Empathy: Underpinning practice but vulnerable to stress

Look at most lists of the attributes of a good health professional and you are sure to find empathy.  Ask a student to define empathy and you are likely to hear varying answers.  In addition, there is frequently confusion between empathy and sympathy. As a desired attribute, there is pressure to assess for empathy and therefore tools to measure empathy have been devised.  Is this person sufficiently empathic? Some studies suggest that a student’s empathy, when it is measured, declines over time at medical school.  However, surely empathy can only be perceived by the patient interacting with the learner or professional and not some external observer or self-assessment tool.

The Concise Oxford Dictionary from the 1960s defines empathy from a psychological perspective: ‘the power of projecting one’s personality into (and so fully comprehending) the object of contemplation.’  This is not particularly helpful from a health professional perspective, though we can assume that the object of contemplation would be the patient.  More useful is a definition from general practice that considers empathy to be the process in which the doctor is able to understand the patient’s situation, perspective and feelings, and because of this is able to communicate that understanding back to the patient and subsequently act on it therapeutically.[1] This process is not easy and involves asking the right questions, listening carefully to the answers, interacting in a way that the patient knows that doctor understands what is going on, and then doing something to help the patient in the situation.  This in fact summarises a large part of the work of a consultation. So, empathy underpins practice.  But again, it is the patient who should judge whether empathy has been demonstrated. 

I don’t remember empathy being mentioned in my undergraduate training.  In fact, looking back, I think the hidden curriculum hindered students from considering patients as people rather than objects that had things done to them.  In the first two years at medical school we rarely encountered patients, being mostly sequestered in lecture theatres and laboratories. Patients would sometimes be brought into lecture theatres to have their conditions described and physical signs demonstrated to link the anatomical and physiological sciences we were learning with clinical practice.  These patients would be brought from their wards in the hospital across the road, wheeled by porters through the subterranean passages to avoid traffic and onlookers, and then were displayed by the lecturer.  The patients had no active role in discussing their lives and emotions. As students, we were not invited to ask them questions.  

In our third year, we crossed that road ourselves and were allowed onto wards. We were attached to firms, a firm being a team of doctors under the leadership of one, or sometimes two, consultants (also known as specialists).  Most of the consultants as I recall were male.  Below the consultant was a hierarchy of doctors from the senior registrar down to the houseman.  ‘House’ was the old term for the hospital, so a ‘doctor in the house’ was a doctor who had historically been resident in the hospital but in my time only slept there when on call. The houseman was the most junior member of the firm, the title reflecting medicine’s patriarchy. This doctor was in the first year after qualification but seemed so much older than us callow students. 

One of the daily rituals of hospital life was the morning blood taking round.  Blood tests are an important part of the diagnosis and management of illness.  Many patients had blood taken every day. It was the firm’s medical student’s job to make sure that blood samples were collected and sent to the laboratory for analysis so that results would be available later the same day.  The houseman would leave forms on the ward indicating which patients should be bled and what tests were required. The student would aim to finish collection before any other duties or teaching.  This meant starting before 8am. 

We had had some experience in taking blood.  From memory, our first venepuncture involved taking blood from a vein in the arm of a fellow student.  Typically, medical students are healthy, well-perfused adults and therefore blood-taking was fairly easy even with shaking hands. Patients tend to be sicker, are not usually welcoming of students bearing needles, and veins can be difficult to find.  I had to get that blood whether on the first attempt (phew!) or if it required two to three punctures, sometimes in both arms, to get the job done. No-one had said how many times it was reasonable to try.  

What is distressing on remembering this daily ordeal for student and patient is that it was important to avoid having to call the houseman for help, adding to his burden and risking his barely disguised wrath at the incompetence of yet another student.  I justified the patient’s discomfort by believing this was a clinically necessary task for the patient’s benefit and therefore the patient had to partake in the process.  But a comfortable outcome for the patient was secondary to my own aim of avoiding embarrassment with my superior.  Even with a successful morning – all blood taken correctly and dispatched on time – I was a stressed and sweaty student by 9am.  One way to learn the skill but not the best way to develop or maintain empathy. 

Fortunately there are now dedicated phlebotomists in most hospitals. 

Through my career I have noticed that tendancy to lose sight of empathy when under stress: in the middle of a night on-call when tired and more worried about making a mistake than the patient’s perspective; when running late in clinic and knowing that I can never make up the time…

Empathy is now part of communication skills education across the professions.  There is a particular emphasis on how to make empathic statements that link the ‘I’ of the health professional with the ‘you’ of the patient.[2] These may be learned and used as appropriate, for example: I can see that you are in a lot of pain; I appreciate how frustrating this must be for you). Being skilled in applying empathic statements does not necessarily, however, indicate empathy to the patient as they work better in the context of a whole interaction – the process outlined above.  Empathic statements used to tick a box (I’ve demonstrated empathy) can come across as unauthentic and even crass. 

For more on empathy, its emotional response compassion as a desire to help, and the experiences of recently qualified doctors (interns) in learning to express compassion see:

Davin L, Thistlethwaite JE, Bartle E.  ‘Compassion, the first emotion ditched when I am busy’. The struggle to maintain our common humanity.  MedEdPublish 2018. https://mededpublish.org/articles/7-167

  1. Mercer SW, Reynolds WJ. Empathy and quality of care. Br J Gen Pr 2002; 52: S9-12.
  2. Silverman J, Kurtz S, Draper J.  Skills for communicating with patients.  Abingdon: Radcliffe Medical Press, 1998. 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: