Ahimza Thirunavukarasu: Thinking about empathy

Ahimza ThirunavukarasuI’ve thought a lot about empathy recently. As a junior doctor on a psychiatry rotation, this is unsurprising, as interacting with people with acute mental health problems on a daily basis requires more patience and understanding than any of my previous roles. But it is one of the reasons I’ve enjoyed the rotation.

I’ve learnt to communicate appropriately with patients from a variety of backgrounds, varying my approach on the basis of their response to me. I’ve learnt how to take it on the chin when the person in front of me hates me and isn’t afraid to show it. I’ve learnt that life isn’t fair for many of the people I’ve met; both the patients and their families. And I’ve accepted that a doctor’s role in improving these lives can sometimes be very limited.

What has struck me most is how our empathy can become substantially limited when the behaviour of a patient appears to be their “fault” in some way. This may seem obvious, as people are generally held accountable for their behaviour. Yet the facts we learn at medical school about behaviour resulting from complex interactions between genes and environments do not seem to affect practice. We abandon this knowledge when confronted with an aggressive or emotionally unstable person, and instead put up our own defences.

Yet empathy is still vital in caring for such patients. Just as those who have developed lung cancer through smoking should receive not just the treatment, but also the help and support that other cancer patients do, we should still empathise with people whose behaviour may be contributing to their mental state. This is crucial because otherwise we risk missing opportunities to develop good therapeutic alliances, and make people less likely to seek help or change their behaviour in the future.

Our resources in this country are strained and it sometimes feels impossible to act with empathy. We may simply be too busy and the extra effort may not directly fall under our “remit” as professionals. The way our colleagues behave also has a big impact. As professionals who are always expected to be on our best behaviour, we learn subconsciously where the boundaries lie. We can very easily learn to mirror the prejudices that colleagues can display (especially if they are senior) sometimes rather overtly, for example, when dealing with psychiatric patients. Despite the training in mental health we receive, due to the pressure and culture within fast paced work environments, we can easily forget how to treat our patients the way we should.

In psychiatry too, the term “behavioural” is thrown around commonly to refer to people whose actions are deemed to be under their own control. This is a useful distinction to make, as it can prevent inappropriate treatment and admissions. However, it can also lead to a feeling of therapeutic futility and, consequently, reduced empathy. Our limits as care providers, within structured systems and with circumscribed resources, may in fact limit our empathy more than the patients themselves. When we feel that we can’t help someone, we give up trying to. Instead, we do what falls under our minimum responsibility before passing on the buck to someone else.

But I don’t think we can just blame our healthcare system’s structures. We have all gone above and beyond these for certain patients during our careers. Maybe they were of a similar age or background. Maybe over time you developed a special bond with their family. But is it really morally excusable to treat people differently based on such personal preferences? If we are capable of such empathy, shouldn’t we be thinking about all of our patients in this manner?

It is important for staff to realise and reflect on where their limits of empathy are, and how this influences their day to day behaviour. To some degree, our limits are reflected in our choice of sector. People often cite the target population of their specialty as a reason for their choice. Some choose to veer away from specialties that they find too emotionally challenging, for example, paediatrics. Others prefer specialties where empathy does not have a key role, for example, radiology or public health. Whatever one chooses, however, a career in medicine invariably demands an ability to try and see things from another person’s perspective.

We are only human. We have our own baggage, prejudices, and tolerance levels. It’s definitely not easy to put these aside. But we should be trying to understand all of our patients; not just the ones who are likeable or who make us feel good about ourselves. Recognising our limitations and how these may affect our practice should be a bigger part of our self assessment. We should be encouraged to question the culture and attitudes within our workplace, and direct our frustrations towards improving the structures we work within.

As trainees, we should not accept disillusionment and hardened hearts as an inevitable part of becoming consultants. Let us instead remain curious and compassionate about all of those we encounter, even when they don’t fit neatly into our notion of an ideal patient.

Ahimza Thirunavukarasu is a foundation year 2 doctor at the North West
Thames deanery. She has a special interest in global health and enjoys
writing in her spare time.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.