gms | German Medical Science

Empathy is considered a vital aspect of good and effective communication, one of the cornerstones of high quality health care [1], [2], [3], [4], [5], [6], [7]. According to Mercer and Reynolds, empathy “involves an ability: (a) to understand the patient’s situation, perspective and feelings (and their attached meanings); (b) to communicate that understanding and check its accuracy; and (c) to act on that understanding with the patient in a helpful (therapeutic) way” [1] p. S11. The prominent position empathy has come to take in health care is supported by studies conducted in recent decades which have empirically demonstrated positive associations between physician empathy and better health outcomes, such as:

• greater patient compliance and satisfaction [8], [9]
• enhanced patient enablement and coping [8], [9]
• better exchange of information between physician and patient [8], [9]
• improved accuracy and ease of diagnosis [8], [9]
• better physical and psychological health [8], [9]
• improved metabolic status in diabetic patients [10]
• shorter duration and a less severe course of the common cold [11]

Studies have also shown physician empathy to lead to a lower likelihood of self-reported medical errors [12] and possibly to more efficient resource utilization [13]. Other investigations have linked medical student empathy to better patient assessments of history taking and clinical examination [14] and to better global clinical performance ratings [15].

As a result of these findings, professional organizations in several countries now include empathy as an aim of medical education [16], [17], [18], [19], [20]. Studies have, therefore, also been conducted to explore the development of and changes in empathy during medical education. In a systematic review, two of this article’s authors and their colleagues identified 18 such studies, 16 of which reported a statistically significant decline in the self-assessed empathy of medical students and residents during their education [9]. Two of the significant factors observed to influence this decline were student and resident distress and entry into the clinical practice phase of study.

Despite the number of studies finding medical education to influence empathy, few have involved an in-depth, qualitative investigation of the specific aspects of medical education that either promote or inhibit empathy. Fewer still have examined these factors from the perspective of students from different medical schools [21]. In our narrative MEDLINE search conducted via MEDPILOT (http://www.medpilot.de) on September 19, 2013, using the syntax (empathy OR compassion OR sympathy) AND (medical AND education) AND (doctor* OR physician* OR student*) AND (opinion* OR view* OR perspective* OR (empirical AND research) OR (data AND collection) OR (qualitative AND research)) we found only four studies examining students’ perspectives on the determinants of empathy or compassion. Three of these were conducted in the United States [22], [23], [24] and one was from the United Kingdom [25].

The most important findings of Wear and Zarconi’s [22] study were that role models and a lack of opportunity for reflection on experiences have the greatest influence on student compassion. According to the study by Winseman et al. [23], the factors reportedly having the greatest influence on empathy were “mentoring and clinical experiences that promote professional growth” and “personal connections, experiences, and beliefs” [23] p. 486. While the students interviewed in Tavakol et al.’s [25] study stated that a lack of clinical practice and personal factors, such as pressure, exhaustion, and intellectual detachment, are barriers to their empathy, they mentioned that it is helpful to receive training in physician-patient interaction. Afghani et al. [24] reported that lack of time and few positive role models were barriers to student empathy and that students need more training in dealing with “difficult” situations, such as breaking bad news, and in dealing with demanding patients. The findings of these four studies are consistent with the research of Lynn et al. [26], who found that clinical practice, self-reflection and role modeling foster student empathy whereas a biomedical focus, a lack of time to reflect and a lack of role models hinder it.

To the best of our knowledge, no studies have examined the promoting and inhibiting factors of empathy from the perspective of medical students in Germany or the influence of different curricula on medical student empathy. Since qualitative methods are especially suitable for exploring areas that have received little research attention [27], [28], we designed a qualitative, hypothesis-generating study aimed at determining:

1.

what educational elements and situational factors German medical students perceive as promoting or inhibiting their empathy toward patients, and

2.

how their perspectives are associated with differences in medical curricula.

In the study, we conducted a qualitative short survey (QSS) [29], [30] using a short, anonymous questionnaire with open-ended questions. The questionnaire had originally been developed for use with practicing physicians and for the qualitative evaluation of courses at medical schools [8], [30], [31]. We decided to use it in our study since most of its advantages applied to our survey of medical students as well [29], [30]:

• Questionnaires allow anonymity and written surveys are less likely to produce socially desirable responses than interviews [32].
• Qualitative interviews usually take 1–1.5 hours per interviewee. Our questionnaire can be answered in approximately 15–20 minutes, so it fits well into students’ schedules and can be filled in on the spot (see Section 2.2).
• The QSS method allows for the comparison of different subgroups, which was one aim of the present study.
• The QSS method is also well-suited for the simple “exploration of a novel issue of interest” [30] using only a few questions.
• Although in-depth or focus-group interviews would have allowed for greater theory building than hypothesis exploration, they would have yielded more data than we could have processed, and our financial and personal resources did not allow for such interviews.

