natural in person, this is a difficult skill to learn or practice over virtual sessions. – Wafa Khoja
I recall a virtual session on ‘How to break bad news’ with an SP. Throughout our heartfelt conversation in which I told them about their terminal illness, I kept thinking to myself how I wished I could have held their hand or passed them a tissue box. Even though this was a simulated experience, I walked away shocked at the restraints that virtual platforms placed on my ability to deliver empathetic care. I especially found it difficult to gauge the patient’s emotions and read their body language through the screen, and as a result it became very hard to connect on a deeper, more humanistic level. – Shaishav Datta
Over time, as virtual care becomes the norm and we focus more on verbal communication, will we lose our ability to communicate non-verbally? Even now, as my classmates assess their SPs virtually, our communication styles are notably different from our senior colleagues. How will the under practiced skills of eye contact, body language, and reassuring gestures affect current pre-clerkship students in our upcoming training; clerkship and onwards?
Unfortunately, this concern regarding virtual clinical skills training is widespread. A December 2020 survey of second-year medical students at the University of Toronto showed that more than 50% of students did not feel that they had the necessary clinical skills needed to start clerkship.3 This feeling of unpreparedness was directly attributed to the virtual clinical skills curriculum due to COVID-19.3 Many expressed concerns regarding the skills they lacked relating to clinical encounters with patients, including expressions of empathy and compassion.
What is in store for this COVID-19 generation of physicians and how does it affect the profession as a whole? Non-verbal skills are mastered through practice and as an ensemble, comprise the underpinnings of a competent physician in the 21st century. They are qualities actively sought out by admissions committees that are now being omitted from teaching curricula because of the limitations of virtual medicine. During the COVID-19 pandemic, pre-clerkship students have been wholly excluded from in-person clinical settings for public-health reasons. Our lack of experience with expression of these emotions and the current way in which we are learning to communicate effectively through virtual means is likely to make the transition to clerkship difficult and uncomfortable for us and the patients we encounter. While we will hopefully recover and build these skills over the course of our training, it is prudent to consider the extent to which these forms of communication are being undervalued in virtual teaching.
We are grateful that medical school faculties have tried to provide pre-clerkship students with the best possible teaching and skills while adhering to public-health guidelines during the pandemic. Some schools adopted creative and expedited methods to deliver clinical skills training to students. For example, the University of Toronto offered an expedited preparation for clerkship “bootcamp” for current second-year students during the summer of 2021. Alternatively, Queen’s University created a system to permit limited in-person clinical skills sessions within small groups. Schools in other provinces across the country also developed strategies that are in compliance with the COVID-19 guidelines in their respective locations. Despite this, we ask you to consider: Is this enough? Will vastly online clinical skills training affect the ability of current pre-clerkship students to competently maneuver clerkship, residency, and future career? These are important questions that we as a medical community must consider to be potential side effects of the COVID-19 pandemic and must answer to prepare for future pandemics.
- Kelly M, Svrcek C, King N, Scherpbier A, Dornan T. Embodying empathy: a phenomenological study of physician touch. Med Educ. 2020;52(5):400-407. https://doi.org/10.1111/medu.14040
- Cocksedge S, George B, Renwick S, Chew-Graham CA. Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions. Br J Gen Pract. 2013;63(609):e283-e290. https://doi.org/10.3399/bjgp13X665251
- Kao J, Chan T. COVID FAQ Survey: A Review of Student Responses [unpublished data]. Toronto (ON): University of Toronto; 2020.