David Jeffrey

Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter?:

Empathy, sympathy and compassion are defined and conceptualised in many different ways in the literature and the terms are used interchangeably in research reports and in everyday speech. This conceptual and semantic confusion has practical implications for clinical practice, research and medical education. Empathy, sympathy and compassion also share elements with other forms of pro-social behaviour such as generosity, kindness and patientcentredness. There is a need for conceptual clarity if doctors are to respond to the calls to provide more ‘compassionate care’. This paper argues that there is currently a problem in the balance between scientific– technical and psychosocial elements of patient care. A broad model of empathy is suggested which could replace the vaguer concepts of sympathy and compassion and so enable improvements in patient care, psycho-social research and medical education.

Clarifying empathy: the first step to more humane clinical care.

Currently, empathy and the ‘humanisation’ of medical care are of particular concern in the wake of high-profile reports. These include the Mid Staffordshire NHS Foundation Trust public inquiry; Dying Without Dignity , a report by the Health Service Ombudsman into end-of-life-care; and the Leadership Alliance for the Care of Dying People report, One Chance to Get it Right .1–3 These reports all pointed to an empathy deficit in clinical care. A disheartening aspect of the current situation is that empathy deficit is not a new phenomenon. In 1927, in a seminal study Peabody wrote: ‘One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.’ 4 Twenty years ago, Weatherall argued that many of the ills of the medical profession reflect a lack of ‘whole person understanding’.5 More recently, Spiro observed that doctors who used to listen to patients now looked at a screen. He wrote: ‘Empathy has always been and will always be among the physician’s most essential tools of practice.’ 6 Spiro argues that physicians must have the time to listen to patients.7 However, medicine’s positivist view prioritises technical progress, evidence-based medicine, targets, and efficiency, so risking a view of patients solely as objects of intellectual interest.8 Mattingly suggests that, because the medical culture does not consistently support the practice of empathy, it becomes easy for doctors to see empathy as ‘nice’ but not an essential part of practice.9 Doctors have always struggled to achieve a balance in their relationship with patients between connection and distance. Doctors can choose between a narrow technical approach based on their competence, or a broader humanistic approach that is more ambiguous and less reductionist.10 The way in which …

A duty of kindness.

‘When I can think of nothing positive to write about in a reference for a junior doctor, I say she is kind,’ commented a colleague. Kindness has now been relegated to an attribute of losers rather than being an integral part of a doctor’s duty to a patient. Because our medical culture does not consistently support the practice of kindness, doctors may view kindness as ‘nice’ but not an essential part of their practice. The Francis Report contained harrowing examples of unkindness to patients and failings in basic patient care. Medicine’s positivist view, prioritising technical progress, evidence-based medicine and targets, risks viewing a patient solely as an object of intellectual interest. Respecting a patient’s dignity now involves pathways, guidelines and risk assessments. The technical and scientific elements of medicine outweigh psycho-social care which is sometimes thought of as part of an outdated ‘nostalgic professionalism’. Professionalism has a dark side and unkindness is often hard to challenge in a medical hierarchy. Some doctors can humiliate students and junior doctors by embarrassing them in the presence of patients and their peers. Unkindness may extend to bullying and harassment which often goes unchecked and even becomes an accepted part of a macho culture. Institutional unkindness may occur in prolonged investigations of complaints which may subject doctors to unbearable stress. Unkindness to patients is often more subtle; by using distancing tactics such as appearing busy, concentrating on scans and the results of tests, and ignoring patients’ anxieties, doctors can leave patients feeling isolated. In a management culture which measures success in numbers, league tables and throughput, time spent with the patient addressing their concerns is not valued so is not seen as an essential part of a doctor’s duty. Medicine is not a competitive sport yet sadly some doctors take a lifetime to learn this. Competition is instilled in students from their school days. When they achieve a place in medical school they are aware from their first day that their future posts as Foundation Year doctors depends upon their grading throughout their medical undergraduate training. Is this the way to foster cooperation and kindness and inspire young people to learn the craft of medicine? It is paradoxical that we have developed the most sophisticated methods of communication but at a personal level these seem to have isolated us from others. We find it difficult to find another human being to speak to face-to-face, to touch, to listen, to share our thoughts, to connect. Independence and self-reliance are now our ethical aspirations. We have come to deny our dependency on others. Rather than embracing dependence and vulnerability, we scorn them as though they are incompatible with autonomy. Kindness inevitably exposes our vulnerability and acknowledges our dependence on others. Kindness can have negative associations with patronising behaviour, pity or paternalism. It may also be regarded with suspicion as either a self-serving behaviour or a form of weakness.

