Sunday, 9 December 2012

Elitism, empathy and excellence: Mutually exclusive or natural bedfellows?

When, at the age of 40, I embarked on my studies as a medical student, I approached this new dominion with no preconceptions. Certainly, I was aware that medical students tended to be the cream of the crop academically speaking. Broadly speaking though, there are three sub-types of student who embark on a medical degree. The first and by far the most common is the student who arrives at medical school straight from school having achieved impressive grades in their A levels a few months previously. The next subtype consists of students who have completed a degree in another, often scientific, subject prior to applying for medical school. The latter often narrowly failed to achieve the requisite grades at A level and sought their entry to medical school by a less direct route. Finally, and by far the least common, are those students who have lived a bit of life often working in a completely unrelated field before having a change of heart at any age from their late 20s to their 40s. Clearly, these three subtypes all have to be committed to their studies and yet they have all arrived from very different routes. By definition, they all have to achieve a baseline of academic excellence in order to gain entry. All well and good so far.
However, it is at this stage that the waters start to become rather more murky. The fact is that excellence of this standard emanates from a wide variety of academic backgrounds. Put bluntly, some students are the product of privilege having had thousands invested in their education. Others have had to do it the hard way with little or no support with many lying somewhere between the two. From the viewpoint of the medical school, all these subtypes constitute the elite who are deemed worthy of a place and the opportunity to study medicine. However, this is merely the viewpoint of the medical school. How these subtypes view one another is rather more interesting. Let me be quite clear about one fact before I proceed any further. Medical school is very competitive. Really competitive. For some students, reaching the top of their cohort constitutes their raison d'etre and all but defines them. The source of this aspiration is not always immediately obvious but can often be a combination of personal and parental expectation. Other students are quite content to just pass their exams and thus be eligible to proceed to their next year of study. It is consequently a rather confusing academic environment within which to study given the massive variance in competition.
To further stir up the already murky waters, the empathy inherent within each student is highly variable. This is not a criticism - this is merely an observation. It does not make one student more acceptable than another. However, if empathy really is an important attribute for somebody embarking on a career in the health service, then my final observation suddenly assumes much greater importance. The problem with empathy though, is that it can't really be taught. You can hardly teach somebody how they ought to feel for a patient in a given situation. By defintion, this has to be an individual choice. However, recent studies strongly suggest that there is a minimum level of empathy which is expected by patients. If this is true, it is difficult to see how empathy can be gauged. Doubtless, somebody has already formulated a psychometric test to try and measure it. The problem with such tests though is that people can practice them and become more adept at them. It is a matter of considerable conjecture to decide if academic excellence and empathy are mutually exclusive but there is a worrying assumption going on here. It is assumed that only students of high academic ability can become a good doctor. I would hope that others would join me in questioning this assumption. While a medical career ultimately culminates in making potentially life saving decisions, it is surely of equal importance that the decision maker has a degree of empathy to augment their decisions.
On a clinical rotation last year, a retiring consultant suggested to me that a high proportion of the surgeons she had met, displayed the characteristic diagnostic criteria for autism. I have nothing against autism and know several such people in my social circle. However, given that one of the hallmarks of autism is poor social skills, I would consider it a trifle worrying to consider a patient being thus dealt with. I'm sure the medical knowledge of such people is excellent and many would argue this is the most important thing. They would argue that the end result of treatment supercedes all else. I would argue that a little understanding is essential in the pratitioner-patient relationship. People on the autistic spectrum are known to lack a Theory of Mind. As such they struggle to acknowledge that others have beliefs, desires and intentions different from their own. Surely, Theory of Mind is essential in being able to understand the person sitting in front of view. Only armed with this could you presume to treat them. Indifference to pain and suffering has been well documented. Some psychopaths are able to mimic caring without actually feeling it and to take the extreme, narcissistic personality disorder have a lack of empathy and seek to maintain a secure emotional distance. Clearly, the psychopaths and narcissists are thankfully low in number but for all that they do exist. To my knowledge, the medical school interview could not accurately pick up such a person. Assuming they would want to, what tools exist to enable them to do so? It is also important to make the distinction between empathy and compassion. Carl Rogers established that a person must have a certain amount of empathy for another person before compassion can be felt. Hence, we can't feel compassion without first having a minimum level of empathy. For this reason, empathy is therefore hugely important in any patient relationship. Research now shows that empathy is attained in humans from the age of two with the rudiments becoming apparent at age one. Rogers also impresses upon us the need to differentiate between cognitive and affective empathy. He argues that those on the autistic spectrum are less able to gauge the feelings of others but have a greater response to stress that they experience others experiencing than so called neurotypical people.
I recognise fully the need to recruit academically able students to pursue a career in medicine, but also argue that steps are needed not to instill empathy in to students as currently occurs but rather to seek those who have a baseline of empathy in the first place. Failure to achieve this will make true one of the oldest cliches in sales management - if you do what you've always done, you'll get what you've always got. If this provokes a debate, great. If it doesn't, I'll just try harder. That is my prerogative.          

No comments:

Post a Comment