For this study, we used an adapted version of the original questionnaire [8], [31]. It consisted of three pages and included four open-ended questions on empathy, a few sociodemographic questions and a Likert scale on the assumed effects of empathy on patients’ health outcomes. A further question, which was unrelated to empathy, was included at the end of the questionnaire. (An English translation of the questionnaire can be found in the Attachment, Section A, of this article [Attach. 1]. The original German version is included in the Attachment, Section A, of the German translation of this article.) For the purposes of this study, we analyzed students’ responses to the following two questions:

1.

“What educational elements of your medical studies have/had a positive or negative impact on your empathy?”

2.

“During your medical studies, what do you find inhibits you from demonstrating empathy toward patients and in which situations are you particularly successful at being empathic?”

Participants in the study were chosen using a mixed stratified purposeful random sampling approach [33] pp. 230–246. Since we were interested in the associations between students’ experiences and differences in medical curricula, we surveyed students from three different German medical programs: the regular medical curriculum (structured as stipulated by the German Regulation on the Licensing of Doctors (Approbationsordnung für Ärzte)) at Bochum University (BU), the alternative medical curriculum (structured in line with Section 41 of the German licensing regulation) at the University of Cologne (CU), and the alternative curriculum at Witten/Herdecke University (WHU). Details on the main characteristics of these curricula can be found in the Attachment, Section B [Attach. 1]. Chenot [34] also provides an overview of undergraduate medical education in Germany. The main aim of our sampling approach was to ensure an even distribution of respondents in terms of stage of medical training and university of study.

The main data collection phase took place in January and February 2011. Fifteen additional sixth-year students were surveyed in February and March 2012 because they had been underrepresented in the sample. One of the authors (FA) approached students on the schools’ campuses and asked whether they would be willing to participate in a survey on their subjective experiences with empathy toward patients. Students were requested to complete the survey immediately.

A total of 115 students participated in the survey. 39 (34%) were from BU, 39 (34%) from CU, and 37 (32%) from WHU. The overall response rate was 50.7% of those students approached on the campuses about the survey. Other sociodemographic data are provided in Table 1 [Tab. 1].

All interview responses were transcribed by one author (FA). Given that the aim of this study was “to describe the key issues of concern” [35] with respect to our research question and to generate hypotheses from these findings, the transcribed data were then analyzed using thematic content analysis as described by Green and Thorogood [35]. Three of the authors (FA, MN and GR) were involved in the analysis process. First, the transcripts were independently coded and main themes and specific factors associated with medical student empathy were identified (see the Attachment, Section C [Attach. 1] for the complete coding scheme). FA analyzed both questions using RQDA qualitative data analysis software (http://rqda.r-forge.r-project.org/). MN and GR coded and analyzed questions 1 and 2, respectively. Next, all three authors met to discuss and validate their findings. Differences were discussed until a consensus was reached.

In order to compare the responses of students from different schools, we compared the frequency of each coding category between the three groups. The RQDA software package (http://rqda.r-forge.r-project.org/) was used for coding the qualitative data and Sqliteman database manipulation software (http://sourceforge.net/projects/sqliteman/) was used for the descriptive quantitative analyses. R statistical software (http://www.R-project.org/) was used to analyze the sociodemographic data.

Data collection was completely anonymous in accordance with the German Federal Data Protection Act and participation was entirely voluntary with no disadvantages for non-respondents. All participants were considered to have full control over the amount of time spent on the survey and the personal details they wished to disclose. Current research practice and legislation in Germany do not require ethical approval for such a study [36].

Responses varied in form and length. While some participants listed just words, others answered narratively with phrases or whole sentences. Some did both. Analysis of the responses identified 84 factors, cited a total of 880 times, as influencing respondents’ empathy. The 10 most frequently cited factors are listed in Table 2 [Tab. 2]. The following four main themes emerged from the analysis:

1.

Practice-oriented medical education has a positive impact on student empathy.

2.

Students’ feelings, attitudes and behavior toward patients can enhance or hinder their empathy.

3.