The process of empathy: insights from John Berger’s A Fortunate Man

A Fortunate Man: The Story of a Country Doctor , by John Berger and illustrated by Jean Mohr’s photographs, was published almost 50 years ago but has recently been reissued.1,2 Berger describes the work of Dr John Sassall, a rural GP in the Forest of Dean. Studying the book provides insights into the process of empathy. There is agreement that we need more of it in medical care, although conflicting evidence suggests that medical students experience a decline in their empathy levels during training.3–6 A Fortunate Man also warns of the dangers of going beyond empathy and becoming overwhelmed by the patients’ suffering.2 An interpretivist approach has been used to explore the text of Berger’s book through a phenomenological lens.7 This involves a double hermeneutic: the reader is interpreting Berger’s interpretation of Sassall’s views and experience of a 6-week period of his practice. Berger acknowledges the subjectivity of his observations and yet from a phenomenological perspective his insights resonate with the problems facing GPs today. The aim of this analysis is to identify themes relating to the process of empathy in the book and stimulate debate about empathic relationships in general practice today. Empathy is a complex, multifaceted construct that has been defined in many different ways.8 For some doctors empathy has been defined in narrow cognitive terms leading to a form of ‘detached concern’.4 This study adopts a broader approach highlighting empathy’s cognitive, affective, behavioural, and moral aspects.9,10 Berger is struck by Sassall’s connection with patients, seeing empathy as a relational process rather than a personal attribute. Sassall begins by spending time with the patient, appreciating the importance of the first contact and learning about the person before considering their illness:2 ‘“The door opens,” he …

Books: How Doctors Think: Clinical Judgment and the Practice of Medicine: The Importance of Anecdote

Kathryn Montgomery Oxford University Press USA, 2012 , PB, 256 pp, £20.49, 978-0199942053 Kathryn Montgomery’s classic text is even more relevant to medical education and practice today than when it was published a decade ago (originally in 2005). The author acknowledges the benefits of biomedical science but argues that clinical medicine is not a science but an interpretative practice. She points out a central paradox in medicine, the disparagement of anecdote, regarded as the lowest level of evidence. …

Books: Against Empathy: the Case for Rational Compassion: Forming a Bridge

Paul Bloom Bodley Head, 2017 , HB, 304 pp, £18.99, 978-1847923141 At first glance, presenting an argument against empathy seems counterintuitive. However, Bloom’s argument is against a narrowly defined form of empathy restricted to the affective domain. Much of the research and debate around empathy is hampered by the muddle surrounding the definition of this nuanced …

Books: Academic Diary: Or Why Higher Education Still Matters: Don’t Make Grades Your Only Goal

Academic Diary: Or Why Higher Education Still Matters Les Back Goldsmiths Press, 2016, PB, 272pp, £9.95, 978-1906897581 Les Back, a Professor of Sociology at Goldsmiths, University of London, has published insights into higher education in the form of a diary of the academic year. The diary consists of around 50 short essays that will be of interest to anyone involved in teaching students. Targets, assessments, market forces, information overload, and audit are some of the challenges facing …

Enhancing empathy: a drama workshop*

The Francis report highlighted a need to improve empathy and compassion in healthcare.[1] The humanities are one way of addressing the empathy gap. Patients may not disclose their main concerns to healthcare professionals who need empathy to ‘see beyond the brave face’.[2] When a patient is describing a traumatic experience they may stop and start; details will be left out and some apparently mundane things will take on significance. Pinter’s stagecraft is particularly relevant for exploring the situation of an individual who is without connection, isolated and unable, in the words of one character, ‘to get it together’.[3] In a clinical setting the doctor or nurse may have difficulty in empathising with such patients, who are sometimes described as ‘poor historians’.[4]

Books: Scar Tissue: Detachment or Empathy?

Scar Tissue Michael Ignatieff Farrar, Straus and Giroux, 2001 PB, 212pp,

Books: Compassion: Compassion, Continuity and Caring in the NHS: Intelligent Kindness.

18.00, 978-0374527693 Dementia can be a devastating neurological disorder which many of us fear. Michael Ignatieff, a Canadian academic, author and politician, explores the territory of dementia in this thoughtful novel, which was shortlisted for the Booker prize. This is a son’s story of his mother’s dementia and a moving meditation on the effects of loss and the nature of personhood. The narrator is a philosophy professor whose observation of his mother’s intellectual deterioration and its effects is contrasted with his brother’s …