Empathy

Towards more empathic medical students: a medical student

hospitalization experience
Michael Wilkes, Etan Milgrom & Jerome R Hoffman

Objective We designed a curricular exercise intended to

expose healthy medical students, near the end of their
basic science training, to the experience of hospitalization. We attempted to assess how a standardized hospitalization, for medical students just about to start
their clinical rotations, was experienced by student
participants.
Design A qualitative observational design was used,
both to explore the perceptions of the hospitalized
students and to generate hypotheses for further exploration.
Setting University and affiliated hospitals.
Participants Second-year medical students, towards the
end of their basic science training.
Outcome measures Qualitative assessment of hospitalization experience.
Results Among key themes expressed by student participants were the following: they felt a profound loss of
privacy; they found the nursing staff to be caring,
attentive and professional, and repeatedly commented

Introduction
As doctors focus more and more on science, technology
and health care economics, medical educators have
come under criticism for training doctors who are
without compassion or understanding of the human
condition.1,2 It has been suggested that a patients
organ system, pathology report or medical record
number and insurer seem to assume a more important
role than do the patients themselves.3 What can
teachers of medicine do to help ensure that the
physicians of tomorrow do not forget that behind
the curtain, at the end of the endoscope or inside the
Center for Educational Development and Research, UCLA School of
Medicine, California, USA
Correspondence: M Wilkes, Office of the Dean, University of California,
Davis, School of Medicine, Davis, CA 95616, USA

528

about how much time the nurses took to talk and listen
to them and to take a complete history; in contrast they
were particularly upset about the distance and coldness
they felt from the medical staff; they expect this
experience to affect their own future practice as
physicians. When asked how this might change their
attitudes in the future, students comments generally
reflected a primary concern with improving the human
aspects of the patient experience.
Conclusions Student participants in a standardized
inpatient hospitalization generally experienced strong
feelings about issues of privacy, and about interactions
with medical and nursing staff, which they expect to
have an important impact on their own professional
development.
Keywords Curriculum; education medical undergraduate, *methods; *hospitalization; patient satisfaction;
professional competence; students.
Medical Education 2002;36:528533

scanner, is a human being who thinks and feels and is

afraid?
Popular movies, such as The Doctor and Patch Adams,
have attempted to highlight the dehumanization which
all too often occurs in the realm of allopathic medicine.
But seeing such stories on the screen is not likely to be
enough to sensitize medical students to the difficulties
associated with a hospitalization. Too often, our medical curriculum focuses on disease processes and the
learning of skills (of diagnosis, assessment and management), and fails to focus on the patients themselves.
Through no fault of the medical students, the patient
assumes the status of his or her diseased organ system
(the clear-cell carcinoma in bed 412A) rather than a
human being with an illness.46
There is anecdotal evidence suggesting that when
physicians are themselves hospitalized they alter their
perspective in terms of the doctorpatient relationship.4

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Key learning points

An inpatient experience for healthy medical students results in commonly shared responses, about
both the nature of the hospitalization itself and the
interactive behaviours of health care providers.
Students exposure to physicians and nursing staff
had a dramatic impact on how they expect to
practise in the future.
Physician examiners, who were not aware that
these patients were actually healthy medical students, documented physical findings consistent
with the admission diagnoses.

Hospitalized patients routinely lose control over all

aspects of their lives. They are told when and what they
can eat, whether they can walk to the bathroom and how
much salt they can sprinkle on their overcooked pasta. Is
it important for a doctor to understand what it is really
like to be a patient in the hospital? When we write our
medical orders, do we really know anything about the
ordeal through which we are putting our patients?
We set out to design a curricular exercise which
would expose otherwise healthy second-year medical
students, near the end of their basic science training, to
hospitalization. Our intent was to assess whether a
standardized experience in the hospital, for medical
students, just prior to the start of their clinical rotations,
would affect their attitudes toward hospitalization. We
used a qualitative observational design, both to explore
the perceptions of the hospitalized students, and to
generate hypotheses for further exploration. In undertaking this exercise, we began by posing the following
questions:
1 Can such an experience help young healthy medical
students to understand the patients perspective?
2 What ethical concerns need to be considered in
designing such an intervention?
3 How do students perceive the experience in terms of
altered attitudes and knowledge acquisition?
4 Does this experience increase empathy?
5 Is there reason to think it will alter how students
interact with patients in the future?
6 What is the financial cost to the medical school of
such an educational intervention?

