Intended for healthcare professionals

Observations Ethics Man

How to be a cool headed clinician

BMJ 2012; 344 doi: (Published 08 June 2012) Cite this as: BMJ 2012;344:e3980

Re: How to be a cool headed clinician

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.

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
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

Competing interests: No competing interests

27 June 2012
David M Wheeler
GP Principal and trainer
Greenwich GP Training Scheme
Gallions Reach Health Centre, London SE28 8BE