Migrants, homeless people, very precarious patients, people with mental health problems... The attitude of physicians to social inequalities in health is one of my favourite subjects. However well-intentioned physicians may be, they are torn between incomprehension and a certain helplessness when dealing with these patients.
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How can we effectively monitor people who sometimes don't even have a home, who tend to respond less well to care, and who are generally less grateful? In the end, this care is not always rewarding. The corollary is the difficulty of finding physicians willing to settle in certain medical deserts - whether in rural areas or in sensitive urban areas.
I have already worked on the issue of empathy among future physicians and how it evolves over the course of their studies. Recently, we published a study1 specifically on the feelings of students towards people in precarious situations, which the Anglo-Saxons call "underserved".
Some studies show that medical education itself tends to degrade the a priori positive attitudes of students. We wanted to understand why this is so, in order to put in place pedagogical tools to fight against this "deformation".
We therefore carried out a meta-analysis of the literature, i.e. 55 studies, all Anglo-Saxon and essentially American (45/55). Reflection on medical education is a field in which the Anglo-Saxons are very advanced. In France, no such study has been carried out, but I think that the results are largely transposable.
These studies included a total of 110,000 medical students. We observed a significant decline in their attitude towards underserved people throughout their studies, and more strongly after the fourth year. Here are our conclusions about some of the preconceived ideas.
One might think that at the age of 20 one would naturally be more inclined to be socially involved, to care for people in precarious situations, and that this would naturally fade away afterwards. Studies have compared the medical curriculum with others, such as that of pharmacists. They show that the decline in empathy towards the precarious is specific to medical studies. The age of the student or his or her maturation does not seem to be a factor.
In the study, medical students' more favourable attitudes towards the disadvantaged were significantly associated with the female gender. This is probably cultural: Girls are still largely educated in 'caring', which tends to steer them towards 'care' professions such as nursing or social work. This is reflected - and I will come back to this - in the module that I offer to students. There is an over-representation of women, 90 to 95%, whereas the ratio should be 60/40 or even 70/30.
This greater interest in social responsibility on the part of women is good news in view of the feminisation of medical studies, but we must not lose sight of the fact that all students must bear this interest in their professional identity.
The social background of students is a relevant factor. Being from a disadvantaged community or ethnic minority seems to predispose to greater empathy with people from the same social background. Why not recruit more students from these backgrounds, in order to have physicians ready to work in disadvantaged areas?
Firstly, because it is very questionable from an ethical point of view: It would mean selecting students from disadvantaged backgrounds and then telling them "Go back to where you came from". Secondly, some studies have shown that it either doesn't work, or that it is effective if it is combined with a programme dedicated to social responsibility. Finally, there are also very privileged students who are very interested in the precarious populations at the beginning of their studies.
I think that the solution does not lie in social selection at the beginning of medical studies, although the diversification of the socio-economic profiles of medical students is an important objective. It is above all a question of cultivating and strengthening positive attitudes in all students. How can this be done? By bringing them into contact with these populations as early as possible, in order to protect them from the sometimes negative influence of some of the older people they will meet during their internship.
A preconceived idea is that empathy, like all life skills, would come naturally on placement, and that it is therefore not useful to teach it. However, it seems that on the contrary, the negative attitudes of some senior citizens during the internship rub off on the students. According to our study, one explanation for the decline in empathy can be found in "role models".
This phenomenon refers to the fact that every student identifies with certain physicians. This is how they form the professional identity that then shapes their attitudes. The impact of role models is stronger in medicine because it is fed by the concrete difficulty of helping precarious people. However, these difficulties, or even powerlessness, are internalised by senior citizens who cannot express them openly. It is easier to stereotype a homeless patient than to admit to a student that you are unable or unwilling to treat them.
Some students in search of role models may even fall back on caricatures such as Dr. House, who portrays a very authoritarian, unsympathetic physician. It is the role of the university to tell them that other role models are necessary and compatible with a high level of technical skill.
This is not, of course, to stigmatise senior physicians, who have to deal with the teaching they themselves have received and the real difficulty of treating certain people. In addition, many senior physicians carry this capacity for social responsibility and pass it on to students. What is emphasised is that the responsibility for the decline in empathy does not lie with particular individuals but with medical education that does not take these processes into account.
Another road to explore in explaining the decline in empathy among students - often rightly put forward by physicians - is the increasing intensity of demands and time constraints during the course of the studies. Such intensity leads to professional and emotional exhaustion of students, which in turn tends to deteriorate interest in social responsibility.
Our meta-analysis shows that the most effective tool to help students collectively fight against this distorting power of study is the implementation of 'community interventions'. This consists of placing students in contact with underserved people outside the hospital setting and as early as possible, so that they can meet them and subsequently escape prejudice.
This type of approach is common in the United States, where medical studies include a social responsibility mission in addition to their three traditional pillars - education, research and clinical care. In France, this is beginning to emerge in several faculties, but it is often the result of individual initiatives by teachers who are aware of this issue.
In Lyon, I am trying to set up a social responsibility approach to health within the faculty. Students can take an optional module from the second year onwards. This year, 25 students volunteered for 40 hours to do school support, to go on patrols for the homeless, to welcome migrants, to support former prisoners, etc. This is not just a matter of helping the homeless. The aim is not to observe but to participate and lead a collaborative project around these issues of social inequality and precariousness: to create awareness-raising tools (podcasts, posters, videos, blogs, etc.), to participate in associative actions, etc.
The time dedicated to lectures is reduced to a strict minimum (20 hours) to prepare them for the experience that they are going to have and that will transform them. Social responsibility is not learnt through powerpoint but through experiential learning in the field, from volunteers and from the people themselves. However, I see the students regularly to review their project.
The programme will be spread over several years. When they are more advanced in their studies, the students can, for example, do a placement in a clinic or with Médecins du Monde. If in the sixth year there are still 25 students taking this module, it will be good. But the main aim is to see how they can raise awareness among others. We don't necessarily need 500 young physicians to go and work with people in precarious situations in Lyon, but we do want to raise collective awareness.
Our next step is the "Solid'AIRS" project, a joint programme with Madagascar and Laval University in Quebec. The aim is to make students aware of the realities of other health systems, especially during this pandemic period. Here too, it is a question of getting out of the usual hospital setting, to go and meet other realities, other ways of living and inhabiting the world. Fifteen or so students from each university will first exchange information via Zoom, then go on a mobility trip proposing collaborative work based on their experiences.
In disadvantaged areas, the direct involvement of local physicians in health care structures seems to be a key. In Vaulx en Velin, a health centre has been set up by general practitioners and paramedics in close collaboration with the inhabitants and local authorities. Elected representatives and local residents are members of the board of directors, which makes it possible to identify the needs of the population as closely as possible. These collaborations are not always easy to put in place, but creating such structures without involving the inhabitants means mortgaging their effectiveness.
As far as continuing education is concerned, certain university degrees enable practising physicians to better understand how to deal with people in very precarious situations, but also what they reflect back to us, how they can put our practices in difficulty, etc. Examples include the degrees “Santé Société Migration” in Lyon and "Santé, société, précarité" in Grenoble.
Édouard Leaune is a university hospital practitioner at the Centre Hospitalier le Vinatier (Lyon) and a lecturer at Lyon 1 University.
1. Leaune, E., Rey-Cadilhac, V., Oufker, S. et al. Medical students attitudes toward and intention to work with the underserved: a systematic review and meta-analysis
BMC Med Educ 21, 129 (2021). https://doi.org/10.1186/s12909-021-02517-x