Openness is often presented as an ultimate Good in clinical practice, but are there healthy limits to empathy and candour, for both patient and carer?
In Science and Charity, a teenaged Pablo Picasso draws us into the intimate, almost claustrophobic, world of a sick woman: his model a starving beggar from the streets of Barcelona; on her right a doctor, taking her pulse, straining for a diagnosis—or at least a prognosis—as her condition visibly worsens; and on her left a nurse offering comfort, and practical support for her family. She stares into the distance, unseeing—seemingly she is already beyond the reach of both.
The painting received an Honorary Mention in the General Fine Arts Exhibition in Madrid in 1897, but failed to receive the top award as the judges thought the patient’s right hand lacked realism. With the benefit of hindsight, we can see that, far from a mistake, this was a sign of Picasso’s future direction, moving first from realism to symbolism, and then experimenting with a huge variety of ways to express truth through the visual arts.
Let’s focus, then, on her hand. The doctor holds her at arms length, his whole body turned away, his sole focus on solving the technical aspects of the situation. We see him transforming the complexities of her illness—and her life—into the measured and ordered categories of disease: an alchemist transmuting gold into lead. In his grip, her hand becomes inanimate, medicalised, something that doesn’t even belong to her any more.
On one level, then, the painting contrasts compassionate, holistic caritas with scientific, uncaring, clinical care; an openness to resonance and connection with a closed attitude of barriers, distance and detachment; good nurse with bad doctor. I think we need to look a little deeper, beyond these surface stereotypes.
Just walk a mile in his moccasins
Before you abuse, criticize and accuse.
If just for one hour, you could find a way
To see through his eyes, instead of your own muse,
I believe you’d be surprised to see
That you’ve been blind and narrow-minded, even unkind.
Openness in clinical care has been increasingly championed over recent decades, with a focus on two complementary dimensions: empathy and candour—the warp and weft of the fabric of our shared humanity. Empathy describes my willingness to see the world through your eyes, to walk a mile in your shoes. Candour speaks of my readiness to open myself to you—my frailty and fears, decisions and doubts, mistakes and misapprehensions—to reveal my own inner humanity.
Each has been proposed as an ultimate Good: an aspiration towards which we should asymptotically strive; an encapsulation of the lesser goods of clinical practice. Certainly, their absence causes problematic clinical interactions. Many observers have noted a reduction in empathy over the years of medical school, and see in this a route towards cold, uncaring doctors, unrooted in compassion, lacking the ability to communicate or connect. Equally, a lack of candour has been associated with the worst aspects of a paternalistic approach to patients—doctor knows best, and the patient is better off not knowing—and a hierarchical attitude to colleagues.
I would argue, nevertheless, that a surfeit of openness can be not only detrimental to, but actually incompatible with, clinical practice.
To sense [their] private world as if it were your own, but without ever losing the ‘as if’ quality – this is empathy.
My first real exposure to patients—to people suffering through illness—was in my third year of medical school: a week with the nurses on a medical ward. Here, I met an elderly lady with a gaping bedsore on her lower back. She needed frequent turning to prevent further skin breakdown, but the slightest movement was excruciating, and the daily dressings change was desperately distressing for her. The nurses felt that we had developed something of a connection, and so every day I was assigned to hold her hand, and watch her tears, viscerally resonating to her pain; and every night my dreams were troubled by her screams. As I continued my clinical placements, I met many others in wretched situations; my poem Shell-shocked remembers three of them:
There’s a picture by Bell, from 1809,
that shows such a patient,
contorted in truly, terrible agony.
It doesn’t come close.
Developing a capacity to distance myself, emotionally, from my patients became, for me, vital for survival. A friend continued to be deeply troubled, feeling each patient’s distress, reliving their experiences, grieving with every relative. She qualified, but quickly withdrew from clinical practice: the demands on her, as a fully empathic person, were simply too high to be sustainable.
Carl Rogers emphasises the vital as-if quality of healthy, clinical empathy, without which we can quickly drown in the emotions and experiences of our patients. In the poem, The Direct Route, I explore this empathic distress, in the context of a traumatic encounter with a teenager, at a time when my professional guard was down:
Naked, exposed, bare back, hands and feet,
not missing my clothes but rather the certainty,
the tools and the teams, the familiar routines,
the comfort of hospital trauma, and my tightly
tied mask of professional detachment.
An excess of candour can also be damaging. I perform long, delicate operations where I am continually questioning what I’m seeing and doing: “Could that be..? What if..? I hope I haven’t..?” This inner monologue of uncertainty is, I think, an important part of my situational awareness, focusing my mind on emerging problems and difficulties. A continuous broadcasting of my doubts, however, would benefit no-one.
Between truthfulness and lying there is no mean; but there is indeed a mean between candour and reticence.
Similarly, in every single operation there are aspects of the procedure that could have gone better: I reflect on them, discuss them with colleagues, strive to continually improve. But I don’t feel that I should unburden myself after surgery, by sharing each minor concern or disappointment with the patient. I’m not advocating that doctors should hide behind a wall of paternalism when things go wrong—truth and transparency are the correct and moral responses to our mistakes—but an excess of candour, particularly when it is unsolicited, is at best unhelpful and at worst extremely harmful. A common reaction to my play True Cut—which explores these areas—has been: “I don’t want to know that my surgeon is human.”
Picasso shows us an instant of care: in this moment the patient needs rational compassion from her doctor—dispassionately concentrating on diagnosis and treatment options—just as she needs to know that her emotional and practical necessities, and those of her family, are being met elsewhere. Her carers are working as a team—melding science with charity—rather than, as individuals, trying to be all things to her.
As her experience of illness continues, however, she needs a fluidity in her carers’ approach: her nurse needs science, her doctor needs to consider its limitations, and their openness should adapt to the current clinical situation.
Rather than being examples of an ultimate Good, there are healthy limits to both candour and empathy; our aim as we practice should not be to strive for ever greater openness, but to stay within healthful boundaries while matching our approach to the needs and wishes of the patient at hand.