“My back is killing me doctor, I’ve barely been able to get out of the house for the last few days, I’ve hardly slept, I’m in agony”
“uh huh … and, um, when did it start?”
“A few days ago … I’m really worried, I’ve got two kids, I’m on my own and if I don’t get to work I don’t get paid, I’ve been in tears all morning, I can’t cope any more …”
“mmm, right, and er, have you had pain like this before?”
“yes, but never this bad, sorry -[cries] do you have any tissues?”
“oh, yeah, sure, there you go. So, um, have you taken anything for it?”
etc.
I wonder why it is that not a single medical practitioner has said to me that they are sorry to hear I am ill. Such a banal social convention: I am sorry to hear about your illness. Why does this convention cease to apply as soon as one enters a hospital ward or a doctor’s clinic? Havi Carel, Illness.
When I read this, barely three months ago, I pulled up, like a race-horse in front of a fence that I expected to clear without breaking my reading stride. “She’s talking about me!” In my haste to make a diagnosis, rule out a serious cause or uncover my patients’ ideas, concerns or expectations, I all too rarely showed concern, expressed sorrow or sympathy. I was good at showing interest I think, but never showed a social convention so banal as, “I’m so sorry,” on giving a diagnosis of cancer, or “that sounds awful for you,” to someone whose operation went badly, or “I can barely imagine how hard that must be, tell me how do you cope?” to someone who is depressed, or, “I can see you’re frightened, it’s ok, I’m going to look after you”, to someone having an asthma attack.
I don’t think I’m a bad doctor, or even an indifferent or cruel one. But I’ve long suspected that empathy is not one of my strengths. I tested this hypothesis by asking my wife and close friends and they concurred. Sceptical about their easy agreement and this unscientific method, I completed an online empathy test, which showed that I ‘have a lower than average ability for understanding how others feel and responding appropriately’. My friends knew this already, but when I shared the results via social media (twitter) it was met with general disbelief from people who know me only through my writing.
This raises several questions. What is empathy? Are we faking it and does that matter? Why is everyone talking about empathy now? Can it be lost? Can it be taught? What is empathy for?
What is empathy?
Studies about empathy, such as those listed at the end of this article, tend to have somewhat idiosyncratic definitions of empathy. I wasn’t surprised to discover that it has been described as ‘difficult to define and hard to measure’.
“Empathy is the feeling that persons or objects arouse in us as projections of our feelings and thoughts. It is evident when “I and you” becomes “I am you,” or at least, “I might be you.” Spiro
[E]mpathy is a multi-step process whereby the doctor’s awareness of the patient’s concerns produces a sequence of emotional engagement, compassion, and an urge to help the patient. Benbassat and Baumal
A predominantly cognitive (as opposed to affective or emotional) attribute that involves an understanding (as opposed to feeling) of patients’ experiences, concerns, and perspectives combined with a capacity to communicate this understanding. An intention to help by preventing and alleviating pain and suffering is an additional feature of empathy in the context of patient care. Hojat et al.
In writing about the moral development of medical students, Branch describes moral behaviour in a very similar way,
[the] components that contribute to moral behaviour [are]- moral sensitivity, commitment and implementation, in addition to moral reasoning.
Many take care to make a distinction between empathy and sympathy, for example,
“Sympathy is ‘concern for the welfare of the other’, while empathy is the ability to appreciate the emotions and feelings of others” Smajdor
I looked into the crowed waiting room and saw two small children playing happily. I had been on duty for nearly 5 hours without a break and was exhausted. I had agreed to see them after speaking to their mum on the phone earlier. She said they had been up all night and were feverish and struggling to breathe. Now they were jumping up and down. I watched them irritably for a short while, I felt far more unwell than they looked. Perhaps I should keep them waiting while I made some more phone calls or checked some blood results. ‘Why are they here?’ I muttered to myself, ‘they’re obviously not ill’. My subsequent consultation was brief and brusque.
Three years later, I’m struggling. I’m at work at 7pm on Thursday night with two patients left to see. I’ve not slept in days. At home my 2 children have been run-down with colds for the last week, noses completely blocked, they’ve been getting up several times at night crying and /or climbing into my bed and then wriggling, snoring and coughing constantly. A couple of times I tried and failed to sleep on the floor or in one of their 4 foot beds. I was woken last night by a feverish, shivering child beside me. I cannot think clearly, my mind is grinding through the gears like a tractor going up the side of a mountain. It takes me twice as long to make a decision as it should and I can barely remember what my patients have told me when I try to type up their notes. Now I know something of what it’s like to be up all night with a sick child, how hard it is to make a rational decision when the night’s fog rolls through the clear light of day, of the enormous contrast between the pale, feverish, wheezing child of the night and the happy, playful child of the day.
“You look shattered”, is the first thing I say to the mum as she brings her children in. “You too doctor”, she replies. We understand each-other. The subsequent consultation was friendly and productive.
Cognitive and affective empathy.
According to psychology Professor Simon Baron Cohen it is helpful to distinguish between two types of empathy: cognitive and affective (emotional). Empathy is distributed unevenly among us, so that we can have low, average or high levels of either type. Baron Cohen’s area of research is autism and at the severe end of the autistic spectrum, people have very low levels of cognitive empathy as a result of a strong drive to systematize things. This includes attempting to systematize people’s emotions and behaviour, which cannot be clearly systematized, and so they find it hard to pick up social cues. Interestingly though, they often have high levels of affective empathy so that they are easily and profoundly moved by other peoples’ emotional states. Baron Cohen contrasts people with autism with people lacking affective empathy. In severe cases, this is characteristic of people with borderline, psychopathic and narcissistic personality disorders. People with psychopathic traits typically have high levels of cognitive empathy, which enables them to manipulate other people, but ‘they don’t have the appropriate emotional response to someone else’s state of mind, the feeling of wanting to alleviate distress if someone’s in pain, [that suggests that] the affective part of empathy is not functioning normally.’
I think that this is a very important distinction and I shall come back to it towards the end of this essay. It is important to note that the none of the studies about medical professionals and empathy make this distinction.
Why is everyone talking about empathy now? Is it being lost? And if so why?
