When I took up my new position in Ottawa a couple of years ago, The Ottawa Hospital ‘vision’ was to be seen literally everywhere: To provide each patient with the world-class care, exceptional service and compassion that we would want for our loved ones. That reminded me of the moment I was asked that question during morning rounds some 20 years previously, ‘what would I want to be done if the patient was my mother or grandmother?’
Empathy is a key component of every doctor’s existence right down to the formation of their professional identity – and it’s not just empathy towards their patients which matters but also empathy towards their family and friends, and to their colleagues. However, the empathy shell can crack and when that happens, burnout is often a contributory factor. When it does, personal relationships can suffer, incivility and unprofessional behaviours to colleagues can emerge and patients can feel that their physician just does not care. So, what about the needs of the physician, a question I became witness to the effects first hand in my eventual role as an Associate Postgraduate Dean for Doctors in Difficulty? Sick patient’s need healthy doctors too.
It was Jodie Halpern who wrote in 2003 that patients seek empathy from their physicians and that this is not the same as the physician displaying detached concern. When I was in medical school in the 1980’s, the emphasis was on developing a sound clinical acumen, establishing the correct diagnosis and prescribing the appropriate treatment. Of course, this is fundamental to the practice of medicine, then, as much as it is now. We observed physicians demonstrating their ‘bedside manner’ (a proxy term used then to encompass such concepts as empathy) and recognized the importance of this. Some were good at this and would emphasize the significance of both verbal and non-verbal communication skills as a means of building the doctor-patient relationship. Those less good were often ‘rewarded’ with the accolade that they possessed excellent diagnostic or technical skills instead almost as if it was an ‘either or’, thus absolving them of their responsibility to possess a good bedside manner. As for clinical empathy, this was not a term often used explicitly; if anything we were taught to remain emotionally detached from our patients in order to remain objective and of clear mind.
This reminds me of my original thought that as a physician I always believed that I was trained to be empathic but at the same time reminded to remain detached emotionally like some kind of protective mechanism which was ingrained into my developing professional identity at that time, as if to protect me from emotional exhaustion. But could this in fact have had the opposite effect? Could I, by taking this approach, end up being neither empathic to my patients nor protect myself from the risk of burnout? A growing amount of evidence is now suggesting that empathic physicians provide higher quality and more compassionate clinical care (as rated by their patients) and are in fact at less risk for burnout – but this comes with a caveat. Empathy can come at a cost to the physician (and the patient) if it is not properly managed. This has led to the development by some of the concept of professional empathy, which in some way is meant to be protective for the physician whilst at the same time remain uncompromising in compassion towards the patient.
Can and do physicians prevent themselves from burning out?
What is professional empathy and can it be learned, can a physician’s professional identity change and if so how does that happen and is that what we mean when we talk about change in the culture of medicine? And now, there’s another relatively new term in our lexicon, resilience. What does the term resilience actually mean, can it be ‘built’ and is that the form of protection which tomorrow’s doctors need to have ‘built-in’ to their professional identities from the word go? And if resilience from day one is to be the key to keeping a physician’s professional identity adaptable to future changes in the social contract between the physician and society, how will that work for physicians who already have an established professional identity? Can they build resilience too in the face of adversity? Surely they can reasonably expect to do better than just survive out there?
Thinking back to my own professional identity during its formative years, it clearly wasn’t ‘wrong’ that I set out to be empathic whilst trying to remain emotionally detached, in fact it was considered appropriate at that time. It is the social contract between the physician and society that has since changed over the years in many ways and continues to do so. Therefore, not only are we now talking about professional identity formation for physicians who are just embarking on their careers, there needs to be professional identity transformation for some (i.e. those who started with a differing professional identity to that which is expected of a physician today) and professional identity reformation for others (i.e. those who started on track with their professional identity and at some point in time have lost their way) in order that physicians of all generations remain able to adhere to their part of the constantly evolving social contract. Our medical schools are rightly preparing tomorrow’s doctors by instilling them with the virtues and professional values which the present social contract demands. But one thing’s for sure, it will all change again. After all, thinking back as we look forward, history tells us it always does.
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