Empathy or Compassion?

Rodger Charlton

HK Pract 2018;40:1-2

In increasingly busy healthcare systems, how do we stay sensitive to the needs of our patients? In the world of medical education, there is an emphasis on selecting more empathetic doctors to study medicine and yet repeated research studies demonstrate how empathy declines during training. At interview, a prospective student is likely to have been tutored to show empathy in mini interview stations using phrases like; “I am so sorry to hear that” or “Thank you for sharing this bad news with me”. But, compassion is more than empathy. Defining compassion is not easy and often it is immeasurable through for example, a kind word or making someone a cup of tea or holding their hand. Perhaps it is best to avoid a definition of what cannot be measured in case this most important aspect of care is denigrated into an algorithm or ticking a box as in empathy scenarios, to say that it has been demonstrated appropriately as part of an assessment.

There are four types of compassion. First and foremost, compassion in our consultations with patients. Indeed when trying to define what makes a ‘good doctor’, is not easy. However, there are two types of doctors; those who are technically good and those who are kind with their patients and listen to them. As a patient one needs both qualities in a doctor and this is captured by the motto of the Royal College of General Practitioners,‘Cum Scientia Caritas’, roughly translated as ‘scientific skill with lovingkindness’. ¹ This is the most important compassion for us to display as doctors, but it may be affected by our experience of the other three types.

Second, there is the compassion of the institution or health care organization that we work for. In a big organization it is important that staff feel valued and that compassion is shown to them in the way they are treated through workload, facilities at work, study and annual leave and pay. For those who hold positions of responsibility in the organization they will need to be role models of compassion so that the workforce is a happy one and not demoralized. Third, being compassionate to colleagues. When a colleague has a large workload, sharing it may help. Often neglected is supporting a colleague who has received a patient complaint. Organized pastoral support is important and a change in culture to make it acceptable to talk about personal difficulties.

Finally, there is self-compassion, the type that many doctors think about least. Reminding all doctors that self-compassion is about being compassionate to one's self where one feels one has failed a patient or been inadequate in providing a service and that perfection is not always possible. Altruism in healthcare is perhaps a Nirvana that is unattainable unlike saying a few kind words to a patient, which may be what they remember the most. At Leicester we have introduced a Health Enhancement Programme in our new curriculum for first year students where they have sessions led mainly by family physicians in mindfulness and so ‘stopping and reflecting on the moment’. There is therefore an emphasis on wellbeing, the practice of which will sustain them in their careers. A healthy work environment is vital rather than insisting on a resilient workforce and will ensure staff are compassionate and so are not at risk of displaying what might be called dispassion.

Personal statements and interviews of potential medical students reveal young people with amazing traits of compassion. However, undergraduate training does not prepare them to work in busy health services. Here compassion fatigue may occur as a result of increasing demands of complex medicine with its multiple comorbidities of an ageing population, seeing large numbers of patients with huge time pressures, long shifts, inadequate staffing levels and achieving targets. In addition, no time to eat, have a coffee break or go to the toilet, leads to a workforce becoming numb to patient needs and what is basic humanity. Longer term this leads to burnout, declining levels of performance, depersonalisation, emotional exhaustion and poor personal achievement. In the short term this inevitably adversely affects patient care with dispassion rather than compassion.

The ‘good doctor’ is difficult to define, but a key attribute is displaying compassion, which may be no more than a bit of kindness. The art of medicine is how to apply the science. This is not the mystique of the ‘Church of Medicine’, but the role of the ‘good doctor’. Compassion means different things to different patients. It cannot be measured or administered from a bottle. Maybe it is was what the late Rabbi Lionel Blue described in his experience as a patient.² He described how he found that kindness is “as essential as technology” but asked “How do you teach kindness on a degree course? For vulnerable oldies, and youngsters too, hospitals become a way of life, and kindness is the difference between heaven and hell.” He went on to say; “In my experience you learn kindness by remembering the kindnesses and unkindnesses you've encountered and how both felt; also the kindnesses you've shown and the unkindnesses you've inflicted and how you catch kindness from people like measles, not just from books.” Kindness, if that is what compassion is, is what matters most to people who are ill.

In terms of research, compassion needs to be addressed further. There are four questions about compassion. Can it be defined? Can it be taught? Is there such a concept as dispassion? Is it possible to create a compassion protocol for doctors? These are challenging questions to answer, but if dispassion exists then as well as teaching doctors to be empathetic with their patients, they should also be reminded to guard against being dispassionate.

There are four possible outcomes of a consultation; being given a prescription, getting a referral to a specialist, being given a sick note and last, perhaps the most important, receiving a bit of ‘love’. In a recent book on the subject of compassion two quotes stand out from contributors, a lay person and a nurse³;

“Compassion is like the sun, it just shines” and;

“Compassion is a kindness that cannot be taught, but can be shown every day. The best skill we have is kindness. Even in the most desperate situation a few kind words or actions are noticed as much as a surgeon’s skill or a key diagnosis.”

There is an overlap between empathy and compassion, but a vital ingredient of good healthcare is compassion.