Empathy and compassion, or the lack thereof, have been making waves in the healthcare arena. David Cameron, the British Prime Minister, recently bemoaned a lack of compassion in the nursing profession and the Francis report is littered with examples of patients being treated in an incredibly callous fashion by hospital staff.
Interestingly, some have recently questioned whether compassion and empathy are quite the unmitigated goods we usually think they are. However, the evidence that empathy is a boon to patients is fairly unequivocal. Among other things, empathy has been shown to improve patient satisfaction, patient adherence to medical treatment, and patient outcomes. Empathic capabilities may also enable healthcare professionals to obtain better information from patients and may decrease the risk of miscommunication and lawsuits. As if to add icing to the cake, there is also some evidence that empathy improves physician satisfaction.
The real puzzle, then, is not whether clinical empathy matters, but how we ensure that the health care professionals of tomorrow are sufficiently empathic. Part of the answer is to modify the selection process so that the right kind of people are recruited into the caring professions in the first place. But it is not just about better selection techniques. It is also about the “educational environment”. In other words, we need to ensure that the training programme for healthcare students and junior healthcare professionals nurtures empathy and compassion.
Perversely there is growing evidence that student empathy levels decline during medical school and that the trend continues during postgraduate training. On the upside this evidence effectively tells us that empathy is a malleable psychological trait rather than a stable aspect of people’s personality. But on the downside it implies that something is going seriously awry in the training of healthcare students and junior health care professionals.
The cause of the decline in empathy is complex and poorly understood. A non-exhaustive list of culprits includes: long working hours and sleep deprivation; burnout and stress; a lack of positive role models; and an overemphasis in medical curricula on the need for health care professionals to remain emotionally detached from their patients. Others argue that the real cause is poor clinical role modelling and a silent “hidden curriculum” of corrosive cynicism.
So where do we go from here? Clearly something needs to be done and, to be fair, the educational establishment has recently tried to respond to the problem. Indeed, over the last few years a veritable smorgasboard of different pedagogical techniques have been deployed to try and rectify the “empathy deficit” including narrative, theatre, literature and art courses; role-playing workshops; wellness training; communication skills classes; and patient-student “co-visits” to hospitals. Indeed, some educators have considered the matter so important, they’ve gone so far as to encourage their students to fake an illness in order that they may experience what it is like to be hospitalised.
Feedback suggests that students appreciate most of these interventions and the evidence provides reason to believe that they also discernibly improve “objective” empathy scores.
Interestingly, there has been less focus on dealing with the stress-time-resource issue or the more insidious problems of abusive hierarchies and ingrained cynicism. But this may simply reflect the enormous difficulty faced by educators who want to tackle the vested interests which undergird these powerful enemies of empathy.
In addition to the methods currently employed I have two further suggestions, one simple and one rather radical, which might help to improve the situation. The simple suggestion is that healthcare schools should employ an “empathy and compassion champion” to lead the charge in relation to improving students and health care professionals’ emotional intelligence.
At the moment a bevy of different individuals and specialists play some role in trying to teach empathy and compassion to students. These include clinicians, communication skills experts, and, yes, even ethicists like me. There is no harm in having multiple people involved. The more the merrier in some ways, since having a number of people from different disciplines teaching students about the same subject may help students to recognise the importance of the issue. However, having one person whose primary, if not sole, job it is to promote and champion empathy and compassion seems like a good way forward - and may even become a necessity “post Francis”.
The more radical suggestion is that healthcare schools should employ Buddhist monks to train students in the art of empathy. This may seem like a surprising suggestion coming from a secular philosopher, but there has long been evidence that some Buddhist monks achieve high levels of “mettā” (or “loving-kindness”) and recent research has suggested that they may be able to impart their skills and attitudes to others by teaching meditation techniques. Alternatively, and perhaps less controversially, psychologists with special training in the methods of meditation could be employed to teach the same techniques in a less religious fashion.
Ultimately, I am hopeful that the decline in empathy that has been recorded in healthcare students can be reversed, but it is very important that we bear one thing in mind. If you look hard enough you can find saints and sadists amongst the healthcare tribe, just as you can in the general population. However, most healthcare professionals are, well, average human beings. As such, the expectation cannot be that doctors and nurses and other professionals will display high levels of empathy at all times and with every patient. To do so would be to mistake health care professionals for angels.
Acknowledging this is not to deny that health care systems, training curricula and, in some cases, personnel need to change in order to increase the levels of empathy in the NHS. But it is to accept a reality that politicians - and many leaders of the healthcare professions - are unwilling to publicly admit.
This should not depress or disappoint or demotivate us. But in case it does we could do worse than to repeat, mantra like, the wise words of Scott Adams, the cartoonist and creator of Dilbert: “Remember there’s no such thing as a small act of kindness. Every act creates a ripple with no logical end.”