Empathy maps in communication skills training

Empathy is a cornerstone of patient‐centred care. However, empathy levels among health care professionals and medical students are currently suboptimal. An empathy map is a tool which aids in understanding another person’s perspective. Empathy maps have up until now not been used in a medical education setting.

outcomes for patients, such as reducing pain and anxiety. 3 The second is patient adherence via the facilitation of information exchange, the growth of interpersonal trust and a sense of partnership. 4 The third outcome is patient satisfaction, primarily through the strengthening of patient enablement and lowering of patient anxiety and distress, 4 and the final outcome is a reduction in patients' thoughts of litigation. 5 Evidence suggests current levels of empathy among medical students are suboptimal. Research measuring patient assessment of health professionals empathy using the CARE scale were pooled across 64 independent studies by Howick et al. (2017). 6 The authors found that medical students and physicians had the lowest average empathy scores compared with other health care professionals. This is despite the fact that empathy training (often experiential and skills-based) tends to be effective. 7 Evidence suggests current levels of empathy among medical students are suboptimal.
Further evidence has suggested that medical students' empathy declines as they progress from their first year of study to their final year and become junior doctors, 8 although see Smith et al. 9 Contributing factors include; a) a high volume of material to learn, b) time pressures, and c) a focus on the biomedical model of health and illness. Furthermore, when confronted with a clinical reality characterized by illness, human suffering and death, medical students may shift their focus from people to technology and objectivity. 10 The focus on the biomedical model of illness and a shift in attention focus to technology and objectivity could potentially leave medical students at a disadvantage when thereafter trying to understand the patients' perspective to base an empathetic response upon.

| Empathy maps -a novel approach
An 'empathy map' is a tool to assist understanding another's perspective. Empathy maps therefore have the potential to aid medical students in their understanding of a patients' perspective, the first component of therapeutic empathy. Furthermore, this understanding may

Empathy Map
Hearing: What does this person hear from authority figures, the media, the public and family and friends?

Name:
Seeing: What does this person see around them?

Saying:
What is this person's aƫtude in public?

Doing:
What does this person spend their Ɵme doing?

Pain:
What are their fears and frustraƟons?

Gain:
What do they want and need?
What causes them major worries?
What makes them happy?
The empathy map bring forth a sense of common humanity: that suffering is part of the shared human experience. 12 This sense would enable medical students to appreciate that communicating empathy and acting upon it, may be useful within the doctor-patient relationship, enhancing the likelihood that the second and third components of therapeutic empathy occur. However, to date we are unaware of any research which has examined the use of empathy maps within medical education.
The empathy map engages with the sensed, lived experience of an individual, alongside their cognitive and emotional world.

| Aims
The aim of this study was to understand the impact of using empathy maps within medical education on student perception of empathy within the doctor-patient relationship. To enable this we addressed the following research questions: The aim of this study was to understand the impact of using empathy maps within medical education.

| Empathy map training
In both institutions first-year students in a group of no more than

| Participants and Interviews
Twenty-eight participants in total agreed to be interviewed, ten male and eighteen female (see Table 1). This included twelve patient part-

| Analysis
Interviews were audio recorded and transcribed. Transcripts were analysed qualitatively using framework analysis. 13 We adopted a relativist ontology which accepted that the representation of things in the world is socially constructed and cannot be taken as a simple reflection of how things are. 14

| RE SULTS
Three main themes were constructucted from the data (see Table 2 for themes and representative participant quotes). Firstly, both patient partners and students enjoyed the experience. Secondly, during interviews following the empathy map training students described how they had come to realise that greater empathic and patient-

| DISCUSS ION
The results of this study suggest that empathy maps were a use- The results of this study suggest that empathy maps were a useful and enjoyable training tool for medical students.
This research has limitations which should be considered. Our recruitment of medical students and patient partners for interview '…yeah they're really, really good. They're a good piece, they're a good induction tool for students in general. I don't think just medical students, I think they'd be good for nurses and stuff as well, maybe dentists and pharmacists.' -Stu_001_M_StA_T2 '…we always come out saying that we enjoyed it, that it's really valuable, that it's nice to see them when they're sort of shiny and new em, so yeah I think we all take something different out of it.' -PP_005_F_StA Impact was opportunistic and therefore the variety of views expressed may be narrower than those of the entire cohort. Those who agree to participate may be the most engaged.
Our findings tentatively agree with previous findings that empathy training can be effective and engaging. 7 Further research is needed to assess whether empathy map training is effective at increasing empathy in medical students, and if so, to what degree. Exploration of the mechanisms of action of the empathy map training is also warranted.
Exploration of the mechanisms of action of the empathy map training is warranted.
The positive impact of the empathy map session was not greatly influenced by the main mode of interaction between students and patient partners (online or face-to-face) and lasted at least until the follow-up period three months following the teaching session.

| CON CLUS ION
This study examined the use of empathy map training with medical students. Students found the empathy map training engaging, perceived value in it and exhibited changes in perspectives as a result of the training.
This shows that empathy maps could be a useful training tool to allow medical students to develop a more empathetic approach to health care.

ACK N OWLED G EM ENTS
The authors are grateful to the patient partners and students who took part in this research.

CO N FLI C T O F I NTE R E S T
None.