Rammya Mathew: The pursuit of being a good doctor

Rammya Mathew observes that the concept of "empathy" is ambiguous, but the article is entitled "empathy is vital to being a good doctor". I would suggest that these two statements are incompatible.

The etymological key to "empathy" is the "em" meaning "in". I would contend that that it is simply impossible to feel "in " another person, however well you think you know them, and especially in a stranger who presents to you as a patient in need.

The underlying assumption that you can, verges on arrogance. On the other hand sym(pathy) means togetherness or being close alongside, acknowledging a common humanity but without entering into the personality of the other person; a figurative or abstract supporting arm around the shoulders. The idea of sympathy and kindness is much more relevant to medical practice than this strange and overused word empathy.

In any case, speaking now as a patient rather than a doctor, what is indeed vital for a doctor is not any "pathy", however desirable, but competence. Competence is so often overlooked and assumed. There is none so dangerous as the incompetent doctor with the good "bed-side manner".

I suggest the title should be rephrased. "Competence is vital to being a good doctor."

Dear Editor,

I perused with interest the article by Dr. Mathew and the preceding correspondences. I agree with the contents.

Empathy differs from sympathy. In empathy, the person always tenders timely help, whatever and wherever it is possible. In sympathy, the spectator only feels it without offering any help. Burnout (emotional exhaustion with depersonalization) is the protective mechanism to avoid depression and mental breakdown due to excessive mental and emotional fatigue, largely because of protracted overwork. Burnout is more of a system-related issue. Unless we manage the system intelligently, we cannot create/train good doctors.

A thought-provoking piece from Dr. Mathew though I wish to highlight a different perspective.

In searching for the answer of what it means to be a good doctor, we must ask and engage with those who are on the receiving end of our care.

In the setting of general practice, a systematic review of patients' priorities was conducted over two decades ago (1) where aspects of care such as “Humaneness”, “competence/accuracy” and “involvement in decision-making” were most often reported as being important markers of good care. The importance of these priorities has not changed over the years.

In a more recent study of Swiss patients, doctors with qualities such as sensitivity to feelings and relatedness were equally as appreciated as those with scientific proficiency. (2)

Indeed, a somewhat surprising statistic from a UK HealthWatch survey in 2018 was that two thirds of people surveyed said “they would rather be treated by a human doctor who is more likely to make a mistake but offers compassion than by a robot doctor that rarely makes a mistake but lacks compassion.” (3)

One can only speculate on the change in proportions if the scenario was based on a life or limb threatening mistake.

Nevertheless, for many patients and members of the public, empathy is clearly as important a quality as technical skill or expert knowledge.

In examining the impact of the empathetic doctor on measurable patient outcomes, Howick et al (4) conducted a systematic review and meta analysis of RCTs, demonstrating that empathic consultations improved pain, anxiety and satisfaction ratings.

Lastly we must consider the impact of empathy towards each other as healthcare professionals. Although one can come at this from many angles, including burnout and retention, I am keen to keep the frame on patients. In a recent BMJ paper by Panagioti et al (5), an estimated one in twenty patients are still affected by preventable harm, of which 12% suffer permanent disability or death.

I wonder about the unmeasurable value of empathy in aiding in the pursuit of reducing avoidable harm. From frontline team working and avoiding communication errors caused by mitigated speech, to the highest levels within our system and investigating errors, we stand the greatest chance of being “good” doctors if we can show empathy to everyone at the workplace: colleagues, allied healthcare professionals and patients alike.

References

1. Wensing M, Jung HP, Mainz J, Olesen F, Grol R.A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain.Soc Sci Med 1998; 47:1573–1588.
2. Luthy C, Cedraschi C, Perrin E, Allaz AF.How do patients define “good” and “bad” doctors? Qualitative approach to the representations of hospital patients. SWISS MED WKLY 2 0 0 5 ; 1 3 5 : 8 2 – 8 6
3. Healthwatch (2018). What do people want from the NHS and social care in the future. Available at: https://www.healthwatch.co.uk/sites/healthwatch.co.uk/files/20180928%20P... Accessed on 28 August 2019.
4. Howick J, Moscrop A, Mebius A, Fanshawe TR, Lewith G Bishop FL et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysisJ R Soc Med. 2018 Jul; 111(7): 240–252
5. Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ2019;366:l4185.

Dr Mathew's welcome comment on empathy in medicine rightly notes that patients put high value on our capacity to "identify with and transiently experience" their emotional states. She does not say how this can be done.

For several years UCL medical students on the Paediatrics and Child Health BSc course have joined regular group discussions based on real stories - 'patient journeys' - of serious clinical predicaments. Here they discover that there are no right answers, only honest ones. What the case material provokes in their minds is a step towards identifying with the experiences of patients and parents.

"The key to getting in touch as a clinician is to use your imagination and to be observant – about yourself as well as others. What might it be like to be that patient or parent? What do you see in the faces and movements of the people you are talking to? What is your emotional reaction to this particular patient’s story?" (1) This is not so much from altruistic concern as a matter of urgent curiosity. The concept of empathy tends to be seen as something that can be added to our skills if we have the time, rather than an essential element of all clinical practice.

(1) Kraemer, S. (2016) 'Getting in Touch: Reflections on Clinical Attentiveness', In (Eds) C. Macaulay, P. Powell & C. Fertleman, Learning from Paediatric Patient Journeys: What children and their families can tell us. CRC Press.
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