Students’ professional and personal experiences can inhibit and/or promote their empathy.

4.

Humanity in the learning environment fosters empathy.

The following subsections provide a description of the specific factors mentioned as influencing empathy and the differences between the responses of the three student groups. The complete coding scheme and additional student statements can be found in the Attachment, Sections C and D [Attach. 1].

The common denominator among students’ responses regarding the impact of their education on their empathy was the degree to which the educational structures and content of the curriculum were oriented toward practice. Namely, students felt that practice experiences and contact with patients enhance their empathy, as does teaching with reference to clinical practice and the patient’s perspective. By contrast, the absence or lack of these elements was stated to have a negative impact. Many respondents expressed this with just a few words, referring to clinical and primary care clerkships, bedside teaching, clinical examination courses and the final-year internship. Some described the positive aspects of practice experiences in greater detail by expressing how their observation of physicians’ interactions with patients and, much more so, their own contact with patients had enhanced their empathy, especially when accompanied by guided reflection with their trainers.

The most frequently cited factor considered to enhance student empathy was the receipt of specific training on physician-patient interaction (see Table 2 [Tab. 2]). Students’ responses indicate that each medical school has its own approach to preparing students for clinical practice and professional contact with patients (see Table 3 [Tab. 3] for the curricular elements unique to each school). A few respondents felt that such training is too theoretical and distanced from patients.

Respondents also mentioned that formal subjects of the curriculum can have a positive or negative influence on empathy (see Table 4 [Tab. 4]). Subjects with an emphasis on practice and the relationship with patients were seen as having a positive impact, while the impact of more scientific subjects was negative. For instance, comments on the subject of Anatomy revealed the importance of experience-based learning. While this subject was generally stated to have a negative influence, the dissection course was considered by some to actually foster empathy. One respondent even described it as being the first opportunity to relate to patients.

Many students reportedly observed that their ability to empathize was affected by patients’ attitudes and behavior. For example, patient behavior that was friendly, open and honest seemed to foster empathy. Demanding, unfriendly, uncommunicative or generally “difficult” patients (Respondent No. 86) were perceived to inhibit it. Some students described cooperative and compliant patients as facilitating student empathy, and uncooperative, non-compliant patients as a barrier.

Patients with psychiatric conditions, such as dementia, depression and addictions to alcohol or illegal drugs, were reported to challenge some respondents’ ability to empathize, as did those with a criminal background. Some students said that it is easier to empathize with children or elderly patients. Severe or fatal conditions made it easier for some respondents to demonstrate empathy; for others, such situations made it more difficult.

As in this last comment, sometimes students' emotions towards patients played a role in their empathic behavior. Patients’ attitudes, behavior and characteristics evoked judgmental attitudes and related feelings in students, which then influenced their empathic response to the patients. Indeed, respondents reported that antipathy and negative attitudes in general toward patients acted as barriers to their empathy. Several students said they had difficulties empathizing with patients if they were prejudiced against them—that is, when they thought that the patients themselves were responsible for their condition as a result of behavior that contributed to their illness, when patients exaggerated their complaints (Respondent No. 42) or when they were apparently not seriously ill.

By contrast, however, liking and identifying with a patient (Respondent No. 114) were perceived to enhance empathy. Common interests and experiences with a patient (e.g., having a similar level of education and either themselves or a family member having suffered the same illness) helped students connect with patients, as did being a similar age and the same gender. Recurrent contact with a patient and being personally touched by an encounter with a patient (e.g., feeling that the patient was in need of help and attention) were considered helpful as well. Some respondents also described specific behavior toward patients as fostering empathy: listening to patients, showing an interest in them, taking them seriously, and being open and attentive.

Perceived feelings and behavior related to professional and personal experiences were described as impacting empathy. For example, some students reported having trouble finding a balance between connecting with patients and maintaining an appropriate distance. These problems were partly due to limited experience with patient contact or to difficulties in managing their own emotions.

Some other respondents mentioned feelings of numbness, disgust and insecurity as having a negative influence. For example, one student experienced being a newcomer to a hospital ward as being a barrier to empathy because he/she was too occupied with getting his/her bearings. Although time pressure was frequently cited (see Table 2) as a negative factor influencing student empathy, having enough time was considered to have a positive influence. Unmet needs, such as being tired or exhausted, were reported to inhibit empathy as well, while “having balance” (Respondent No. 99), “being in a good mood” (Respondent No. 96) and feeling secure were perceived as positive influences. A substantial number of students mentioned that the pressure to perform, pass examinations and keep up with learning are barriers to empathy. Other respondents considered stress in general to be a barrier.