Methods
For reasons associated with logistics we decided to
provide a voluntary experience to as many medical

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students as possible. Once a curricular plan was

developed, the authors set about building broad support among various groups in the academic medical
community and in our hospital. Over the course of
months we met, often repeatedly, with students, members of the medical centre administration, including the
Hospital Director, the Director of Quality Assurance,
the hospital attorney, and the directors of the major
allied professional clinical departments (e.g. nursing,
social work, etc.).
At some point in this process the Hospital Director
endorsed our educational intervention, as did the other
administrators, and they agreed to provide financial
resources necessary to cover the cost of all hospitalization expenses for the student-patients. A student
informed consent document (available upon request)
was drafted to protect and inform students, and all
hospitalized students were required to sign it. We
pilot-tested the hospitalization experience with 3 thirdyear students, 8 weeks prior to the start of the secondyear curriculum . This allowed us to work out kinks in
the admission process, the relationships with the
attending physicians, and the survey instrument which
we would use to collect our data.
Given our desire to avoid using services which might
be needed by actual patients, we decided to limit the
hospitalization to 9 students. We planned to admit
three students early in the day on 3 consecutive
Saturday mornings, with discharges planned for the
following (Sunday) afternoon, 2430 h later. In this
way the students would stay over Saturday nights
traditionally the night of the week with the lowest
hospital census (although this still averaged around
78%). All students without any previous personal
history of hospitalization were offered the option of
participating, and students were offered neither extra
credit nor any other incentive. The names of the 9
students who would be hospitalized were then drawn
randomly out of a hat from among those of the 48 who
volunteered (out of a class of 144).
In order to improve the chance of a realistic hospitalization experience, pains were taken to ensure that only
the Director of Hospital Admissions, the Director of
Nursing, and the attending physician for each participating service knew the students actual non-patient status.
Eight of the nine attending physicians kept the students
status concealed from their medical team of residents and
interns. One attending physician felt that keeping such
information to himself was deceptive, and he chose to tell
his medical team that the patient was actually a student
being admitted for a school experiment.
None of the selected students had ever had an
overnight stay in the hospital. Students were given

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pseudonyms, as well as one of 3 presenting complaints

(see below), and were coached prior to the hospitalization about how to portray appropriate symptoms. The
hospital administration provided the students with an
overview of what to expect during the admission process,
as well as a reminder that their care would be provided by
the usual hospital teams. The nature of hospital care was
not described to them. Students were also advised that
they had the right to decline any procedure or treatment
that was more aggressive than the placement and
maintenance of an intravenous line and phlebotomy
for basic laboratory studies.
The hospitalized students were randomly divided
into 3 groups. Each group of three students was
admitted on a different Saturday morning over
several weeks, to a different medical service. The 3
admissions on each individual Saturday were staggered over several hours to avoid raising suspicion
and to avoid shifting hospital resources away from
actual patients. The 3 presenting symptom complexes
were as follows:
1 acute intractable lower back pain with left lower
extremity weakness and numbness, status post motor
vehicle accident, with a right femur fracture stabilized
in a full leg cast at a local community emergency
department;
2 dehydration secondary to nausea, vomiting, and
diarrhoea in an HIV-positive patient, and
3 acute loss of consciousness for several minutes
following head trauma secondary to a fall from a ladder.
Students were admitted directly by the attending
physician on each service, and processed through the
admissions office rather than through the emergency
department (to prevent unnecessary utilization of
resources). Once admitted, to either the internal
medicine or family medicine services, students underwent history taking and physical examination by house
officers, who could order whatever tests they deemed
appropriate, according to standard practice. Students
were gowned in the usual hospital attire; placed in
standard hospital beds, with monitoring if ordered; only
allowed to eat the usual hospital food, and encouraged
to comply with admitting orders such as strict bed rest
or nothing by mouth.
On Sunday afternoon, following discharge, all students met with 2 faculty members (EM and MW) for a
debriefing and to evaluate the project. All students
completed a 21-question written survey instrument. In
addition, students were asked to participate in a formal
discussion with the entire second-year class of students.
Although students were not financially responsible for
their hospital stay, they all received representative bills
for the services provided.

