BACKGROUND: Empathy is important in the physicianpatient relationship. Prior studies have suggested that physician empathy may decline with clinical training.OBJECTIVE: To measure and examine student empathy across medical school years. DESIGN AND PARTICIPANTS:A cross-sectional stud of students at Boston University School of Medicine in 2006. Incoming students plus each class near the end of the academic year were surveyed. MEASUREMENTS:The Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a validated 20-item self-administered questionnaire with a total score ranging from 20 to 140. JSPE-S scores were controlled for potential confounders such as gender, age, anticipated financial debt upon graduation, and future career interest.RESULTS: 658 students participated in the study (81.4% of the school population). The first-year medical student class had the highest empathy scores (118.5), whereas the fourth-year class had the lowest empathy scores (106.6). Measured empathy differed between second-and third-year classes (118.2 vs 112.7, P< .001), corresponding to the first year of clinical training. Empathy appears to increase from the incoming to the first-year class (115.5 vs 118.5, P =.02). Students preferring people-oriented specialties had higher empathy scores than students preferring technology-oriented specialties (114.6 vs 111.4, P=.002). Female students were more likely than male students to choose peopleoriented specialties (51.5 vs 26.9%, P<.001). Females had higher JSPE-S scores than males (116.5 vs 112.1, P<.001). Age and debt did not affect empathy scores.CONCLUSIONS: Empathy scores of students in the preclinical years were higher than in the clinical years. Efforts are needed to determine whether differences in empathy scores among the classes are cohort effects or represent changes occurring in the course of medical education. Future research is needed to confirm whether clinical training impacts empathy negatively, and, if so, whether interventions can be designed to mitigate this impact.KEY WORDS: empathy; medical student education; physician attitudes.

BackgroundWe define electronic consultations (“e-consults”) as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults.MethodsWe searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based.ResultsOur final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers.DiscussionE-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.

Bedside teaching is valuable but underutilized. Including the patient, collaborating with learners, faculty development, and promoting a supportive institutional culture can redress several barriers to bedside teaching.