The thought that a healthcare professional might lack the emotional response necessary to want to alleviate distress is deeply worrying to most people. Recent high profile revelations from Winterbourne View care home for people with learning difficulties, where undercover footage showed staff repeatedly assaulting patients, and from Mid Staffordshire hospital where elderly patients were neglected, has led many people to ask whether health professionals have lost empathy and compassion. The ideas that medical professionals lack empathy and that medical education and clinical culture erode empathy have been hotly debated for years, and as the articles below suggest, the weight of opinion is that there is an erosion of empathy during the process of becoming a doctor. It is easy to think of reasons why:
- In medical education students do not experience as much care and support from those that teach them as they experience humiliation and neglect
- The focus of medical education is on learning facts about diseases rather than learning how to understand people with diseases
- Medical education pays little attention to the social and political determinants of health
- A lack of role models. One study found that 34% of medical students identified a lack of good role models as a barrier to learning about empathy. In the same study, 64% of students said that time pressure was a barrier. These are serious concerns in a medical culture that is increasingly time pressured and in which ever increasing amounts of education are being delivered electronically.
- The undergraduate curriculum and the working conditions of medical staff are intensely pressured
- Years of under-funding and under-staffing are now being compounded by cuts and targets
- An increasingly competitive environment
- An increasingly threatening environment: Threats cannot make healthcare workers more compassionate
- The loss of continuity of care which is essential for relationships to develop between patients and professionals
Empathy and the hidden curriculum
The culture of medical education, as distinct from the subjects taught, is referred to as ‘the hidden curriculum’. It is here that behaviour or virtues are learned, as distinct from the ethics taught in the lecture theatres:
… medical training above all else involves the transmission of a distinctive medical morality… To recognise medical training as a process of moral socialisation is to acknowledge medicine’s cultural distinction between attitudes and behaviour for what it is – something much more ideological than rational. What students learn about the core values of medicine and medical work takes place not so much in the content of formal lectures … or at the bedside (medicine’s preeminent metaphor) but via its more insidious and evil twin, “the corridor”. It is time medicine started claiming ownership of both realms. Hafferty 1994
If at one level empathy can be demonstrated by a ‘banal social convention’ such as acknowledging my patient’s suffering, at another, empathy is inseparable from the moral obligation to care. When we say that doctors and nurses lack empathy, at one level we might actually mean that they simply lack basic courtesy and at another deeper level we mean that they don’t actually care.
Perhaps etiquette is a thinner version of empathy as ethicist Anna Smajdor, in an excellent paper about the limits of empathy in medical education and practice concludes. She suggests that we should settle for teaching this stripped down version of empathy. After all, it is clearly in short supply as any patient or health professional will testify. Kate Granger’s experiences of being a patient with cancer, led to her powerful call for healthcare professionals to introduce themselves. #hellomynameis has made a great and lasting impression.
What is empathy for?
Smajdor is not alone in suggesting that we settle for a limited version of empathy, Hojat et. al. in common with, and more explicitly than other authors, share the opinion that cognitive empathy is good for doctor patient relationships, but affective empathy, which is more like sympathy, is bad
Cognitively defined empathy always leads to personal growth, career satisfaction, and optimal clinical outcomes, whereas affectively defined sympathy can lead to career burnout, compassion fatigue, exhaustion, and vicarious traumatization.
I can understand the risks, I experience the emotional labour of care every day, I know what it is like to visit a dying patient at home and then see a mother with post-natal depression and another 20 patients in a single morning and then repeat work of the same emotional intensity in the afternoon, and the next day and the next. But if an excess of affective empathy can lead to burn out, then losing the ability to engage emotionally is a sign that we are burning out. Empathetic, emotional encounters are the highlights of my working life. They may be bitter-sweet, but I wouldn’t ever wish to be without them. This isn’t something that GPs need but not surgeons. After an extraordinary and profoundly empathetic account of trying and failing, to save a young man’s life, South African tauma-surgeon, Bongi concludes,
I no longer wanted to be what i am. i no longer wanted to struggle and fight in theater against the odds to stave off the inevitability of death. i no longer wanted to see the snuffing out of promise and life. i no longer wanted to think about the devastation left in the wake of the disasters that cross my table. i no longer wanted to be a surgeon. Thumbs Up
You have to read the full account to appreciate that his is not an essay about the dangers of too much empathy, but an account of the great pain that is sometimes, in extraordinary circumstances a necessary and essential part of care. It makes our work deep and meaningful. Whilst it is possible to suffer from too much empathy and over-identify with patients, I think we worry too much about this, even if there are times when we are not as composed as our patients need us to be,
“I could see you struggling not to cry and I thought God if my doctor is crying, it must be bad, really bad. I needed you to be strong then, strong for me…………” GP, Dr Michelle Sinclair
We cannot, as professionals engage with the same degrees of empathy at all times, and yet I am deeply concerned that the growing interest in teaching empathy is an attempt to pour oil on a storm brewing in an ocean of medical (and more broadly, social/political) culture. As noted above, it is neither bioethics lectures or clinical skills training that shape doctors’ moral character and empathy for their patients, but the hidden curriculum, the cultures in which we living and working. Smajdor and other seem resigned to this,
What students can learn in their ‘soft skills’ training is perhaps more akin to the McDonalds style, ‘You have a nice day now’ than to the rich nuanced and individualised conception of empathy… But this is no bad thing – as long as we are able to recognise that this is the case and ensure that our doctors have at least this basic ability. As Jodi Halpern writes:’… physicians today are increasingly caring for strangers in bureacracies’. In these circumstances we lack the resources to be truly empathetic.’ Smajdor 2010
A culture that lacks the resources to be truly empathetic, for reasons I’ve suggested above and more, destroys that capacity for affective empathy most of all. A thin veil of courtesy may be all that remains after trying to look after too many patients with too few resources for too long in a threatening and bullying culture torn between cuts and targets. As Baron Cohen notes, people lacking affective empathy share is a childhood scarred by abuse and neglect. If we treat our healthcare workers this way, what we risk creating, is no less that what Baron Cohen described above, doctors and nurses trained in high levels of cognitive empathy, but stripped of affective empathy, in essence, psychopaths.