Results
Seven admissions went according to plan. In 2 cases
there were problems with the admissions process. In the
first case, the admissions office would not admit the
student because they had no documentation of insurance coverage. In the second, the admitting team felt
the student should actually have been admitted to the
surgery service, and therefore sent the student to the
emergency department in the hope that the patient
would be placed on a different service. In both cases the
faculty supervisors intervened to rectify the situation.
There was substantial uniformity in the work-ups done
for each clinical scenario. All 3 students with back pain
and lower extremity numbness underwent magnetic
resonance imaging (MRI). All three students with mental
status changes were placed on a monitored bed, had a
head computed tomography (CT) scan and received
neurological checks every 2 hours. All those admitted
because of dehydration received intravenous fluids.
Student perceptions

Comfort
In the questionnaires completed at discharge, all
students reported that the hospital rooms were clean.
At the same time, all commented that the rooms were
cold, austere and sterile.
Seven students reported discomfort about having to
share a room with a stranger, and having to listen to
their roommates every move or statement. They found
their sleep extremely disrupted by technological gadgets, TVs, hallway noise and people (patients?) yelling
from other rooms. When asked what surprised them
most about the hospital stay, most expressed the feeling
that it would be very difficult actually to be sick while in
the hospital. Typical comments included:
It was exhausting and difficult. I actually felt sick and
tired by the end of the stay.
It was strange how sick I actually felt after one night
in the hospital.
When asked what made them most uncomfortable while
being a patient in the hospital, most of the students made
comments concerning the uncertainty about the process,
and the slow pace with which things were accomplished.
The following comments are representative:
Not knowing what was going on or when, why or
what was going to happen to me next. I would be told
I was going for a scan in a short period and then
hours later I would still be sitting in my bed waiting.

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No one ever told me what they were doing or why.

I was bored to tears. I longed for someone to come in
to the room to talk to me. Anyone I just was so
bored. I was thrilled when the hospital dog came in to
see me, and I dont even like dogs!
Interactions
The students most favourable ratings were given to
members of the nursing staff, whom the students found
to be caring, attentive and professional. Five commented about how much time the nurses took to talk and
listen to them and take a complete history. In contrast,
four students were particularly upset about the distance
and coldness they felt from the medical staff. Two
complained that the radiologist in the MRI suite was
non-communicative, and made no effort to comfort or
even explain the procedure to the student. Typical
comments included
The residents tended to stand far away from me, at
the foot of the bed, talk rapidly and walk toward the
door even before they finished speaking.
I was ignored by the residents.
I was ignored by the doctors while the nurses seemed
to really care.
No doctor ever asked me how I felt, rather they asked
me about this body part or that.
I was ignored by the doctors from 7 p.m. to 7 a.m.
even when the nurses called them they never
answered. The nurses tried their best to comfort
me but were obviously frustrated with the doctors but
they never complained or put down the doctors.
I was impressed at how persuasive the nurses can be.
I actually agreed to have a Foley catheter inserted. I
cant believe I did that. It was not a required part of
the experience but I decided to go ahead. The nurse
did such an great job explaining it, and she reassured
me so well that I didnt have the heart to tell her I
didnt want the procedure. It actually wasnt that
bad, but I wouldnt want it again.
Privacy
Several students commented on how awkward it felt to
have a group of residents come in for rounds. Most
students referred in some way to the awkward nature of
hospital gowns and the difficulty of sharing toilets.
Some students referred to compromising or embarrassing situations. For example, one male student described being confined to a bed and being forced to use a

