Many medical students enter training motivated by science, service and a desire to care for patients with compassion in their most vulnerable moments.
As medical training progresses, however, research suggests that empathy levels ebb and flow, with the most demanding periods sometimes making it harder for medical students to stay connected to the human side of care.
When do medical students most frequently experience dips in empathy levels? How can they maintain perspective and retain focus on their altruistic reasons for pursuing a career in medicine? Recent study data and insight from a medical school dean offer insight on those questions.
Medical student empathy trends
For a study published in the journal International Medical Education last summer, researchers examined cognitive empathy, compassion, self-compassion and resilience among 98 medical students across all four years of training. Their findings suggest that empathy-related traits come under the greatest strain during the second and third years of medical school.
Across all four years, the study points to a broad pattern in which empathy-related traits appear more intact at the start of medical school, come under greater strain in the second and third years, and then rebound somewhat by the fourth year.
The study’s authors noted that while traditional narratives in medical education have held that empathy dips are most pronounced during the third year, the second year may also be a key pressure point.
Step prep, clerkship rotations and empathy dips
The study found that self-compassion and cognitive empathy levels were lowest among second- and third-year medical students.
Mark Meyer, MD, is senior associate dean for student affairs at the University of Kansas (KU) School of Medicine. He said those patterns are familiar to medical educators.
“The high point of empathy and compassion is at the start of medical school. As identified in the study, it begins to drop as early as the spring semester of first year, and it continues into year two,” said Dr. Meyer, an AMA member.
Traditionally taken at during the second year of medical school, Step 1 of the United States Medical Licensing Examination (USMLE) series is a major milestone and potential stressor for second-year medical students. Though first-attempt pass rates are above 90% and the exam has been scored as pass-fail since 2022, the run-up to taking the test is intense, and the stakes of a potential setback loom large.
In the weeks after taking Step 1, medical students are usually making the transition to their core clinical clerkships. That shift comes with increased patient exposure, longer days and increased responsibility.
“The shift to clinical medicine in the third year is rigorous and unfamiliar,” Dr. Meyer said. “It’s chaotic at times, and schedules are highly variable. You’ll work overnights and weekends and that causes fatigue at every level.”
Learn concrete actions that help medical students navigate the challenges of their educational experiences in the AMA STEPS Forward® toolkit, “Medical Student Well-Being: Minimize Burnout and Improve Mental Health Among Medical Students.”
The fourth-year rebound
The study also found that empathy-related measures appeared to rebound in the fourth year of medical school.
“Fourth-year med students know what they are going for,” Dr. Meyer said. “They are applying to residency and doing rotations in fields they want to go into. That is a shot in the arm.”
The post-Match period can often be a high point for medical student well-being, Dr. Meyer said. But that does not mean the years ahead are easy.
“As you go through residency into practice, you will have several transition points that can be demanding,” he said. “But as a career progresses, there are fewer surprises and physicians get to invest more time in their life outside of medicine, and things do tend to stabilize.”
The University of Kansas School of Medicine is a member of the AMA UME Curricular Enrichment Program, which provides on-demand education through a micro-learning approach to help medical students distinguish themselves for residency and succeed in medicine. Educators can assign specific elements such as health care business fundamentals and developing leadership skills and receive reports on student progress, track via a dashboard, send reminder emails and customize reports. Schedule an introductory call now.
How medical students can maintain empathy
Dr. Meyer said efforts to maintain medical student well-being should start at the intuitional level.
At KU, that work begins during orientation, when students are introduced to some of the stressors they may encounter throughout medical school. The medical school also offers faculty coaching and group coaching to help students process challenges, and it builds structured activities such as social outings and community service into the academic calendar.
In offering guidance on what students themselves can do to protect their well-being, he pointed to basics that can be easy to neglect during demanding stretches of training.
“It sounds a bit trivial, but proper diet, physical activity if not actual exercise and getting adequate sleep, these things matter,” he said. As does “doing things in and outside of medicine to bring an individual joy or a sense of connectivity. That could be service activities or prioritizing time with family and friends.”
The habits medical students form can help them navigate turbulence when it arises long beyond their time in training.
“The goal is to give students “the wellness toolbox and skills that will serve them well throughout a decades-long career,” Dr. Meyer said.
The authors of the International Medical Education study noted the early nature of the findings. They plan to explore, with additional longitudinal data, how the introduction of empathy and compassion courses incorporated throughout medical school affected the empathy and compassion trajectory. The study was conducted at the University of California, San Diego, School of Medicine and supported by T. Denny Sanford Institute of Empathy and Compassion.