Empathy and the critic
English professor Ann Jurecic has written an excellent book, Illness and narrative about the multiple ways in which we read and interpret literature about illness and suffering. She pays particular attention to the complex nature and often conflicting uses of empathy, for example,
when public figures such as writers, entertainers, and politicians, evoke positive or negative emotions—from empathy and love to fear, agony, and shame—these feelings serve existing structures of power. Compassion, for instance, has been claimed by politicians across the political spectrum. In his 2000 presidential campaign, George W. Bush advocated a politics of “compassionate conservatism.” He used the term to suggest that dependence on free-market economics demonstrated compassion for society as a whole and justified reduction of the social safety net for the disadvantaged. To Bush’s opposition, the phrase came to signify a cynical politics that favored the wealthy while obscuring the deepening political and economic divide between the “haves” and “have nots.”
One reason empathy can serve power is by standing in the way of understanding. This can have important implications for doctors and patients. Brene Brown, one of the most widely quoted researchers in the field of empathy, says that ‘staying out of judgement’ is one of the four qualities of empathy. Patients often complain about being judged by doctors, and teaching empathy to doctors seeks, in part to overcome this. But a lack of judgement is at odds with critical, analytical, skeptical or otherwise thoughtful ways of responding to what our patients tell us about their illnesses. The practice of medicine is especially demanding because we are expected to be empathetic and skeptical at the same time.
It is also important to note that patients do not always want or need empathy so much as thorough professionalism. In her essay about living in pain, author Hilary Mantel describes meeting a neurologist,
His hour with me stands as a shining example of good practice. His history taking was so structured, so searching, so thorough, that I felt for the first time my pain was being listened to. The consultation itself was theraputic.
In her essay, Empathy and the Critic, Jurecic warns those who want to teach empathy to doctors,
the lived complexity of empathy cannot be reduced to an outcome to be assessed, a feeling to be argued out of, or a neurological response. For these writers, empathy is instead an inexhaustible subject for the practices of contemplation, exploration, and creation.
Rescuing empathy.
Empathy depends on how we care for and relate to one another. The importance of continuity of care cannot be stated often enough. Its failure is encountered as often in general practice as it is in outpatient departments and hospital beds. Dr Kate Granger, in her book, The Other Side written to teach doctors what they can learn from her experience of being a patient with cancer writes,
A middle aged woman breezes into my room without knocking and announces her unpronounceable name, which I have no hope of remembering as she does not wear a name badge. She says she is a Gynaecology Registrar and has been assigned presenting my case at the MDT meeting. I think this strange as I have never met her before but continuity of care has already been sadly lacking since my admission. She continues to ask me inane questions in broken English, which make me think she has not even read my medical notes. I am really not in the mood to repeat myself yet again so am polite but relatively short with her in my manner. She then says something that I still cannot fully comprehend to this day. She asks me why I am upset to which I respond “because I’m 29 years old and I’ve got cancer”. Her astonishing reply to my frank yet accurate answer is “do not be silly, this won’t turn out to be cancer, you are too young.”
Continuity of care is part of the price paid for convenience and consumerism as the government forces on the NHS ever-increasing opening hours, spreading human resources ever thinner. It is undermined by fragmented care from multiple providers, increasing specialisation and a loss of general medical and nursing skills as professionals find lower paid assistants take over ever more of their duties,
It is an enormous defect of health-care organizations that professionals often cannot express this commitment [to continuity] because there are constant territorial disruptions over who stays how long and does what. This structured disruption of continuity of relational care is more than an organization problem; it is a moral failure of health care, deforming who patients and clinicians can be to and for each other. Arthur Frank
The relationship between doctors and patients depends on trust. This is because far more often than we care to admit, illness undermines autonomy, so that when we are sick we need to be able to hand over our bodies, our children or our elderly relatives to professionals to take care of them. The imbalance in power is inescapable, so we need to demand higher moral standards than mere etiquette. The relationship is, to borrow a legal term, ‘fiduciary’,
A fiduciary duty[3] is the highest standard of care at either equity or law. A fiduciary (abbreviation fid) is expected to be extremely loyal to the person to whom he owes the duty (the “principal“): he must not put his personal interests before the duty, and must not profit from his position as a fiduciary, unless the principal consents.
Until now, I’ve argued vehemently that patients are not customers, clients or consumers, but my detractors have stuck to their insistence that patients are customers. The process of patients becoming customers is beautifully portrayed in the satirical play, Knock, A Study in Medical Cynicism, The traditional model of medicine as a vocation, health care as a public good and the sick patient as a vulnerable citizen who has a right to care (and for whom the clinician has a duty of care) is steadily being replaced by a new era of market values where medicine is a business, health care a transaction and the sick patient a customer.
The consequence of this change in culture, as we shall see, increasingly I fear, is that empathy becomes little more than a mask to cover up and compensate for a culture that makes empathic behaviour extraordinarily hard.
It is not empathy training that we need, but a change in culture, in medical education, clinical practice and managerial and political culture, one based on mutual respect, trust, kindness and meaningful relationships,
we should emphasize that empathy is multidimensional, flawed, fascinating, and inescapably—for better and worse—at the heart of social relationships. Jurecic. Empathy and the Critic
As I concluded in my essay about kindness,
The relentless focus on efficiency and productivity in healthcare highlights the intrusion of market values into the NHS. There is an urgent need to to defend the values of social solidarity and rediscover an intellectual and emotional understanding that self-interest and the interests of others are bound together and acting upon that understanding. By committing ourselves to a change of culture that nurtures kindness we may yet rescue the NHS.
References and further reading:
What is Empathy?
Empathy doesn’t have to be intuitive to be real. Lovely article with Ethicist, Deborah Bowman. June 4th 2014
The Empathy Exams. An actress writes about receiving empathy when playing patients during medical student exams. Wonderful writing
What is empathy and can it be taught? Spiro 1992
What Is Empathy, and How Can It Be Promoted during Clinical Clerkships? Academic Medicine 2004
Empathy’s failures. It’s easier to care for fewer people than more. Badscience 2010
Clarifying misconceptions about compassionate care Dewar 2013
The empathic surgeon: Thumbs up
The Empathic GP, too much empathy?
The Doctors are not alright. “Recently one of my colleagues told me that they are emotionally incapable of caring for their patients any more. How can I help them?”
