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12 ARTICLE UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk Sympathy in the surgery Doctors are encouraged to be open with patients when things go wrong, to show compassion when dealing with sensitive issues and to communicate effectively. Sarah Whitehouse asks whether there is room for empathy, or even emotion, in the clinical setting “ I remember telling a family that their father, who had been admitted only hours earlier, had died in theatre,” recounts Mr Tom Berry, a trainee general surgeon. “I prepared as I have been taught. I took a nurse with me. I left my pager with someone else. I ensured that we had somewhere private. I prepared to answer any expected questions and what I would say the next steps were. Despite all this, as I broke the news to his wife, I realised I had tears in my eyes. His wife asked if I was okay. I felt guilty, as if I was intruding on their grief or trying to elicit sympathy.” WHAT IS EMPATHY? Coined from the Greek roots em and pathos (feeling into), empathy is the ability to put yourself in another person’s – the patient’s – shoes. 1 It is understanding a person’s subjective experience by sharing it vicariously, but maintaining an observant stance. 2 The observant stance is perhaps the key to empathising effectively in medicine – as a doctor, you cannot afford to become so consumed by a situation that you do not have the capacity to treat. Emotion, though, is what makes us human – should it be seen as something to shy away from? EMOTIONAL INTELLIGENCE “I don’t think I would be able to do my job properly without being able to empathise with my patients,” says Dr Ayesha Rahim, former Deputy Chair of the UK’s BMA Junior Doctor Committee. As a junior doctor in psychiatry, she explains: “It’s a huge thing for patients to tell you something extremely personal about themselves. It’s important to be attuned to what they are saying, and how they are saying it, by looking out for non-verbal clues.” Traditionally, empathy in clinical practice was bound up with the vague term “bedside manner” – you either had it, or you didn’t. It couldn’t be taught or improved. Now, however, empathic communication can be seen more as a taught skill, and one that is essential in order to fully understand a patient’s condition. Clinical empathy is about understanding a patient’s symptoms and feelings, and communicating that fact to the patient. It is important to check back with the patient when taking a history to show you fully understand, for example, “Let me see if I have this right.” Verbalising their emotion, eg, “You seem anxious about your chest pains,” demonstrates active listening. Being blind to emotional cues can lead to longer consultations and increased frustration from patients. It might even make a patient more likely to pursue a clinical negligence claim or complaint, should something go wrong. Dr Ann McPherson is Medical Director of the DIPEx Health Experiences Research Group, which established www.healthtalkonline.org, documenting patients’ experiences of their treatment. She says: “It’s not easy to be empathic to vulnerable, needy people 100% of the time. Being able to do it is something healthcare practitioners have to learn – in the same way that they learn clinical skills. “Over ten years, researchers employed by Oxford University have carried out detailed interviews with more than 2,000 patients. Many of them express gratitude and respect for the practitioners who have cared for them, but you only have to click on the ‘communication with healthcare practitioners’ link to find examples of people who have been upset, embarrassed, or even damaged by a lack of empathy and compassion on the part of doctors and nurses.”
There is concern that “too much” feeling can cause burnout among already overworked healthcare professionals. Little is said about how distressing situations can affect doctors emotionally © Brand X Pictures STOP, LOOK AND LISTEN Empathy is difficult to express unless it is truly felt. Although there are stock phrases that doctors use to empathise with patients, it is important that these are not repeated by rote, with little regard for the individual situation. Empathy as a taught skill can soon become formulaic emotion – something patients do not buy. Dr Pauline Leonard, a consultant medical oncologist at London’s Whittington Hospital, is leading a national programme, Connected, teaching doctors how to break bad news. She says: “There should be templates around empathy, but doctors should be encouraged to move the template to fit the patient – that is the art. “Doctors like templates because they are nervous. Ultimately, doctors are scared that when they empathise really well, so much emotion is unlocked in the room that they don’t feel equipped to cope with the situation and put the patient back together again.” If you empathise well, however, all you need to be equipped to do is sit and listen. Patients need to know that you are there to answer any questions, that you are not frightened of strong emotions. A good rule might be: don’t just do something, stand there. Tempting though it may be to bring an awkward conversation to a quick end, try not to brush off fear, uncertainty or anger with “Don’t worry, everything will be okay,” or “I know how you must feel”. Pausing and listening is more important, and more empathic. IN SYMPATHY Empathy in medicine may have its place, but the jury is out on sympathy’s role. Sympathy, when a person experiences feelings as if they were the sufferer, involves emotional identification with a patient’s set of circumstances, eg, if your eyes fill up with tears when a patient recounts their illness, or you feel anger when a patient tells you of a preventable adverse incident. In complete sympathy, a doctor would be unable to help, as there cannot be complete equality or complete sharing. 4 If you fully grieved for the loss of a parent’s young child, you would be overcome by the loss of the situation and wouldn’t be able to offer support. You would need support yourself. Dr Rahim explains: “It is difficult for a patient who has come to you to help contain their anxiety and distress to see their own doctor in extreme distress.” The more a doctor’s anxiety and aggression are under control, the calmer the patient is likely to be. 5 Dr Ming-Keng Teoh, MPS Head of Medical Services (Asia), warns that doctors can present a risk to themselves if they let their emotions get the better of them in the heat of the moment. He cites as an example a doctor who, when faced with a patient with a lifethreatening haemorrhage in an ED, was accused of assaulting a colleague while hurrying and pushing him to release the required drugs. A complaint was lodged against the doctor to the hospital and, later, the Medical Council, despite an apology. In emergencies, it is important to retain your cool. The Hippocratic dictum of “do no harm” cannot be met if a doctor is consumed with their own emotional reaction to a situation, perhaps putting distressed patients and their families under added stress. At worst, sympathy can descend into pity, a condescending emotion that would serve to undermine the doctor–patient relationship. There is concern that “too much” feeling can cause burnout among already overworked healthcare professionals. Little is said about how distressing situations can affect doctors emotionally. Mr Berry argues: “More needs to be done to help doctors with considering the aftermath. The event of discussing bad news is well documented, but then it’s back to work and no more said.” Distressing conversations can prey on a doctor’s mind and, before moving on to the next consultation, or the patient in the next bay, doctors must be able to discuss these feelings if they wish. Similarly, it is important to know when to step back from a situation. Dr Brian Charles, consultant for MPS based in Barbados, says: “A common situation in the Emergency Department is the deathly sick child. Frequently, these cases affect staff, especially when they have young children or siblings of a similar age. I always advise the staff that it’s okay to have empathy and sympathy for the patients, but if it’s likely to affect judgment and objectivity, then someone else should take over. The difficult part is realising ‘when I can’t cope’ and when to call for help.” MAINTAINING BOUNDARIES An excess of emotion can blur boundaries. MPS medicolegal adviser Dr Richard Dempster explains: “There is a wide range of opinions as to what is appropriate professionally. Advice can at best only be general, because of the huge number of differing reactions to a doctor’s behaviour by patients. How doctors react and support patients will depend on the previous relationship they have had, and the knowledge that a doctor has of the patient’s personality.” In the UK, the GMC stresses that to fulfil your role in the doctor–patient partnership 13 ARTICLE UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk
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Page 3 and 4: ON THE COVER 8 On the defensive Whe
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Page 11: Be open about error Dr Aidan O’Do
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Dr Rob Hendry - Medical Protection Society

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