Rammya Mathew: The pursuit of being a good doctor
BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5139 (Published 20 August 2019) Cite this as: BMJ 2019;366:l5139
All rapid responses
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."
Competing interests: No competing interests
I was supervising a mock exam station with a role playing actor for undergraduates in their final year. The scenario was a patient presenting with a PE. Early in the scenario the patient would complain of chest pain. To a person the students all said a variant of “we’ll get your pain sorted shortly, I just need to take the history first”. The answer to part of this is that we had taught the students to be goal oriented (the history) rather than patient centred.
Another part of it I agree is being so busy and trying to do so many things that we have to protect ourselves. If you define Resilience as “learning to put on more armour so you can be beaten more” then what needs to change is not mindfulness training for students but a better funded fully staffed system to allow staff to give patients empathy.
Competing interests: No competing interests
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.
Competing interests: No competing interests
Dear Editor
We read with great interest the commentary by Dr Rammya Mathew titled ‘The pursuit of being a good doctor’. Dr Mathew raises some interesting points; empathy is an ambiguous topic, empathy decreases as we progress through training, empathy is affected by time and environmental pressures [1].
Recently we sent out an online survey to several hospitals and medical schools in United Kingdom, Europe, America, Asia and Africa. The survey was open to all members working in a healthcare environment including administrative staff, students, nurses, doctors, therapists and auxiliary staff for approximately 12 weeks. The survey included six simple questions. Question six, “Which one of the following phrases in your opinion best describes the term ‘compassion’”, was the most critical question with the following options provided: ‘displaying kindness’, ‘easing suffering’, ‘showing pity’, ‘being empathetic’, ‘being considerate’, ‘being thoughtful’, ‘other (please specify)’.
Interestingly we found that out of 323 responses, the response to the deemed most appropriate definition of compassion demonstrated that 42% associated compassion with ‘showing empathy’ while only 13% associated it with ‘easing suffering’.
As Dr Mathew has mentioned ‘alleviating suffering’ is the epitome of our career but surprisingly only 13% of our cohort associated the word compassion with ‘easing suffering’. It is important to acknowledge that participants may interpret the concept and values of compassion differently due to cultural influences and previous experiences. This does not necessarily mean that they are unaware of its value or importance. We agree with Dr Mathew with introducing mindfulness in the medical curriculum could help improve the care we provide however active education and emphasis about compassion is also important. Education will help connect these complex perspectives in order to create an appreciation of how compassion can be enhanced in action.
Sinclair et al created a Healthcare Provider Compassion Model to address the poor understanding of compassion. They defined compassion as ‘a virtuous response that seeks to address the suffering and needs of a person through relational understanding and action’ [2]. They explored the aspects of compassion important to the patient and various healthcare providers and summarised it into four categories; virtuous intent, relational space, coming to know a person and forging a healing alliance [2]. Resources such as these should be actively used when training health care professionals in compassion.
References
1. Mathew, R. (2019). Rammya Mathew: The pursuit of being a good doctor. BMJ, l5139. doi: 10.1136/bmj.l5139
2. Sinclair S, Hack T, Raffin-Bouchal S, McClement S, Stajduhar K, Singh P et al. What are healthcare providers’ understandings and experiences of compassion? The healthcare compassion model: a grounded theory study of healthcare providers in Canada. BMJ Open. 2018;8(3):e019701.
Competing interests: No competing interests
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.
Competing interests: No competing interests
I read the opinion article of Dr. Mathew’s with great interest (1).
Being a good doctor and being an empathetic one go head to head perhaps through the centuries. Hippocrates said “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing” and in the 17th century version they explained no wrong-doing as “First do no harm (Latin: Primum non nocere)” (2).
Today’s General Medical Council, UK established “Good Medical Practice” (3) as follows in summary:
For you as a medical doctor your first concern should be your patients
Be component and up to dated on your field
Take prompt action if you think patient safety is being compromised
Establish and maintain good partnerships with your patients and colleagues
Maintain trust in you and the profession by being open, honest and acting with integrity.
GMC went further and implemented “Revalidation” in 2012 (4), in view to scope individual physician's practice against the GMC set up values.
