How to be a cool headed clinician
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3980 (Published 08 June 2012) Cite this as: BMJ 2012;344:e3980
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Dr Dalton,
Thanks for your query.
Clinicians are generally advised against providing medical care to either themselves or loved ones, such as family members. The current GMC guidance is as follows: ‘Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship.’ The rationale, in part, is that the emotional proximity can distort a clinician’s professional judgment. This is what I meant by the degree of dispassion needed to maintain the ‘medical gaze’.
I hope that clarifies matters.
Competing interests: I am the author of the article
Dr Sokol, maybe there is a typographical error in the sentence below, if not perhaps you could clarify what you mean by:
"A degree of dispassion is needed to maintain a medical gaze not blurred by too great a concern for the patient as a person."
Competing interests: No competing interests
Sokol, as many commentators have said, confuses empathy, which has been defined as both an affective capacity to be sensitive to and concerned for another person and as a cognitive capacity to understand and appreciate the perspective of another person (1), with an uninvited emotional display in response to what is felt. There is a considerable body of literature that would consider empathy as a critical component of supportive relationships but most people would not equate empathy with crying in front of the patient, except in certain exceptional circumstances. It is generally accepted that a supportive person steps back from actually expressing the emotional state in order to more fully support the one who is upset.
William Osler, whom Sokol praises for preaching emotional detachment to doctors, practised in the late 19th century and was concerned with promoting expert-led objectivity in medical practice. Society is now very different - less hierarchical and paternalistic. However, even one of his junior contemporaries, Dr Francis Peabody, wrote in a paper in JAMA in 1927 about the importance of the patient having “complete confidence in the sympathetic understanding of the physician” (2).
Sokol sets imperturbability against empathy whereas most doctors would agree you need both. The former is essential in an emergency situation or during a difficult operation. The latter is core to communication particularly when difficult and upsetting decisions or conversations have to take place. Kind or polite platitudes will be seen as false by patients who perceive a lack of emotional understanding by their doctor. What may work well in a courtroom does not work in a GP surgery or at the bedside of a distressed patient.
I would argue that empathy can be learnt, usually through modelling and also by specific training in communication skills (3). One novel way is by “clown improvisation” (4). Imperturbability comes with experience and knowing what to do. We need caring doctors working in a caring environment where health professionals feel valued for being patient-centred rather than chasing management targets. If we side-line empathy in an increasingly target led health system there is a danger the patient will not be listened to and doctors will become depersonalised, cynical and demoralised.
References
1. Quince TA, Parker RA, Wood DF, Benson JA (2011). Stability of empathy among undergraduate medical students: A longitudinal study at one UK medical school. BMC Medical Education 11:90 http://www.biomedcentral.com/1472-6920/11/90
2. Peabody FW (1927). The Care of the Patient. JAMA 88: 877-882.
3. Shapiro J, Morrison EH, Boker JR (2004). Teaching Empathy to First Year Medical Students: Evaluation of an Elective Literature and Medicine Course. Education for Health 17 (1): 73-84.
4. Wheeler, D. (2008). "More than clowning around". BMJ Careers http://careers.bmj.com/careers/advice/view-article.html?id=2967
Competing interests: No competing interests
Some clinicians, as Sokol says, associate ethicists with bleeding hearts and sentimentality, but what William Osler said in the 19th century about imperturbability stands next to a passage in Abraham Verghese’s recent novel, Cutting for Stone. In it, Thomas Stone, head of surgery, asks his students, “What treatment in an emergency is administered by ear.” Only one knows the answer, “Words of comfort.”
Imperturbability is a quality, Sokol says, that can be developed. That may well be true, though probably some people have a head start over others. I think that empathy is much more difficult to teach and acquire.
There is plenty of evidence suggesting that as a GP you are less effective without empathy. There is a time and a place for imperturbability, but when a patient has just been told their son has been killed in a car crash detached calm isn’t much good to them. They want to feel the empathy from their doctor. That doesn’t mean crying in front of them: it means using a blend of non-verbal and verbal communication to make them feel understood.
In combat or in the middle of a difficult operation, empathy has no place because the action of the hero or surgeon is paramount, but there are few situations like that in general practice. A GP without empathy will struggle massively to find meaning in his job and life in relation to not only his patients but also his colleagues and his family.
Sokol’s article reminds me of the ’theory’, taught to medical students, of how to break bad news. These students are encouraged to follow guidelines when breaking bad news, such as finding a quiet environment for it and making sure the person has relatives with them. But the theory marginalizes all the emotion the doctor has to deal with. In reality, there is no substitute for actually breaking the bad news: it has to be done. If one is cool and detached that is fine when giving the news, but the doctor who can be empathetic as well is much better equipped to deal with the emotional fallout afterwards for the patients ¬– and for the doctor.