How your doctor feels about you could affect your care: The Hidden Curriculum 3.30-4.00 There is the explicit curriculum – what you’re taught and the hidden curriculum, what you see in practice. Also see paper on role models and empathy. 6.00 Clinical curiosity is a form of empathy. 10.50 Most of us when we’re sick want to be taken care of
Why doctors should be more empathic, but not too much more. Scientific American 2011
Empathy lost and found
When do medical students lose their empathy? Kevin MD 2013
Help, I’m losing patient-centredness! Experiences of medical students and their teachers. ASME 2010
Empathy, lost or found in medical education?
Is There Hardening of the Heart During
Medical School?
The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School AAMC 2009
Reports of the Decline of Empathy During Medical Education Are Greatly Exaggerated Colliver 2011
Teaching empathy
Empathy’s blind spot. John Slaby. Medicine, Health and Philosophy.
Teaching empathy to medical students: an updated, systematic review. December 2013
Teaching the Human Dimensions of Care in Clinical Settings
The limits of empathy: problems in medical education and practice Smajdor 2010
From detached concern to empathy. Humanising medical practice.
The hidden curriculum, ethics teaching, and the structure of medical education
Supporting the Moral Development of Medical Students Branch 2000
The Ethics of Caring and Medical Education.
Is ethical development impeded in young doctors? Branch 2001
Care for Nurses Only? Medicine and the Perceiving Eye
Medical Students’ Perspectives on Clinical Empathy Training
Should medical schools be schools for virtue?
Patients’ Trust in Physicians: Many Theories, Few Measures, and Little Data Pearson 2000
On Kindness, John Launer: “I’m not a clever doctor, but I am a kind one.”
Association of Perceived Medical Errors With Resident Distress and Empathy
Reification and compassion in medicine: A tale of two systems
Compassion in healthcare Zulueta. Clinical Ethics December 2013 It is clear that attempting to force individuals to be compassionate whilst creating systems that militate against it will fail. Trying to harmonise conflicting ideologies is also undoubtedly a very difficult task. Perhaps we do need a radical paradigm shift
Clinical Ethics
Compassion isn’t the key to NHS failings according to UEA report (above)
The last thing the NHS needs is a compassion pill. Penny Campling, author of Kindness in Healthcare
Zero degrees of empathy. Simon Baron Cohen
Phenomenology and its application in medicine
Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland
Empathy flowing both ways: The empathic patient
The Developing Physician, becoming a Professional NEJM
A prescription for what ails: We need to promote great medical education today, and this requires that we renew our focus on building meaningful relationships between three essential people: the learner, the educator, and the patient
Brene Brown, The Power of Empathy Open Culture
A Better NHS 
I like how you discuss the value of empathy, the need for training and a supportive culture. As well as proactively building empathy there’s a need to look at the reasons medical staff may resist being empathic, and see how we can unlock this resistance.
Do you know Isabel Menzies’s paper, “Social Systems as a Defense Against Anxiety”? http://www.moderntimesworkplace.com/archives/ericsess/sessvol1/Lythp439.opd.pdf
She spent time in a teaching hospital, and came to realise that many of the practices that reduced empathy between staff and patients – like the discontinuity in care you mention – served to protect staff from the upset and anxiety of working with seriously unwell people.
A simple answer to this is supervision, giving medical staff someone to talk to who’ll listen, show empathy to them, and let them offload the stress of their difficult jobs. This will restore staff’s capacity for empathy, and give them the resources to bring empathy to patient relationships.
Thanks Ollie,
My previous post about the emotional labour of care reference Menzies and updates it with a few contemporary references. I’ve written essays about how shame presents in healthcare relationships and about the role of forgiveness.
I’m sure you’re right about supervision, it’s hard to do well. I’ve written about it in a post called, Love, hate and commitment. I think Schwartz rounds have great potential too.
Jonathon
I think you put your finger on the paradox at the heart of the modern NHS: on the one hand we are told that it needs to emulate ever more closely the market/consumerist ideology that permeates the rest of our society; and on the other, we are told that as practitioners, we need to found our practice on a totally opposing discourse, that of person-centred empathy and compassion. Oh, and by the way, all this needs to take place against a background of diminishing resources and rising demand.
Business has answered this conundrum, as Dr Smajdor points out, with the ‘have a nice day’ McDonalds school of customer relations. The public isn’t fooled – they rightly treat it as a joke. But is it preferable to the standard of interaction sometimes showcased by NHS personnel? And what are people entitled to anyway? How much real empathy or compassion is it realistic to expect a single individual confer?
The government seems intent on politicising compassion (at least as far as nursing is concerned) by making pay awards partly dependent on an ability to demonstrate it. No one knows how they plan to measure this ability, but one possiblity is by focusing on communication. If patients have been on the receiving end of good communication (and I don’t mean counting how many times they are enjoined to ‘have a nice day’ – but asking patients if, for example, they felt listened to, even if the professional could not ultimately provide the answer they were looking for) the question then becomes: does the patient also have to right to expect to be on the receiving end of the professional’s deep and genuine compassion? The answer has to be: what would they expect in any other walk of life? Or are we going to say that health care is subject to special rules of its own?
I think we make exceptional demands of healthcare professionals (HCP), hence my inclusion of the fiduciary relationship. The imbalance of power is inescapable no matter how much we aim for and succeed with patient involvement, shared-decision making and so on, – all of which is good of course. It might narrow the power gap, but it can never eliminate it.
This means that HCP have to follow a code of ethics which acknowledges the power we have over our patients and patients have every right to demand higher moral standards from HCP than they do from people selling them goods or services.
The minimal ethics demanded by an emaciated version of empathy – mere etiquette – might be ok for someone working in MacDonalds, but is insufficient for HCP. We must aim higher, we must understand why they are threatened and try to do something about it.
Agree that we must try to understand why patients feel threatened and to do something about it. My question was more about the degree of emotional involvement that is needed in order to achieve that. On a personal level, I would find any attempt at emotional involvement from a professional unwelcome and patronising – I’m unique: I don’t want anyone else to ‘undertstand’ me! I would hope for kindness. knowledge, honesty, and a willingness to listen to my point of view – but nothing more. I don’t think we should expect HCPs to be superhuman, and it’s a concern that the government seems to be encouraging the public to think we should be.