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urinal. He had great difficulty urinating when others

were in the room and it always seemed there was
someone around. After he had finally urinated (in a
supine position), he spilt the contents all over himself,
requiring a complete change of attire and bedding.
Other comments included:
It felt so intimidating to have them all examining
me at once; all trying to feel my abdomen. I felt
invaded.
When I was questioned by the doctors about my
history and my family history my roommate could
hear all my answers. The doctor then examined me
so that my roommate could see every part of me.
Another student, with a supposed head injury,
described being wheeled down to the CT suite by a
hot-rod gurney driver.
When I finally arrived in the CT suite I felt as if I had
real head and back injuries from the gurney ride. We
must have smashed into six walls and rammed our
way through three double doors. When he wheeled
me into the elevator I was surrounded by 8 or 10
people who were so physically close to my face that I
felt my space totally invaded.
Impact of the experience
When asked how this experience might change their
attitudes in the future, students comments generally
reflected a primary concern with improving the human
aspects of the patient experience. Typical comments
included:
I think communication is the key. Be compassionate
and attentive to possible patient concerns. Patients
need to be told what doctors are doing and when
delays occur you need to tell patients why the delays
are occurring.
Communication is important. So is respect. I would
tell them when I would drop by and then make sure I
keep to that schedule. I would use please and may I
a lot more than they do.
I would pay attention to details like noise in the halls
and privacy.
I will try to check on my patients several times a day.
Improve the food! How can you get better with that
type of food?
Try to develop remote vital sign and IV fluid
monitors so the nurses dont need to come in and
keep waking me up.

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Someone ought to invent an IV machine that doesnt

beep and keep beeping in your ear all night every
time there is a tiny problem. The beeping drove me
crazy.
I will sit down and talk to the patient rather than
standing up and having them crank their necks up to
see me.

Controversy

The curricular intervention created a number of concerns. Two students expressed hesitancy about fooling
the busy and overworked house staff. However, the
student who had been hospitalized on the unit where
the attending physician insisted that all members knew
he was a student reported a very different hospitalization experience from the others. For that student, the
nurses were attentive (they did not know the status of
the surrogate patient), but the physicians came in to his
room joking, at the time of his admission, and then did
not return to see him until the time of discharge. That
student reported that his experience was much less
meaningful than that of the other students.
There were some problems with unexpected truepositive and false-positive findings turned up by the
evaluation. At a forumdiscussion, conducted by the
student participants for the entire second-year class,
several weeks after the hospitalization, one of the
hospitalized students commented:
I was surprised when I read the admission note after I
was discharged. I couldnt believe how many false
physical findings those that werent present the
residents found. I was admitted with supposed
dehydration and it seemed the house staff found
every classic finding described in the book for
someone with dehydration poor skin turgor,
orthostasis, flat neck veins, and dry mucus membranes. In fact, I was perfectly normal.
Another student, who had a supposed head injury,
was placed in a monitored bed. He proceeded to have
multiple premature ventricular complexes (PVCs) in
couplets (11 per minute). The cardiology department
was consulted and action was underway to transfer the
student to the coronary care unit until the service
attending physician, who was aware of the exercise,
interceded.

Discussion
This paper describes a curricular intervention, which
seemed to have had a great impact on the participating

