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: None declared

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: None declared

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: None declared

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

[1]http://www.gmc-uk.org/news/12220.asp

[2]http://www.bmj.com/content/344/bmj.e3085

Competing interests: None declared