On a personal level, some respondents reported that reflection—either on their own behavior or on that of physicians—helped them increase their empathy. Students’ biographies and personalities were mentioned, especially when the respondents felt that empathy is developed before entry into medical education:

Students’ learning environment was another factor expressed to have an influence on empathy. In general, an environment characterized by “humane” interactions (Respondent No. 70) between faculty and students was seen in a positive light. Such interactions include the exchange and contact between fellow students, empathic behavior and an empathic atmosphere on the ward, and students being addressed by faculty members by name. Good communication with other members of the health care team was also considered to play a positive role. By contrast, an environment in which communication with peers is negative (e.g., fuels students’ prejudices), in which students are confronted by hierarchical behavior and attitudes on the part of physicians and professors, and in which students do not receive adequate guidance, was perceived as having a negative influence on student empathy.

The way students see physicians treating patients also appears to have an impact. Many respondents cited specific examples of physicians who demonstrated or lacked empathy. While a demonstration of empathy was seen to foster student empathy, a lack of it was considered to create a barrier. A few, however, stated that non-empathic physician behavior actually helped them to develop their empathy because they realized how they did not want to deal with patients.

In addition, whereas a disregard for patients’ individuality by primarily focusing on science instead of the patient and by treating patients as “objects” (Respondent No. 12) was experienced as having a negative influence on empathy, consideration for patients’ individual needs was perceived to have a positive influence. Similarly, situations where focus is placed on medical facts (e.g., teaching settings, ward rounds, diagnostic procedures) were described as a barrier to student empathy. A lack of patient privacy—for example, during bedside teaching—was also perceived as a barrier.

By contrast, situations which promote dialog with patients, especially a quiet and private setting, were repeatedly stated to have a positive influence.

Comparison of the responses of students from BU, CU and WHU revealed that students from all three schools discussed the influence of training in physician-patient interaction and teaching with reference to practice and/or patients with about the same frequency. BU students mentioned the subject of Medical Psychology (in which they receive their main training in physician-patient interaction), the impact of disease severity, patient compliance, and students’ feelings and emotions more often than students of the other two schools. Respondents from CU and WHU talked more often about experiences with physicians (including role modeling), the time factor, their like or dislike of patients, experiences and interests they have in common with patients, and their reactions to medical school and their work demands. Students from CU also brought up the met or unmet needs of students more frequently than other students. Unlike students from CU and BU, students from WHU less often stated that they thought they could not answer our questions (e.g., because they felt they did not have enough experience). However, they made more frequent mention of practice experience with patient contact (especially talking to patients) and the importance of enough privacy. They also reported more often about their experiences with closeness to and distance from patients, about their attitude toward patients, and about how their professional knowledge had influenced their empathy.

This study was conducted to explore students’ subjective perceptions of the factors positively and negatively influencing their empathy during medical education at three German universities. Analysis of their responses found that these factors can be categorized into four dimensions of medical education affecting student empathy:

1.

practice-oriented medical education,

2.

students’ feelings, attitudes, and behavior toward patients,

3.

students’ professional and personal experiences, and

4.

humanity in the learning environment.

These findings are consistent with those of qualitative research on the perspective of medical students from other countries [22], [23], [24], [25], [26].

As illustrated in Figure 1 [Fig. 1], these dimensions are connected. Students need practice-based curricula in order to have practical experiences with patient contact. Such experiences evoke feelings, emotions, thoughts and behavior, which in turn influence students’ interactions with patients. Empathy is dependent on how students deal with these internal processes. Giving students the opportunity to reflect on these internal processes while providing adequate guidance can foster self-awareness and, as a result, positively impact students’ empathy.

This interpretation of our results is based on our understanding of the concept of empathy, which corresponds to Mercer and Reynolds’ [1] definition as presented in the introduction. Students’ conceptualizations of empathy were found to be similar to our understanding and therefore support our interpretation. Preliminary analysis of students’ responses to another question of our survey—namely, “What do you understand by ‘physician empathy’?” (FA, unpublished data)—revealed that students’ understanding of empathy is primarily focused on perspective-taking (i.e., understanding the patient’s situation) and that students frequently mentioned the subsequent therapeutic action taken based on that understanding [1]. While about 10% of respondents saw empathy as being closely related to sympathy, the majority of students’ definitions of empathy did not overlap with those of sympathy or compassion. A few students even made an explicit distinction between empathy and sympathy or compassion in their definition or emphasized the importance of an objective stance toward patients. Students’ definitions of empathy are important to the understanding of their responses regarding their own feelings and how they identify with patients.