We’re working on the empathic culture change at:
Center for Building a Culture of Empathy
http://cultureofempathy.com/
see our Sub Conference: Empathy in Health Care
How can we transform health care system to be more empathic and compassionate?
http://j.mp/N98AoS
As a patient with a complex condition I have been subject to the complete range of experiences. Small things can make a big difference say for example a hand shake and introduction. I don’t mind abrupt efficiency it gets the job done and protects the doctor. The best consultant I ever had recognised the difficulty, showed kindness, let his personality come through, was knowledgeable but admitted when he wasn’t and referred me on, listen to my knowledge about my own condition and respected it, respected my doubts about certain medications, shared small amounts of information about his own concerns for example his grandaughters chicken pox. He had patients with worse prognosis than me and I respected that he in turn showed admiration for what I was achieving alongside managing my health. While I was in the consulting room he cared about me but I knew he did not carry my problems along and I felt happier for it as that was not part of my expectation.
I wished everyone could have the chance to train with someone like that. But even if they did would they get it? I agree that work pressures are currently so immense that it is perhaps too much to ask – so shake my hand, respect my opinion and don’t take my problems home with you.
The worst practioners get angry with me when they feel they can’t help me. It really does not help to try and shove medications or procedures down my throat that will make it worse.
Empathy is the ability to walk in another man’s shoes. The more we have the less empathetic we get – hence when the patient said they couldn’t work = can’t earn money = will incur personal suffering (perhaps not being able to feed the children) because they’d got a bad back, the doctor can’t empathise because they can never visualise themselves going hungry in a developed society.
That’s what the patient was saying but the doctor couldn’t walk in the other man’s shoes. To the doctor the bad back wasn’t a big problem, to the patient it was massive.
Thanks. This excellent essay eloquently outlines a great conundrum I have been grappling with for a while and has helped me clarify my own thoughts and understanding of the conundrum. Essentially, are doctors too busy to care? Are they too abused and unloved to care?
How are doctors abused?
Nobody is ever too busy to care. Ever.
Empathy isn’t about building a personal relationship (although maybe a better relationship will develop from it) Empathy is about understanding your patients and assessing impact. This is about medical staff doing their jobs properly and effectively. You cannot make this about the staff. You don’t go to a bank manager and expect him to start moaning about his financial affairs – do you? Medical professionals really have to start understanding that they are not the most important person in the scenario – they really aren’t. It’s doing the job properly that is important.
If you go back to the original scenario of the patient self employed and worried. Let’s put the boot on the other foot. Tomorrow the NHS are announcing that their will be no more sick pay given to staff. You are off sick and you don’t get paid. End of story, no arguing.
My bet is that your first thoughts on reading that statement is “They can’t do that. They won’t do that. That won’t happen to me.”
But what if they did (it is actually possible within law) – there would be uproar. Yet the doctor in the initial scenario never even considered the implication for the self employed patient.
In the simpliest of terms, the doctor didn’t care.
And you think doctors ought to be ‘loved?’
I’d aim for some old fashioned earned respect and keep my fingers crossed.
… and I know I’m leaving another comment (and maybe it won’t get past moderation) but here we go:
When I say that doctors are not the most important person in the scenario – their skills (if they are good doctors) are – and this is why:
The harsh reality is that medical care, for the most part, is needed in our society to maintain a good economic status.
People get sick, they are out of the employment arena, they are not producing money for the economy.
The medics are there to put those people back into economic productivity.
The medical profession in itself is non-productive. It is only productive when it does it’s job well and, obviously indirectly, by getting people back into work.
Because it doesn’t produce anything of monetary value directly, if it doesn’t do its job well, all it is is a drain on the finances of the nation. It becomes a financial liability.
You obviously have expections in a so-civilised society – geriatrics etc – but for the most part the function medicine performs is economic.
As a doctor of many parents, a parent of 2 children and a relative of sick family members, I’ve often found myself too exhausted, worn down and worn out to be as empathetic as I would like to be. You could read the last blog about the emotional labour of care and the references to see what I mean.
I also think you have confused professional behaviour and etiquette – which I agree, and emphasise in this blog – are in short supply, with a deeper concept of empathy and caring.
I tend to think that the attitude that carers should be able to care without being cared for to be (at best), naive and counterproductive.
Karen, by abused and unloved I refer to the highly stressful and pressurised environments modern day doctors often work in. See Johnny’s discussion of undergraduate and postgraduate training above. In addition, doctors come in for criticism from many angles – patients, politicians, managers, and the press. I’m not saying it’s always undeserved, just that it’s there.
There are manifold demands on a doctor’s time, energy and resources, and yes, on their capacity to empathise and care. I don’t say this to defend myself or other doctors. I say it in lament. I wish I was afforded the time and resources to spend more time with each patient I see, to build a relationship and have time to really care, but unfortunately this is not always the reality of my daily work.
I think it was really courageous of Johnny to publish this essay, especially so publicly examining his own empathy, behaviour and practice. But I think it is important that we be transparent with patients, the public and politicians about the reality of the system we work in. I would also concur with Johnny that it is, at best, naïve to think that carers can care without being cared for, or working in a caring environment.
Oh, I agree on many points – for instance I think there is a little confusion between simply good manners “Good Morning, how are you?” and empathy.
And I also think we have to examine the working situation of different types of doctors. Take GPs for instance. These days, you can’t go to a doctor at the weekend. Most close around 6. Many close for lunch. Things have changed – GPs work less hours than they used to.Of course there is going to be less time for each patient.
However, if you fail to empathise, you fail to do your job properly. Asking the correct question sometimes gives you an insight to the problem. And if you get that insight perhaps that patient would be able to attend less frequently?
What is the difference between a GP (I’ll be specific) seeing a patient and a patient attending a doctors and inputting information into a machine?
If you have no empathy, if you have no insight, a patient could just as well walk into a cubicle, and tap on a touch screen – where is the pain (options) it is sharp/dull/aching (options) – it seems extreme, but I am actually serious. Have a few nurses around to take bloods etc and assist and the machine recommends, referral/dispensary etc.
Think about it. 24 hour round the clock 7 days a week.
(If Jeremy Hunt is reading this column he’ll be having a field day!)
And I think I should comment on this statement:
“I would also concur with Johnny that it is, at best, naïve to think that carers can care without being cared for, or working in a caring environment”
What is it you are asking of the patient?
To expect a lower standard of care because of your situation?
I can understand how someone can be in this situation,obviously – what I can’t understand is what you are expecting a patient to do about it, other than accept they will get a lower standard of care because of your situation.
