Observations Ethics Man

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
  1. Daniel K Sokol, honorary senior lecturer in medical ethics, Imperial College London, and barrister, Inner Temple, London, UK
  1. daniel.sokol{at}talk21.com

Imperturbability is an essential characteristic for doctors, reflects Daniel Sokol, but how compatible is it with empathy?

At law school, as at medical school, however hard you study nothing quite prepares you for the real thing. In court, when your opponent rises to invoke an unfamiliar and potentially killer point, the mind tends to panic: “Where did this come from? Did I miss something in my preparation? What am I going to say?” Searching frantically for a response, you watch in despair as your opponent sits down. The stern looking judge nods expectantly in your direction: it is your turn to rise and speak. The world is now a lonely place, with nowhere to hide. Although stressful, this experience is central to professional development.

Experience alone, however, is of little value. The psychologist Anders Ericsson, an expert on experts, declared in a recent book that he had been “unable to find any evidence showing that experience has any benefits unless people pay attention to feedback and actively adjust.”1 For it to be effective, experience must be reflected on. This article is part of my reflection, but I have also got into the habit of jotting down key lessons after an eventful day in court. Recently, I simply wrote: “imperturbability.”

Although empathy, compassion, and kindness are buzz words in medical schools (so much so that some clinicians associate ethicists with bleeding hearts and sentimentality), the great William Osler told medical students in 1889, “In the physician or surgeon no quality takes rank with imperturbability. The physician who has the misfortune to be without it,” Osler continued, “who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.” This appears at odds with the modern focus on empathy, but does Osler’s view have a place in medical practice today?

It is often said that before the past few decades medical ethics emphasised manners, etiquette, and decorum, with empathy having only a small part to play. The importance of empathy today can be ascribed, at least in part, to the unprecedented use of technology in medicine; the limited time available to see patients; and the integration of communication skills, ethics, and the humanities in the medical curriculum. Empathy emerged as a counterpoint to the “stranger at the bedside” phenomenon, attempting to give the stranger a human face. The focus on empathy in the training of medical students has made the Oslerian virtue of imperturbability unfashionable.

A key problem with empathy is that it cannot readily be taught to those who are not, by nature, empathetic. You cannot teach empathy as you teach how to perform a lumbar puncture. In that respect, there is much to be said for focusing on less nebulous qualities, such as courtesy and politeness. As I have argued previously, these are undervalued traits in medicine, and although their importance may be obvious their application is more challenging in the heat of a busy clinic, when frustration and fatigue can test even the most patient doctor.2

Aside from the difficulty in teaching empathy, it is debatable whether it is a desirable quality for doctors.3 Indeed, the ill effects of empathy underpin the reason why doctors should not treat loved ones. A degree of dispassion is needed to maintain a medical gaze not blurred by too great a concern for the patient as a person. Yet, the questionable benefits of empathy do not derogate from the importance of kindness, which is a less demanding emotion. Few patients would object to a kind doctor. Many more would have concerns about an empathic doctor, fearing this shows either inexperience or a lack of mental fortitude. In the debates on the acceptability of doctors crying in front of patients, praying with them, or displaying outward effusions of emotion, at the risk of appearing heartless, I side with Osler. There must be an outward calm, a reassuring coolness, although it must not veer into indifference. Imperturbability is compatible with showing concern for the patient, and Osler himself is a case in point.

The million dollar question is how to develop the quality of imperturbability, and here lessons can be gleaned from the world of elite performance. According to the Yale psychiatrist Andy Morgan, who has conducted research on stress in military trainees in the United States, perception is key: “How you frame something in your head has a great deal to do with your neurobiological response to it. Once you start saying to yourself, ‘Oh my God, this is awful,’ you begin releasing more cortisol and start this cascade of alarm.”4 Neuroscience is deepening our understanding of stress and decision making, but it is clear that the poise of those doctors we admire is more than innate disposition. It requires repeated gritty experience and subsequent postmortems to discover what went right and wrong and to find ways to improve. This appreciation of the potential value of experience may, in itself, be reassuring next time an unexpected difficulty arises in the clinic, the operating theatre, or in Uxbridge County Court in front of a stone hearted judge.


Cite this as: BMJ 2012;344:e3980


View Abstract