Looking back, the most important lessons we learnt as medical students both in and out of the wards were those that made us human. And by learning to be better human beings, we became better doctors.
Commentary published in ‘Today’ 7 March 2013
Empathy, the real measure of a doctor
There is a hug I will never forget. Our twin babies had been born severely premature and had just breathed their last. An obstetrician not involved in their care, who was just walking past, looked in and stopped. We just hugged quietly; no words were needed.
Medical school deans have identified empathy as the most important attribute they look for in potential doctors. In this era of powerful diagnostics and instant information, the relevance of empathy has never been greater. Expensive machines and elegant consultation rooms do not and cannot offer empathy. Only humans can.
Medical schools rigorously look for signs of empathy in candidates, often through psychometric tests but the science is imprecise. The science, though, is increasingly suggesting that empathy can at least partially be taught or unlocked.
Doctors in a University of Chicago study underwent functional brain imaging while watching videos of acupuncture treatment. Compared to controls, the physicians showed significantly less response in the “empathy” regions of the brain and also showed significantly greater activation of areas involved in executive control and self-regulation.
SCHOOLED IN EMPATHY
Can empathy be taught then? In one recent study, doctors were randomly put through three 60-minute empathy modules.
The empathy training group showed greater changes in “empathy” scores compared to the control group, and showed greater changes in knowledge of the scientific basis of empathy and in the ability to decode facial expressions of emotion. Three hours was all it took. The authors hypothesised that “the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education”.
Medical schools over the world now emphasise empathy training. These take multiple forms, including movies, drama, poetry and literature. Among other initiatives, Duke-NUS here in Singapore uses extensively “standardised patients” to teach communications and highlight verbal and non-verbal cues to better communicate and show empathy. The Yong Loo Lin School of Medicine puts all students through modules in communications as well as a “disability session” where students are artificially blinded with dark glasses, made hearing impaired with ear plugs, and so on. Gratifyingly, the students of both schools are active in community service projects, both locally and overseas.
Unfortunately, there is compelling data that empathy actually declines through medical school and specialist training.
The focus on science and rationality emphasises detachment and objective clinical neutrality, and prioritises the technologic over the humanistic. The balance is a tricky one.
As Professor Richard Frankel, of Indiana University School of Medicine, describes it: “The public tells us they want physicians who are good diagnosticians and also caring people. We start with students who are very caring but have no diagnostic skills, and end up with physicians with great diagnostics skill but who don’t care.”
Physicians also become worn out, says Dr Jerome Groopman, author of How Doctors Think, by heavy workloads, intense time pressures and a diminished sense of autonomy in the healthcare system.
Is there an antidote? Medical schools can more consciously balance the academic and humanistic attributes needed in doctors, and hospitals can actively strive for care settings that are as conducive to empathy as possible.
This is admittedly very challenging, as hospitals, especially public hospitals, have to run very efficiently and turn around patients as quickly as possible. Productivity is valued and rewarded financially, and doctors who don’t see as many patients as their peers are derided as slow and inefficient.
TEACHERS WHO INSPIRE
Perhaps, it is timely to remember that at its heart, medicine is an apprenticeship, and empathy (like values) is caught more than taught.
Countless cohorts of medical students have sat at the feet of Professor Low Cheng Hock, Emeritus Consultant at Tan Tock Seng Hospital and this anecdote would be familiar to many.
As a young surgeon, he used to perform mastectomies for breast cancer (In those days, surgery was mutilating as it was believed that the entire breast and surrounding tissue had to be removed completely for adequate cancer control). In the clinics, the women would be composed and calm when signing the consent form and he would silently admire their stoicism.
One evening, he walked past a patient whom he thought was well-prepared. The question “Is everything all right?” opened the floodgates, and all the pent-up fears over the surgery, post-operative sexuality, survival erupted.
Prof Low told us young medical students: “That night, I learnt to be a doctor”.
How then should we teach empathy? One of Prof Low’s favourite quotes is: “The average teacher TELLS, the good teacher EXPLAINS, the better teacher DEMONSTRATES, the great teacher INSPIRES.”
Dedicated to the memory of Prof Lim Kok Ann, my first mentor who taught empathy by his life’s example. Prof Lim was former dean of the faculty of medicine, National University of Singapore, and isolator of the Asian Flu virus in 1957 (for which he was termed “Singapore’s Flu Fighter”). He was also the “father of chess” in Singapore. He died 10 years ago on March 8, 2003.
Dr Jeremy Lim has held senior executive positions in both public and private healthcare sectors. He is currently writing a book on the Singapore health system. This is part of a series on health policies in Singapore.