Other people, if they are in that situation, have to change jobs, or give up jobs, or take time off (if they are allowed.)
You can’t be a vet and tell a farmer – sorry, but I’m really too shattered to look at your cattle properly today. If they don’t die, I’ll come back next week if I’m feeling a bit better. Oh, and by the way, I still want paying.
I think to suggest that taking empathy out of the equation reduces the function of a doctor to something that could be replaced by a computer is massively oversimplifying one of the most complex fields of human endeavour.
Right now I’m not asking anything of the patient. I just feel we need to have an open and honest conversation about the reality of our health system. The reality is, if you give me 8 hours to see 10 people I can spend much more time with each than if you ask me to see 50 or 60 in the same time. And obviously the amount of time available for a consultation has an impact on the quality of the consultation. And since this is the reality for most doctors, all of us giving up or changing job is not going to help. In fact, if some leave it is likely to be worse for those that remain.
Regarding your farmer example. That is where clinical judgement comes in. Not all patients need to be seen straight away and it is sometimes appropriate to ask them to wait. Doctors have a duty to practise safely, and overtired doctors can make mistakes.
I understand what you are saying but this thread is about empathy for patients. It’s about doctors not really understanding what empathy is (except the realisation is dawning that they expect to receive it.)
The analogy between doctor and machine, I think, based on personal experience, is quite accurate.
The thing that drew me to this thread, is that I went to my doctor with a bad back. My GP’s response was, ‘Oh yes, I had that a few months back and I couldn’t ride my bike for 2 days.”
Since I earned part of my living doing very strenuous out-door work and not only couldn’t I do it, but I couldn’t sleep either (because of the pain) so I was zombiefied to say the least, I found his response, trite, patronising and totally lacking in empathy (He didn’t care whether I earned money or not) He also told me to take 8 paracetamol per day (which improved it next to nothing) But this situation went on for 3 months by which time I was in pretty much a mess (financially speaking)
Further down the line, it transpired that the bad back was indicative of a much more serious condition.
Would I have been better off sitting in front of a machine that looked at facts only?
Would I have been better off with a doctor who empathised with my situation and decided to do other tests sooner because they knew I wasn’t in a position to sit with my feet up or I was going to cause further damage by having to lift heavy loads etc?
Some might say that my GPs comments about his bike was his effort as building up a rapport – but that only carries weight if he continued to show further concern about how my illness was affecting me.
I think we do need to have an open and honest discussion about the state of the system – because in a lot of ways I don’t know why it is going wrong on so many sides.
I look at France that has nearly the same population, it has less doctors, yet it functions effectively.
Yes, people will say that more money goes into it as a percentage of GDP (and I would question how it is calculated) but that doesn’t alter the maths. You get a rural doctor, you get a waiting room full of patients (and they are always full) time to see patients is not limited, yet everybody appears to be happy.
Although even if you have an appointment be prepared to wait a couple of hours.So what is it. They aren’t knee deep in admin staff, blood tests are done away from the surgery (time saver, sort of) loads of things are different.
Is it the basic care in the UK that’s at fault? The, ‘you can only mention 1 or 2 or 3 symptoms’ situation (when many symptoms may be indicative of 1 condition.)
What I do remember from many years ago is being told “If you choose to work with people or animals then you choose a vocation rather than a job – don’t ever expect it to be just a job. With a vocation you will always give a lot more than you get.”
I really don’t know if doctors in different countries have different struggles with empathy, I’m not aware of any studies, though the research on the emotional labour care I referred you to earlier, as well as the references in this post are from the International (albeit English speaking) literature, so I don’t really understand your comparison with France. I don’t claim that empathy is more or less lacking in any particular nation’s health-service, but I have no doubt that anyone who cares struggles with it, at least a little, which is why I wrote this post.
Your personal experience is a valuable contribution, but the range of interactions we have with patients is unlimited and so too the extent to which empathy is (or needs to be) part of those interactions.
My experience is that for the majority of healthcare workers, their choice of career is a vocation, after all, most of us were motivated by a desire to help people, but some were forced to become healthcare workers by ambitious parents, their own experiences of health and caring, financial necessity, intellectual curiosity, a love of science, an interest in human relationships, social justice, etc. etc. the reasons are endless as I have discovered by teaching young medical students for the last decade or more. I think anyone in healthcare expects to give more than they get, that’s the nature of caring after all. But the question is whether our capacity to care empathetically is without limits, or if we assume not, where might those limits be and how might they be shifted.
Jonathon
My comments about France were purely in respect of how the French system functions effectively overall – not specifically relating to empathy. However some of the factors may contribute as to why they can be more empathetic and make a better health system. The patients and staff are proud of their system – they have got to be doing some things that the UK could learn.
Your last paragraph sort of sums it up for me. You’re now appearing to say that doctors do empathise but they can’t do it limitlessly? Why the article in the first place? It is titled Teaching Doctors Empathy.
One way to get more time – work weekends. That way you get more time with your patients, you may pick up on things sooner, and they may attend less.
You say you know what a vocation is – it means working weekends. Not in its entirety obviously, but it’s not 9-5 Monday to Friday. Yes, it will play havoc with your personal life, but hey, it’s a vocation, you are driven to do it. Yes?
It’s no use dismissing what I say as one case, you have to take it on board. You have to accept that if that doctor behaved like that toward me, he probably did it a lot.
You know it says throughout this that empathy is the ability to walk in the other man’s shoes – can it be taught? You can teach anything. Can it be learned? – I actually really doubt that.
The evidence about whether we can teach empathy depends on how you define it, measure it and teach it or learn it. I’ve included all the references if the blog doesn’t answer those questions for you. A lot of people feel quite strongly one way or the other. There is an up to date systematic review of studies asking if empathy can be taught linked above, also here: http://www.ncbi.nlm.nih.gov/m/pubmed/23807099/
There are a lot of thoughtful descriptions of what it means for medicine to be a vocation. I’ve written about it here: https://abetternhs.wordpress.com/2012/12/05/love/ but perhaps the most eloquent description is by Iona Heath: http://www.internationalfuturesforum.com/u/cms/Iona_Heath_Lecture2012.pdf
David Loxterkamp has written very well too: Doctor’s work, Eulogy for my vocation: http://annfammed.org/cgi/reprintframed/7/3/267
I’ve hoped to add some original thoughts to the debate and I’m glad you’ve found them interesting, thanks for your thoughts too.