Although the three schools apply different approaches to teaching interpersonal skills (see Table 3 [Tab. 3]), these approaches were mentioned by all three student groups with about the same frequency. Most often, students commented on how the receipt of specific training in physician-patient interaction is effective in improving empathy. Students in a study by Tavakol et al. [25] also reportedly valued the role of education in empathy enhancement, and quantitative studies have indicated that communication training can have a positive effect on student empathy [37], [38]. One striking finding from our study, however, was that respondents participating in the alternative medical programs (CU and WHU) made more frequent reference to the influence of factors stemming from clinical practice and direct contact with physicians and patients as part of their education. Such factors include patient contact itself or students’ liking or disliking a patient. This finding suggests that while training in physician-patient interaction in general has an impact on empathy, the characteristics of that training (i.e., the curriculum) can shape students’ views of the factors influencing their empathy.

Although students in our study described training in physician-patient interaction as effective in teaching empathy, some criticized it as being often too remote from practice. Likewise, students in Tavakol et al.’s study [25] perceived empathy training to promote “checklist empathy” instead of “in-depth opportunities to develop empathy skills” [25]. It has also been argued that the teaching of empathy needs to be based on learners’ own experiences [1], [39], such as through an experiential empathy training course [39].

Apart from receiving training on physician-patient interaction, students in our study reported that their own experiences during clinical practice, including contact with patients, have a positive influence on their empathy. These experiences were among the most frequently cited factors in our study, a finding which corresponds with the findings of studies by Winseman et al. [23], Lynn et al. [26] and Tavakol et al. [25]. In addition, two systematic reviews observed improvements in empathy, patient-centered care and general communication skills as a result of experiences gained in the clinical setting [40], [41]. In light of Mercer and Reynolds’ [1] definition of empathy, which includes the ability to “understand the patient’s situation, perspective and feelings” [1] p. S11, it seems logical that regular clinical practice is a key factor in the acquisition of empathy.

Despite the perceived positive impact of training and clinical practice experiences, several respondents said that being empathic in their interaction with patients can be challenging. First of all, patient characteristics, such unfriendly behavior, a lack of compliance or simply being “difficult,” can create barriers to empathy. Second, while the students’ own positive thoughts and feelings evoked by an encounter (e.g., liking or identifying with the patient) were found to foster their empathy, a dislike for a patient, prejudice or distancing attitude were felt to hinder it. Similarly, Winseman et al.’s [23] respondents reported that “negative feelings and attitudes toward patients” [23] p. 486 had affected their empathy, and Tavakol et al. [25] mentioned that their students perceived physicians’ and patients’ personalities to have an influence on empathy. These findings suggest that students need guidance, not only regarding their medical skills but also in processing their experiences and in learning how to deal with their feelings, emotions [22], [23], [42] and personal attitudes, including prejudice and stigmatization [43], [44]. Such unconscious feelings and attitudes have been described as relevant bias factors that can interfere with clinical care [43] and the physician-patient relationship [44]. By contrast, self-awareness—the state of being conscious of one’s own feelings and emotional responses to specific situations [45]—is a prerequisite for empathy [5], [43], [44]. It therefore seems appropriate to include medical student self-awareness in medical education in order to promote student empathy.

Some respondents indicated that (self-) reflection is a helpful activity for improving empathy. However, many expressed that more reflection is needed on the relationship between patients’ characteristics and behavior and students’ feelings and attitudes toward patients. Reflection, the “critical analysis of … experience, in order to achieve deeper meaning and understanding,” is one requirement for self-awareness [46] p 596 f. and may help students deal with “hindering” attitudes and feelings if appropriately incorporated into medical curricula. Wear and Zarconi [22] and Lynn et al. [26] point out that reflection is important to students for processing their experiences and subsequently developing compassion [22] and empathy [26]. Others have suggested that such reflection should include students’ attitudes and their own personal history [43], [45], various influences of the learning environment [22], [23], [26] and, on a philosophical level, the implications of medicine’s underlying thoughts [44]. However, simply adding additional elements to the curriculum is probably not enough to give students the opportunity for such professional and personal development; they also seem to need a learning environment with adequate role models and where they themselves are treated with empathy [22], [26]. In this way, students could see that they are able to actively shape their interactions with patients and could learn how to empathize (e.g., with uncooperative patients or in the presence of antipathy). Therefore, through reflection, encounters with “difficult” patients could be converted into opportunities for professional and personal growth [23], [42], [43].