Well, those initiatives and measurements look ideal, would also be helpful the “ticking box” exercises without doubt but in the very heavy burden work load of current clumsy National Health Service (NHS). Managers deal with the figures and rolling out overloaded clinics, and “race against the clock” is a norm of the current NHS. I am afraid to say that showing satisfactory empathy and being a good doctor in a limited time frame would seem to me a bit unrealistic, wouldn't you agree?
References:
1. Rammya Mathew. The pursuit of being a good doctor. BMJ 2019;366:l5139.
2. Hippocratic Oath. [ cited 2019 August 21]. Available from: https://en.m.wikipedia.org/wiki/Hippocratic_Oath.
3. Good Medical Practice. [cited 2019 August 21]. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/goo....
4. Revalidation. [ cited 2019 August 21]. https://www.gmc-uk.org/registration-and-licensing/managing-your-registra....
Competing interests: No competing interests
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.
http://bit.ly/2dCn4kL
Competing interests: No competing interests
I would not question the importance of a feeling of empathy but question whether communicating this understanding is always in the best interests of patients. The increasing move towards ensuring patients leave the consultation with a relative feel-good factor may not always be in their best interests in helping them to cope with adversity present and future. Nor for that matter in helping them to come to an optimal decision about treatment. It is of course crucial that one should recognise clues - verbal and non-verbal -before deciding whether or nor to respond to them.
Competing interests: No competing interests
Good doctors could finish last
I wholeheartedly agree that we should pursue “good” doctor behavior. <1> But the main barrier is the lack of moral incentives to become an empathetic doctor. For instance, during my general practice and specialty clinic placements, I observed the drawbacks when doctors walk the extra mile to help patients beyond their scheduled appointment time. These doctors tend to stay late at work, and receive numerous complaints from patients and co-workers for not being punctual.<2> Their seniors could also accuse these empathetic doctors for poor time management and inability to prioritise. This could lead to doctors becoming unempathetic and interruptive during consultations in order to finish on time.<3><4>
In another instance, I observed doctors being very careful with their jobs and often acting on patient’s best interest. These doctors have low thresholds to call hospital specialists for advice. Nevertheless, these empathetic doctors could end up receiving hostile responses and even mockery from hospital specialists.<5><6>
Although there is the GMC Good Medical Practice guidance to direct us to become a good doctor, this guidance is frequently misused as a mean to accuse doctors of not full-filling their ethical duties. For instance, I heard of junior doctors receiving anonymous feedback of being a poor team player when they exercise their rights to take vacation and leaving work on time. When doctors publicly raise concerns, they could be accused of “revealing too much” that affect the public’s trust in the profession.<7><8>. Similarly, doctors who decline to work extra locum shifts have been threatened with GMC referrals.<9> It is suggested that healthcare system likes to take advantage of doctors to work excessive hours for free, but sees their services as an expense rather than resource.<10>
We need better measures to promote good doctor behavior, but not scare tactics to threaten those who fail to comply due to external circumstances.
References
1. Mathew R. Rammya Mathew: The pursuit of being a good doctor. BMJ. 2019;366:l5139.
2. McCartney M. Margaret McCartney: Why GPs are always running late. BMJ. 2017;358:j3955.
3. Singh Ospina N, Phillips KA, Rodriguez-Gutierrez R, Castaneda-Guarderas A, Gionfriddo MR, Branda ME, et al. Eliciting the Patient's Agenda- Secondary Analysis of Recorded Clinical Encounters. J Gen Intern Med. 2018:https://doi.org/10.1007/s11606-018-4540-5.
4. Mohammed RSD, Yeung EYH. Physicians Interrupting Patients. J Gen Intern Med. 2019. doi: 10.1007/s11606-019-05140-1.
5. Al-Rais A. Why we should avoid handover hostility. BMJ. 2017;356:j1272.
6. Fletcher B. Listening: a neglected aspect of safe handover. BMJ. 2017;359:j5200.
7. Sokol D. Doctors shouldn’t reveal so much. BMJ. 2018;361:k2495.
8. Yeung EYH. Are doctors wrong for stating the elephant in the room? BMJ. 2018;362:k3117.
9. Rimmer A. Junior doctors are threatened with GMC referral for refusing locum work. BMJ. 2017;358:j4037.
10. Rich P. Health care system takes advantage of doctors' work ethic. CMAJ. 2019;191(20):E567-5751.
Competing interests: I have been paid for working in primary and secondary care, but not for writing this letter.