Overview
This chapter outlines the complexity of empathy. It describes the centrality of empathy in patient care and the doctor–patient relationship. The empathy gap in teaching and clinical practice is discussed. The widely reported decline in medical students’ empathy is examined. The research approach is described and the audience for the book considered. I describe my motivation for carrying out the study. The chapter concludes with an overview of the book.
The Nature of Empathy
In the scientific literature, empathy is defined in different ways, one definition highlighting the emotional aspect of empathy;
the natural capacity to share, understand and respond with care to the affective state of others. (Decety 2011, p. vii)
On the other hand, Hojat et al. (2009) take a cognitive view of empathy, excluding emotions but introducing a moral motivation to care.
Empathy is a predominantly cognitive (as opposed to affective or emotional) attribute that involves an understanding (as opposed to feeling) of patients’ experiences, concerns and perspectives, combined with a capacity to communicate this understanding. An intention to help by preventing and alleviating pain and suffering is an additional feature of empathy. (Hojat et al. 2009, p. 1183)
In medical practice and research, empathy is largely viewed as a cognitive construct, leading to a form of professionalism described as ‘detached concern’ (Hojat et al. 2009; Kelly 2017; Halpern 2001). Alternatively, empathy has been described by combining a number of processes, cognitive, affective, behavioural and moral, in a single concept (Morse et al. 1992). Batson (2011) took yet another view by describing eight different empathies. To add to this conceptual complexity, empathy is often used interchangeably with terms such as compassion and sympathy (Sinclair et al. 2016). Batson (2011) argued that there is a need to clarify the complexity of empathy.
The uncertainty surrounding the definition of empathy has practical implications for research, education and clinical practice (Halpern 2001; Shapiro 2012). Although the various definitions of empathy in the literature share the capacity to understand another person’s thoughts and feelings, they differ widely as to whether this capacity includes sharing another’s feelings (Decety and Ickes 2011; Batson 2011). The debate surrounding the appropriate emotional content of empathy for clinical practice lies at the heart of this book.
Why Study Empathy?
Empathy enables people to develop and sustain mutually respectful relationships (Cooper 2011). Empathy is an integral part of a trusting patient–doctor relationship (Neumann et al. 2012; Stepien and Baernstein 2006; Derksen et al. 2013; Pedersen 2009). The expression of empathy by healthcare professionals results in improved clinical outcomes and increased patient satisfaction (Derksen et al. 2013; Kim et al. 2004). Pedersen summarised the clinical importance of empathy by explaining that it was needed to understand a patient’s illness, their emotional reactions to it and to ascertain what is most important to them, in order to diagnose and treat them appropriately (Pedersen 2010). Empathy also has an ethical role in motivating care and generating altruism (Noddings 1984; Batson et al. 1991).
The General Medical Council (GMC), in defining their outcomes, standards and expectations for undergraduate medical education, highlighted the importance of treating patients as individuals (General Medical Council 2013, 2015). Interest in empathy in medical undergraduate education has increased over the past decades, although most research has been concerned with measuring medical students’ empathy rather than seeking to understand the factors which may influence empathy (Underman and Hirshfield 2016; Batt-Rawden et al. 2013; Pedersen 2009).
Despite a general acceptance in the literature of empathy’s central role in the patient–doctor relationship, some authors have cautioned that empathy has limits (Macnaughton 2009; Smajdor et al. 2011). They have raised doubts about the extent to which one can understand what another person is thinking and feeling (Macnaughton 2009; Smajdor et al. 2011). However, although it is true that we cannot know completely what it is to think and feel as another person, it is possible to try to imagine the world from the other person’s point of view from a basis of our shared humanity. Concerns have been raised in the literature that empathy, in particular its emotional component, might cause burnout in doctors and students, and that emotional empathy might lead to biased clinical judgements (Bloom 2016; Smajdor et al. 2011). This book argues that empathy is integral to medical education and practice and is necessary to provide a balance to mechanistic cognitive-based learning (Cooper 2011).
The Empathy Gap
Although it is accepted that empathy is central to patient care, it is of concern that some high profile reports, such as the Mid Staffordshire NHS Foundation Trust public inquiry, revealed severe failings in patient care (Francis 2010, 2013). The Francis Report identified contributory factors to the gross failures of care; compassion fatigue, overwork, excessive demand, lack of continuity of care and a failure to see the patient as a fellow human being (Haslam 2015; Francis 2013). The Parliamentary Health Service Ombudsman (2011) also found a lack of compassion and a failure to recognise the humanity of frail elderly patients, stating in her report:
the action of individual staff described here add up to an ignominious failure to look beyond the patient’s clinical condition and to respond to the social and emotional needs of the individual and their family. (Parliamentary Health Service Ombudsman 2011, p. 8)
The Parliamentary Health Service Ombudsman concluded that breaches of care were widespread and recommended strongly that the NHS should respond to the failings in care identified in her report (Parliamentary Health Service Ombudsman 2011).
Although the appalling lapses in care described in these reports were not entirely due to a lack of empathy, there is a consensus amongst healthcare professionals that a lack of empathy in the provision of health care in the NHS is a problem (de Zulueta 2013a, b; Cummings and Bennett 2012; Cornwell and Goodrich 2009; Francis 2013; Parliamentary Health Service Ombudsman 2011). Some authors have highlighted the need for doctors to guard against a lack of compassion (Das and Charlton 2018).
Francis (2013) responded to the lack of empathy in patient ...