students (and, by word of mouth, may well have had a

substantial impact on the second-year class as a whole).
While it would have been ideal to hospitalize many
more of the second-year students, this was not feasible
for reasons of both cost and logistics. Despite this, we
have gained some understanding that allows us to
derive formative answers to several of our research
questions. It does seem possible to provide young
healthy medical students with a better understanding of
the patients perspective. While, of course, we cannot
reproduce the pain or worry which accompany being a
patient, this experience seems to have promoted
heightened sensitivity among participants to the experience of real patients. We are unable to assess whether
this new awareness will have any long-term impact on
the patient care provided by the participants, however.
The charge for the intervention was about $1600 per
student, but it is difficult to assess actual cost. We
recognize that this project would involve using a small
amount of health care resources for educational rather
than directly medical goals. Nevertheless we feel this is
justified, for a number of reasons. First of all, we
arranged the project so that no real patient would go
without any needed service, and no delays in care
would result from the presence of our student patients.
Secondly, in terms of resource utilization, the amount
spent was trivial compared with either the operating
costs of our hospital or the budget of our medical
school. Given the amount spent on other educational
programmes, many of which, we would argue, have
substantially less educational value (histology laboratories, lectures on the life-cycle of parasites, etc.), we
believe that the money allocated for this exercise was
well spent.
While acknowledging concern about the ethics of
deceiving house staff, nurses and others, the students
nevertheless felt this was justified, in order to attain
educational value from the experience. (We note that
the student whose team knew his actual status reported
that he had learned almost nothing from participation.)
Furthermore, students stated that they would not mind
if roles were reversed, in the future, and they themselves
had to spend time admitting patients who were not
genuine, for a similar educational purpose. Nonetheless, the question remains whether such deceit is
justified in the interest of a worthy goal. It might be
valuable for house officers to hear feedback from the
students, both in the hope that this could help improve
some aspects of the quality of care they provide, but
also so that they could understand the benefits that
accrued from their unknowing participation. We also
speculate that if more students had the chance to
participate in an event like this (or watch their class-

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mates participate), they might well be less likely to

resent taking part in the future as house officers.
The documentation (in 7 out of 9 cases) of physical
findings expected on the basis of the presenting
symptoms, even though they were not actually present,
is of concern, if not entirely surprising. It is well known
that clinical thinking is affected by pre-formed biases,
but the degree to which this was observed in this
exercise needs to be addressed further by faculty
responsible for supervising house officers.
The hospitalized students reported, both in anonymous written questionnaires and in oral presentations,
that their attitudes and knowledge about hospitalization
were significantly changed in a manner which gives
them confidence that they will be far more empathetic
to patients than they might otherwise have been. It is
possible that this belief simply reflects a desired
response set (if I gave up all this free time, and did
without sleep for an entire night, surely I will be better
because of it)? It is also uncertain whether these
students who have experienced hospitalization will, in
fact, be more empathetic or more compassionate about
hospitalization issues.
The differences between the interpersonal skills of
nurses and physicians, as perceived by the student
participants, is striking. Although this may to some
extent reflect the rigours of an academic training
programme, it was an eye-opener for students to see
how poorly physicians performed in this respect. We
believe this gave the students even greater appreciation
of their experience, and that it underlines the need for
better training of physicians, at all stages of their
careers, in the areas of humanism and doctorpatient
communication. We further believe that this affirms the
potential value of exercises like this one.
Despite the limitations inherent in a situation where
healthy volunteers underwent only limited diagnostic or
therapeutic interventions, and in the absence of real
pain or anxiety over illness, the experience was positively received by the students themselves. (Anecdotal
reports from house staff, patient advocates who served
as consultants, nursing staff and the hospital administration were also highly supportive.) We cannot be
certain that this intervention will change behaviours, or
justify its cost. Nevertheless it is apparent that the
hospitalized students (and their classmates) were affected by the experience, and we are planning both to

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make it available to more students, and to evaluate

formally its impact on subsequent studentphysician
behaviour, both in the short and long term.
We conducted the intervention prior to the end of the
second year, before the students had had any meaningful inpatient experience. It may be that providing
this experience at a later time, perhaps in the middle of
the clerkship year or late in the fourth year, prior to
starting internship, would be more productive. It is also
worth exploring whether there are less expensive ways
to accomplish the same goals.

Contributors
MW planned and ran the exercise, gathered and
analysed the data, and wrote the manuscript. EM
planned and ran the exercise, gathered data and helped
write the manuscript. JH gathered and analysed data
and helped write the manuscript.

Funding
The project was funded by UCLA School of Medicine.

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Received 15 October 2001; editorial comments to authors 2 January
2002; accepted for publication 4 March 2002

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