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Jonathon, when I first read this discourse I felt that I needed to go away and reflect on my own “limited” experience from a lifetime in the secondary care arena. Now, a few days later, I will share my own take on the meaning and value of Empathy.
For starters we have a word which, like so many other words in the English language, means different things to different people. My interpretation relates to the experience of having been in the same situation as the patient. However, there are far too many medical scenarios for one to have been able to experience all of them. Therefore one develops ones approach by applying a mixture of one’s first hand personal experience with second hand experiences through other people’s eyes.
If a student embarks on a medical career as a vocation, then empathy should already be part of that calling. Today, I get the impression that fewer and fewer doctors are entering the profession with “vocation” stamped on their souls. In that case can you really “teach” empathy?
The second issue with empathy is how you transmit your empathy to the patient. No two patients are the same. Your body language is probably more important than any words you might choose to say. Good eye contact and a gentle hand on the patient’s shoulder might mean more to some patients than any combination of words. Empathy should come at the end of the consultation when you have completed your “scientific” evaluation of the situation. After all, the patient sought your advice as a medical professional. If all they wanted was “empathy” then a leader of their own religion might be more appropriate.
However, when all is said and done, there is the inescapable fact that we have allowed the politicians to dictate how we should practise; with targets, Working Time Directives, and endless volumes on governance and revalidation, but without giving us the resources to deliver these arbitrary outcomes.
Anyone wanting to see how this has impacted on care should read the Immediate Review Report on Cancer Services in Colchester, published on 19th December 2013 (Publications Gateway Reference – 00958.
Many of us started with “Empathy” emblazoned on our hearts only to find that the political handicaps cast in our paths make it extremely difficult to keep that flame alive.
Excellent essay.
As a stroke patient who’s mostly recovered through no help at all from the NHS and anything but empathy from the NHS staff I encountered over several years, I’m moved to comment.
All this talk about ‘Well they expect us to be more competitive and businesslike, empathy can’t possibly survive let alone flourish in business!’ is sheer nonsense.
In a decade of atrocious and often callous, even breach-of-duty-of-care abusive NHS responses, ALL the empathy and help I ever got was from the commercial services I dealt with in everyday life. I will name them here because they are shining examples of how to run a successful business by concentrating on customer care and satisfaction by invariably going the kind, empathic extra mile:
Tesco stores (brilliant people), NatWest (does your banker hug you every time you go in? because she knows how you feel because she lived through the dire way her poorly husband was treated by the same local NHS…), DirectLine (seriously and practically kind), VirginMedia, the local utilities companies, the Halifax, Standard Life, B&Q and many local/small businesses.
IMHO, NHS staff have got to stop feeding themselves this massive myth that ‘business is callous’ and using it to fuel the ‘we must not be privatised’ protest. How do NHS staff think that successful businesses actually build and maintain customer loyalty?
I take your very good point that doctors, nurses and other frontline clinical staff are not supported or loved or valued by their bosses at NHS Central. With intra-staff bullying running at about 25% of the workforce (BMJ and NMC surveys), it’s absolutely true and scandalous, heinous even in an organisation that parades itself as caring for people’s health and wellbeing.
But that’s no excuse to pass on your pain via callousness to patients. Why not address the problems with your bosses? (Hint: being a coward doesn’t work! Extra pay doesn’t cut it either. You have to stand up for what you need and deserve!).
All the best
Sam
Thanks for your comment Sam. I share your experiences of very different treatment from different types of providers of banking, groceries, utilities and so on. I agree with you that it is simplistic even to suggest that business is necessarily corruptive of good customer service, clearly in most cases, business success depends on treating customers with respect.
Likewise a childhood of abuse and neglect might explain but does not necessarily excuse an adolescence of deliniquency.
The Labour of Care – discussed in the blog preceding this one is an important part of my concern, caring for sick people is not the same as dealing with their plumbing or their internet connection. As Iona Heath says in her review of Intelligent Kindness:
… “it is easy to forget the appalling nature of some of the jobs carried out by NHS staff day in, day out—the damage, the pain, the mess they encounter, the sheer stench of diseased human flesh and its waste products.” Of course, such forgetfulness is not at all easy for those actually doing this work, those struggling not to allow any hint of their physical revulsion to show, but these challenges seem hardly to register in the conscience or consciousness of those charged with the running of the NHS”
Courtesy, courage and compassion are all desperately patchy in the NHS, and after all I have written above, I do think that there is a lot that can and must be done to improve our behaviour, in spite of the bad and worsening conditions we’re facing.
With warm regards and seasons greetings, Jonathon
Thank you for your kind reply which has added further thought-provoking dimensions.
Of course, many others must contend with human wreckage and pain daily and up close. I think of e.g. firefighters, police officers, MacMillan nurses, the many hundreds of thousands of unpaid carers without whom the NHS would probably collapse, good nursing homes (there are quite a few!) and people who work in hospices. With some horrible exceptions, it seems that mostly these other people get on with their very demanding work reasonably satisfactorily. That suggests to me that there is a profound systemic problem in the NHS – could we say a failure of courtesy, courage and compassion from the top which taints all it comes into contact with?
“Courtesy, courage and compassion” makes such a good operating principle mantra. I’d like to suggest that frontline staff would have the public’s greatest support if they stood up in a courageous, calm, concerted way to the ‘excess of callous’ heaped upon you (and then passed on to patients) by NHS Central, wherever that is – I suspect it’s an amorphous giant octopus with many tentacles, none of which take any responsibility for their own brainless and heartless activities!.
The point is, I think, that this movement has to come from within – clearly politicians aren’t too successful at inspiring compassion, courage and courtesy, neither are patients who are too often ignored and derogated. The fundamental change that’s needed has to be both top down and bottom up. You deserve much better – and so do patients….
May your new year be filled with cheer as well as courtesy, courage and compassion! (apologies for all this C-word alliteration! Conjured up by Christmas care and concern…?)