Saying to a patient ‘I understand’ and opening oneself to the richness of an emotional life does not mean you are a quivering wreck, but that you bring to your practice a holistic approach. Empathy from GPs makes perfect sense and is greatly valued in our ‘imperturbable ‘society.
Competing interests: No competing interests
Right & Wrong Meaning & Understanding
Daniel Sokol is right to raise awareness of experience, feedback & reflection to enhance learning. He is wrong that empathy cannot be taught and enhanced and also that empathy & imperturbability are not compatible.
His concept of empathy is sympathy. True empathy is being able to put ourselves in another person's shoes (their situation, thinking, feeling and meaning) and, most importantly, to communicate that understanding to our patient or colleague. Empathy and not sympathy is the key ingredient of Motivational Interviewing (Miller & Rollnick) and the major influence in deep learning (Carl Rogers--Freedom to Learn).
Imperturbability means balanced, unbiased, independent, calm & coherent--not indifferent and uninterested.
Empathy and balance are compatible.
I hope that doctors involved in my family care have these attributes and that medical teachers have empathy and imperturbability towards their learners and promote these as important medical skills to be learned and fostered in the years ahead.
Competing interests: No competing interests
Daniel Sokol in his article how to be a cool headed clinician sets a dangerous precedent not only by misrepresenting what empathy actually means but creating an idea that the quality of imperturbability is incompatible with genuine clinical empathy.
Empathy is a complex, multidimensional concept that has moral, cognitive, emotive and behavioural components. It involves the ability to understand the patient’s situation from their perspective and communicate that understanding to them in a helpful (therapeutic) way (Ref 1). It is a powerful clinical skill that can be taught with specific communication skills training. It is not the ability to cry with someone but the ability to convey to another individual that you are attuned to their emotions. It does not require the doctor to have those feelings too. Daniel Sokol is describing sympathy and not empathy.
Training all doctors to be empathic has a very positive impact on the patient experience as it conveys genuine regard rather than the often stereotyped image of the cold, distant professional.
In a highly charged situation imperturbability is indeed a very effective quality but is more likely to be gifted to an empathic individual who is able to put themselves in someone else’s shoes to see it from another’s point of view.
1. Mercer SW et al
. Empathy and quality of care. Br J Gen Pract 2002;52Suppl:S9–12
Competing interests: I am National Clinical Lead of Connected© - an advanced communication skills training programme
Other responders have pointed out the most basic error in Sokol's article---that he does not know what empathy is. I have two points to add.
1. Empathy is an essential quality in the practice of Cognitive therapy but you will not see therapists crying or otherwise emoting in session, even in the face of massive emotional outpourings by clients. Sokol might find it useful to sit in on such a session.
2. Is there no-one on the BMJ senior editorial team who knows what empathy is? It took me about 30 seconds to see that the whole premise of his piece was totally in error. Shame on you!
Yours empathetically
Declan Fox
Competing interests: No competing interests
Dr Leonard is correct to highlight Daniel Sokol's apparent confusion between sympathy and empathy and I applaud any attempts to train doctors or allied professionals in empathy.
However I suspect that empathy comes more naturally to some hospital clinicians (and managers) than others.
You can take a horse to water, but ....
Competing interests: No competing interests
GMC's view seems to be that "we make sure every patient is treated with empathy and compassion"[1]. Thus, empathy is clearly an essential quality for doctors rather than a desirable one. Without mastering the application of empathy, it would be difficult to develop a satisfactory rapport in most situations; those who work in psychiatry will know this well. Having recently berated doctors for 'closing of the ranks'[2], I am surprised that Sokol is now attempting to dilute the importance of empathy; lack of empathy and compassion seem to be the very issue that is prevalent among doctors who 'close ranks'. Surely, empathy cannot be replaced with imperturbability. Similarly, empathy and sympathy are two different issues; reasonable patients will know the difference well and unlikely to be concerned about an empathetic approach.
References
Competing interests: No competing interests
Re: How to be a cool headed clinician
Doctors could be in a dilemma when it comes to matters of empathy and their role in attuning emotionally with patients. Much as they may try to detach themselves from their patients feelings, the patients seemingly expect doctors to genuinely empathize with the.
Take the example of oncologists and the dreaded disease ‘cancer’. Many people perceive cancer as a death sentence and this therefore means that such patients have a need for empathy from their doctors. What needs to be emphasized clearly is that empathy is quite different from sympathy. By definition empathy is the ability to understand and share failings of another. Sympathy on the other hand, is a feeling of care and understanding for the suffering of others .The two words may have similar usage but differ in their emotional meaning .
According to Canadian Medical Association, showing clinical empathy to patients can improve their satisfaction of care, motivate them to stick to their treatment plans and lower malpractice complaints. Though in clinical practice clinicians do not express empathic responses frequently, the new studies show that empathy is an important medical tool and it can be taught at medical school.
Competing interests: No competing interests