A guest blog post by Dr Natasha Yates
Would you mind if your doctor was a sociopath? Sociopaths, I am told, have normal – and sometimes higher than average – levels of cognitive empathy. Would we agree that empathy is an important aspect of good clinical care? If so, why wouldn’t you want a sociopath looking after you? The reason is simple: another important aspect of clinical care is to “first do no harm”, to keep the patient’s interests front and centre of the decisions that are made about their healthcare.
Although the Hippocratic Oath is rarely sworn in its original form any more, those who deride it fail to realise how radically it changed medical practice in the ancient world. Prior to Hippocratic medicine, the doctor had the power to both harm and to heal. Sometimes this could be achieved with the same drug – the healing dose was simply a fraction of the harmful dose. If someone sought the advice of a doctor, they hoped that they were paying for healing. However, could they be sure that someone else had not paid that same doctor more for their harm?
The Hippocratic Oath, by stating “First do no harm”, precluded doctors from ever deliberately harming their patients, which is something I think we take for granted in modern Western medicine. Even today, “witch doctors / traditional healers” in Africa are feared because of their supposed ability to decide who lives and who dies. “First do no harm” is a concept which a sociopath would disregard. Sociopaths, by definition, have a pathological egocentricity and are prepared to lie, deceive and manipulate for profit or self-amusement. They also blatantly disregard the safety of others – not the kind of doctor (or colleague) that any of us would want, even if they did have higher than average empathy!
So empathy is important but obviously not in isolation.
However, empathy can be a double-edged sword. If we are empathic, we are “feeling with” our patients. This can be a problem in a profession that constantly brings us face to face with suffering and pain. The smart thing to do when you are in pain is to withdraw. If you step onto a hot bitumen road in the middle of summer in bare feet, your reflexes will cause you to pull your foot away. The exception to this is if there is something that is a bigger priority to you than feeling the pain – you are actually able to over-ride your reflexes and push through the pain. If your toddler is running into the middle of that road, you don’t care about your painful feet, you run after them and rescue them! Painful feet are a small price to pay for the life of your child.
In clinical practice, when we empathise with our patients, we have two choices: we can either withdraw (the reflexive and “smart” thing to do to protect ourselves), or we can press in. The term for this second response is “compassion”. Compassion is empathy that is being acted upon. The etymology is simple: com = with, passio = suffering. In other words, when we are compassionate we are not just feeling, we are doing.
Dr Dan Siegel, who coined the term “mindsight”1, describes brain research which shows that the circuitry of empathy alone is different to the circuitry of empathy with compassion. Empathy alone causes the brain to be overactive and it “shuts down”. Therefore, empathy can lead to burnout. (Perhaps we should talk about “empathy fatigue” not “compassion fatigue”?) However, if the empathy moves quickly to compassion, we obtain connection and meaning and actually have less burnout.
So in summary, empathy is identifying and feeling the pain and suffering of a patient; compassion is then asking “What can I do to alleviate the suffering?”
Compassion is a distinctive attribute of purposeful doctors, in contrast to doctors who feel paralyzed.
What does compassionate care look like in practice? Firstly, it does NOT look like this: organising investigations or treatments simply to be seen as “doing something”! Such over-treatment is doctor centered and not patient centered care. It is the antithesis of compassionate (or indeed effective) care. Compassionate care may include listening well, appropriate touch, and working with the patient’s community.
But it may also be as simple as being with a patient – our presence, our refusal to abandon them. This may be the most important aspect of their care.
In her book, Kitchen Table Wisdom2, Dr Rachel Remen recounts the story of her patient, Jessie, who spent the day in an emergency department alone. When Rachel asked her later why she didn’t call a friend or even Rachel herself, Jessie replied that none of her friends knew anything about bowel obstruction, and in fact neither did Rachel – them being there would not have helped the pain.
Rachel simply replied, “It wouldn’t help the pain; it would help the loneliness”.
- Siegel, D. “Mindsight; Change your brain and your life” Scribe publications, 2012 ISBN: 9781921844997
- Remen, R. “Kitchen table wisdom: Stories that heal” Riverhead Bools, 1996 ISBN:9781573220422
Natasha Yates is an experienced General Practitioner and Medical Educator on the Gold Coast, Australia. She has a particular interest in helping students develop compassion, resilience and the habits of reflective practice. This blog is her space to write about the more interesting (and sometimes esoteric!) things over which she mulls, some directly related to teaching but some simply and potentially impacting the way she grows and changes. She a wife and mother of four primary aged children and enjoys good coffee – although with four children, some days any coffee will do!
You can follow her on @DrTashY or contact her via this website.