Thanks again Sam. I’ve just started a 2 year period of study to try to work out how to help healthcare workers develop, nurture and sustain the virtues we need – which are there in abundance already in my experience of many parts of the NHS. My recent blogs have been just testing the waters to see what is known and what evidence exists. This was sent to me last night and gives some useful guidance http://mobile.journals.lww.com/academicmedicine/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2012&issue=07000&article=00010
I look forward to sharing my discoveries!
Happy new year
Jonathon
I should of course gently argue that winterbourne view and countless other privately run institutions have suffered from deficits of courage, courtesy and compassion, I don’t think that the NHS is exceptionally lacking in these qualities, though as you note bullying and rates of staff sickness are exceptionally high and undoubtedly related.
Dear Jonathon
In the course of my research, I’ve just come across a superb and eloquently written paper which, I humbly submit, sums up much of what we’re saying and explains, in depth, the dynamics of NHS management failures vis a vis real human beings who have to comply with a plethora of fubar cost-cutting targets and control freakery diktats on a daily, practical basis.
Although written in critique of the NHS’s IAPT project, the author takes a broader view of the increasing ‘surface audit’ practices which are mistaken for and misrepresented as successful ‘patient outcomes’ and the overweening governance/performance measurement culture of the NHS.
Most pertinently for our discussion, I was particularly struck by the case study. Younger/inexperienced staff articulated that they were anxious about the pressures of the bureaucracy involved and the lack of space for empathy which, they felt, are much to the detriment of their patients and their own emotional/psychological health (i.e. risk of curtailing or eradicating their authenticity and congruity – their compassionate humanity in other words!).
Despite “considerable resistance from senior managers”, staff support groups were eventually permitted by these managers. At a meeting with clinicians though they imposed the caveat “that the groups should be closely monitored and evaluated to demonstrate their value.”
One of the managers at the meeting said, “Well, I suppose we need to be seen to be doing the ‘touchy-feely’ bit”.
If that foul, almost sociopathic utterance didn’t set alarm bells ringing throughout the corridors of power at NHS Central then I fear we’re sunk – or at least we have a massively monumental job ahead in saving and supporting the normal, healthy compassion and humanity of normal frontline staff in the NHS, as elsewhere in public services.
[Ref:
The perversion of care:Psychological therapies in a time of IAPT
Rosemary Rizq
Department of Psychology, Roehampton University,
Holybourne Avenue, London, SW15 4JD, UK
Version of record first published: 09 Jan 2012.
Downloadable PDF: https://docs.google.com/file/d/0B5cLaT3gdm9Nc2xMSXE4WnVmRWs/edit?pli=1 ]
Again, like you, I’m certain that there are many NHS staff who are brimming over with the milk of human kindness. But they are being systematically eradicated and/or terminally suppressed by this “fascist state of mind” of the bureaucrats and bean counters.
I very much appreciated the paper to which you linked ( Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians
Leape, Lucian L. MD; Shore, Miles F. MD; Dienstag, Jules L. MD; Mayer, Robert J. MD; Edgman-Levitan, Susan PA; Meyer, Gregg S. MD, MSc; Healy, Gerald B. MD
Academic Medicine
July 2012
Vol. 87 – Issue 7: p 845–852)
Thank you – another candid, no-punches-pulled, must-read for anyone concerned with encouraging and nurturing genuine compassion and safety in the NHS et al.
A happy new year to you too, and all power to your project.
Sam
Reblogged this on Lorraine Cleaver.
I went to a nursing home today and this jolly nurse came with me to see the patient and helped me with my enquiries. We walked to the door together and I smelt that nursing home smell and I thought i’m leaving but you are here day in day out, probably the only trained staff, working alone, confined in a small space, no chance to go outdoors, with no-one to talk to and middling pay, so I looked at her and said ‘you do a difficult job’. We reached the door, she smelt the air and I could see the pallor of institutionalism break for a moment, and she said ‘I do’. I told her I understood. I went to my car to go back to the surgery and she said ‘what is your name again? Dr? ‘ ‘alexander’ I replied, ‘charlotte’. She smiled again. My afternoon was hard, but hers was harder. We have to be kind to each other, otherwise we become degraded and there is nothing real left for any patient. We have to make time to make work bearable and fun if possible, nothing is as important.
I came over to your post from another website as I did a search for empathy. There is also a word bandied about now that is “empath.” I read your article and I commend you for your service to people. My father (who worked until he was 80 years old) was a “general practitioner” — he was an excellent diagnostitian and as I was growing up I saw him never miss work and this was instilled in me and my siblings as well. His patients came first; we were a second it seemed, but we knew that what he was doing was important work. Was he empathetic? Yes, but his personality allowed him to be empathetic and to also protect himself. Why was I looking up websites about empathy? Because I have just “burned out”… after 2 1/2 years on a hospital floor (and as a new nurse) I am calling it quits. I look at my father and I look at me. One of the differences between us always was that I was more of an “empath” than empathetic. I in the end could not emotionally sustain the long hours and drama and sorrow and day to day, being a “healer.” I think that empathy is not dead. I believe that the “caregivers” — doctors, nurses, PTs, OTs, social workers, psychologists, patient care technicians, etc. are to a breaking point or retreating into themselves, for survival in a system that will use them up and spit them out. I think just saying to a patient, “I’m sorry that you are feeling bad. Let’s see what we can do” is sufficient…. if you pour your heart and soul into this work, you will be shattered! It happens more than anyone realizes. It’s not reported because everyone thinks that you are being paid a lot of money to do what you do…etc. I will say to you, keep your boundaries strong. Learn some phrases of empathy, mean them when you say them, and go on to serve your patients as you do. I also believe from my own personal experience as a nurse, that the less empathetic you are in these fields, the longer you will last. There is a great inbalance in the system as it is. Not sure what will “heal” it. Here in the States everyone thought that when we got our brand of “national healthcare” that that would take care of “the problem with healthcare.” Guess what that might not be the answer to the problem. Certainly we needed to do something for those of us who needed health care insurance. It’s just one little piece though. Are we asking the wrong questions? I have no answers… I am getting out while I have my sanity and health. I pray daily for the doctors, nurses and other staff that are doing their best to give care.
Thanks so much for sharing your experience, I wonder if you are familiar with Menzies Lyth’s work on buses and social defenses? It reminds me very much of what you describe
See my blog on the emotional Labour of care for links. I worry about pressurising nurses and other health care professionals to be more Compassionate without also looking after our emotional needs much better,
Jonathon