Based on our results, we derived the following hypotheses for improving empathy training in medical education:

1.

Medical student empathy is likely influenced by a number of factors which can be categorized into four different dimensions of medical education:
a) practice-oriented medical education,
b) students’ feelings, attitudes and behavior towards patients,
c) students’ professional and personal experiences and
d) humanity in the learning environment.

2.

In order to foster empathy, it may be reasonable to provide communication training that explicitly addresses empathy in theory and practice with adequate allotments of curricular time and resources and to include students’ own personal and professional experiences in these trainings [1], [5], [39], [43].

3.

Students need sufficient opportunities for practice experience with patient contact in order to develop their empathy.

4.

Reflection in “safe spaces” [22] p. 952 could effectively help students process their experiences, deal with their evoked feelings and emotions, and find out about the influence of their attitudes, values, and personal history on their professionalism, thus improving self-awareness [22], [23], [25], [42], [43], [44], [45].

5.

This could be achieved through mentored small group discussions (e.g., Balint groups), individual counseling, role play, student self-care support or mind-body skills courses and through faculty who explicitly address and model self-awareness in their teaching [42], [43], [44], [45], [47], [48].

One of the strengths of our study is that it seems to be the first investigation of the determinants of medical student empathy in Germany from the perspective of medical students. It also appears to be the first multi-center study giving insight into the subjective perceptions of students from different medical programs. Third, while previous studies have often failed to address the influence of the formal curriculum and its potentially positive aspects on empathy [49], we included these relations through the openness of our study design. Students’ responses in our study contained many references to the formal curriculum. Fourth, our responses were anonymous, making the issue of social desirability bias very unlikely [32]. Finally, we achieved an acceptable overall response rate of about 50%.

Despite the study’s strengths, there are some limitations that should be considered. First, our data collection method did not allow for the interpretation of hidden meaning, as would have been possible if, for example, we had conducted in-depth qualitative interviews. Thus, our results could only be used to form hypothetical conclusions and not to build theories [29], [30]. Second, the wording of our questionnaire is based on the deductive assumptions that student empathy can be influenced by positive and negative elements of medical education, situational barriers and facilitating situations. Thus, we may have evoked students’ memories of certain experiences while excluding others. Third, our data collection method may have produced a biased sample through positive self-selection of the respondents. Finally, although preliminary analysis of the students’ responses suggests that their concepts of empathy are similar to ours, we cannot prove that their understanding is the same.

Given the hypothetical nature of our conclusions, they warrant validation or falsification in intervention studies. In-depth qualitative research should be done to deepen the understanding of the learners’ perspective on empathy. The influence of medical training conditions on empathy is still underresearched [21].

This exploratory study with German medical students from three different medical schools provides a picture of the possible factors promoting and inhibiting student empathy during medical education. Our results suggest that a greater focus on learning and teaching in practice (e.g., by providing students with more opportunities for practice experiences with patient contact) may effectively help students develop empathy. However, in order to promote students’ personal and professional growth, these experiences may need to be accompanied by sufficient opportunities for guided reflection and greater self-awareness. Our study develops hypotheses as a contribution to future studies aimed at improving medical student empathy and ultimately at more humane and better quality care with good health outcomes.

We are grateful to the 115 students who participated in the survey and to Prof. Dr. Thorsten Schäfer and Dr. Dirk Hallner of BU, Dr. Christoph Stosch of CU, and Dr. Marzellus Hofmann and Prof. Dr. Martin W. Schnell of WHU who willingly answered our questions and helped us to report on the medical curricula of their respective schools. We would like to thank Fawn Zarkov for her invaluable help with our use of English in this article and her translations of the questionnaire and student statements. We would also like to thank Ewa Juszczyszyn, who translated the English original manuscript back into German, Fabian Hanneforth, who helped FA use software effectively, and Friederike Ahrweiler and Rico Queisser, who commented on the figure.

Part of this study has previously been presented at the International Conference on Communication in Healthcare held at St. Andrews in Scotland (2012); at Witten/Herdecke University’s Faculty of Health Research Day held in Wuppertal, Germany (2012); and at the Mixed Methods International Conference held in Leeds, England (2011).

The authors declare that they have no competing interests.